Trends and predictors of aggressive therapy for clinical locally advanced prostate carcinoma

Efficacy and Safety of Neoadjuvant Luteinizing Hormone-Releasing Hormone Antagonist and Tegafur-Uracil Chemohormonal Therapy for High-Risk Prostate Cancer

BACKGROUND

This retrospective single-center cohort study evaluated the efficacy and safety of a combination of neoadjuvant luteinizing hormone-releasing hormone (LHRH) antagonist and tegafur-uracil (UFT) therapy (NCHT) and investigated the medical records of patients with high-risk PCa who underwent robot-assisted radical prostatectomy (RARP). The therapy was followed by RARP for high-risk PCa.

MATERIALS AND METHODS

The enrolled patients were divided into two groups: low-intermediate-risk PCa patients who underwent RARP without neoadjuvant therapy (non-high-risk) and those who underwent NCHT followed by RARP (high-risk group). This study enrolled 227 patients (126: non-high-risk and 101: high-risk group). Patients in the high-risk-group had high-grade cancer compared to those in the non-high-risk-group.

RESULTS

At the median follow-up period of 12.0 months, there were no PCa deaths; two patients (0.9%) died of other causes. Twenty patients developed biochemical recurrence (BCR); the median time until BCR was 9.9 months after surgery. The 2-year biochemical recurrence-free survival rates were 94.2% and 91.1% in the non-high-risk and high-risk-group, respectively (p = 0.465). Grade ≥3 NCHT-related adverse events developed in nine patients (8.9%).

CONCLUSIONS

This study indicates that combining neoadjuvant LHRH antagonists and UFT followed by RARP may improve oncological outcomes in patients with high-risk PCa.

Determinants of variation in radical local treatment for men with high-risk localised or locally advanced prostate cancer in England

BACKGROUND

Many factors are implicated in the potential 'under-treatment' of prostate cancer but little is known about the between-hospital variation.

METHODS

The National Prostate Cancer Audit (NPCA) database was used to identify high-risk localised or locally advanced prostate cancer patients in England, between January 2014 and December 2017, and the treatments received. Hospital-level variation in radical local treatment was explored visually using funnel plots. The intra-class correlation coefficient (ICC) quantified the between-hospital variation in a random-intercept multivariable logistic regression model.

RESULTS

53,888 men, from 128 hospitals, were included and 35,034 (65.0%) received radical local treatment. The likelihood of receiving radical local treatment was increased in men who were younger (the strongest predictor), more affluent, those with fewer comorbidities, and in those with a non-Black ethnic background. There was more between-hospital variation (P < 0.001) for patients aged ≥80 years (ICC: 0.235) compared to patients aged 75-79 years (ICC: 0.070), 70-74 years (ICC: 0.041), and <70 years (ICC: 0.048). Comorbidity and socioeconomic deprivation did not influence the between-hospital variation.

CONCLUSIONS

Radical local treatment of high-risk localised or locally advanced prostate cancer depended strongly on age and comorbidity, but also on socioeconomic deprivation and ethnicity, with the between-hospital variation being highest in older patients.

Surgery for pathological T3a, T3b and lymph node positive, prostate cancer: surgical, functional and oncological outcomes

Objective:

To investigate and document the surgical, functional and oncological outcomes following surgery for high-risk prostate cancer patients.

Patients and methods:

Patients with pathological T3a, T3b and N1 disease were extracted from our prospectively updated institutional database. Data include demographics, preoperative cancer parameters, short and long-term complications and functional results. Details of biochemical recurrence, type and oncological outcome of salvage treatments, cancer-specific and overall survival were also obtained.

Results:

A total of 669 patients were included; 58.9% had T3a disease, 35.9% had pT3b and 11.4% N1 disease. With a median follow-up of 66 months (8–129), overall survival was 94.3%, cancer-specific survival was 98.7% and biochemical recurrence was 45.6%. Average inpatient stay was 1 day and the overall complication rate was 9.1%; 54.2% experienced a biochemical recurrence and 90.3% went on to have one or more salvage treatments, which were varied. Significant predictors of biochemical recurrence included pathological stage, any positive margin and patient age ( P<0.005). A total of 44.9% had an immediate biochemical recurrence, with 90% receiving subsequent treatment and 20.5% having a durable response. None of the patients receiving prostate bed radiotherapy alone had a durable response. 54% had a delayed biochemical recurrence, with 63.5% receiving subsequent treatment and 44% having a durable response.

Conclusions:

Surgery is associated with encouraging surgical and functional outcomes, cancer-specific survival and overall survival rates in these patients. Pathological stage is a significant predictor of biochemical recurrence. The present analysis shows that long-term observation for certain patients with biochemical recurrence is appropriate and questions the effectiveness of further local salvage treatments in patients with an immediate biochemical recurrence postoperatively.

Level of evidence:

II

Marital status independently predicts prostate cancer survival in men who underwent radical prostatectomy: An analysis of 95,846 individuals

Marital status is an independent prognostic factor for survival in several types of cancer, but has not been fully studied in prostate cancer (PCa). A total of 95,846 men diagnosed with PCa were treated with radical prostatectomy (RP) between 2004 and 2009 within 18 Surveillance, Epidemiology and End Results registries. Survival curves were generated using Kaplan-Meier estimates and differences in survival were assessed using the log-rank test. Cox regression models were used to assess the impact of marital status on survival outcomes. The results demonstrated that the 8-year cancer-cause specific survival (CSS) rate of married men was higher than unmarried individuals. Further analyses revealed that divorced/separated men had a higher proportion of high Gleason scores (GS) PCa at diagnosis [hazard ratio (HR), 1.12; P=0.007] and those patients had the worst survival outcomes independent of age, ethnicity, grade, stage and sequence number [HR, 1.61; 95% confidence interval (CI), 1.34-1.93]. Interestingly, it was observed that CSS among divorced/separated men decreased as the GS increased (GS≤6: HR, 2.5; GS=7: HR, 1.71; GS≥8: HR, 1.50; all P<0.05). Apart from that, no significant differences in CSS were observed in those who had never been married (HR, 1.20) or were widowed (HR, 1.13) relative to the married group. The results of the present study support the hypothesis that marital status is an independent prognostic factor among men with PCa who underwent RP. It was demonstrated that the mortality rates of divorced or separated men with PCa were significantly greater compared with the other groups. A further understanding of the potential associations among marital status, psychosocial factors and survival outcomes may help in developing novel, more effective methods of treating different groups of patients with PCa.

Assessing the clinical benefit of a nomogram to predict specimen-confined disease at radical prostatectomy in patients with high-risk prostate cancer: An external validation

OBJECTIVE

The objective of the current study was to test generalizability and clinical value of a recently published nomogram to predict specimen-confined disease (SCD, pT2-pT3a+R0+pN0) at radical prostatectomy (RP) in patients with clinical high-risk prostate cancer (HRPCa). The nomogram allows improved decision making with curative intent within this heterogeneous patient cohort, which is important, as RP in patients with clinical HRPCa remains a topic of controversy.

METHODS

We externally validated the nomogram in 1,669 men with clinical HRPCa who underwent RP and extended pelvic lymph node dissection between 1992 and 2011. A Kaplan-Meier analysis to estimate 5- and 10-year biochemical recurrence-free survival was performed. To investigate the SCD model׳s performance, the previously reported regression coefficients of the SCD nomogram were applied. Within loess calibration plots, the extent of overestimation or underestimation was graphically explored. Finally, decision curve analysis (DCA) to assess the clinical value of the SCD nomogram was performed.

RESULTS

Overall, 49% of men showed SCD after RP. The 5- and 10-year biochemical recurrence rates for men with SCD were 66% and 56%, respectively, vs. 32% and 20%, respectively, for men without SCD (log-rank test P<0.001). External validation demonstrated comparable accuracy in relation to accuracy derived from internal validation (68.1% vs. 72.0%). Calibration was suboptimal, showing a tendency to underestimate SCD probability. In DCA, the nomogram׳s usage was associated with a clinical net benefit relative to both treating all and none.

CONCLUSIONS

Within our cohort, the nomogram׳s use was associated with a clinical net benefit according to DCA. However, one-third of men were falsely classified as having SCD or non-SCD. Nevertheless, in the absence of superior tools, the SCD nomogram represents a useful clinical decision aid.

Results of radical prostatectomy in newly diagnosed prostate cancer: long-term survival rates in locally advanced and high-risk cancers

BACKGROUND

Until just a few years ago, locally advanced or high-risk prostate cancer was generally considered incurable. Recently, however, evidence has accumulated that, even for these patients, the oncologic outcome after radical prostatectomy is not uniformly poor.

METHODS

13 262 evaluable patients with prostate cancer were treated with radical prostatectomy from 1992 to 2012. 4391 had a locally advanced stage, lymphogenous metastases, and/or unfavorable histopathological tumor characteristics. The endpoints of this retrospective, monocentric study were biochemical recurrence-free survival (postoperative PSA value less than 0.2 ng/mL), carcinoma-specific survival, and overall survival.

RESULTS

The rates of biochemical recurrence-free survival, carcinoma-specific survival, and overall survival at 10 years were 53%, 98%, and 89% for patients with extraprostatic tumor growth (tumor stage pT3a, 2675 patients); 19%, 87%, and 79% for patients with demonstrated invasion of the seminal vesicle (pT3b, 1373 patients); and 3%, 77%, and 69% for patients with tumor invasion of neighboring organs (pT4, 53 patients). The corresponding figures were 14%, 81%, and 71% for patients with lymph node metastases (682 patients); 32%, 93%, and 85% for those with a preoperative PSA value above 20 ng/mL (728 patients); and 25%, 70%, and 58% for those with a prostatectomy Gleason score of 8 or more points (559 patients).

CONCLUSION

Even patients with locally advanced, nodally metastasized, or localized high-risk prostate cancer do not necessarily have a poor outcome. Although most such patients have a biochemical recurrence after radical prostatectomy, their carcinoma-specific mortality within ten years of radical prostatectomy ranges from 2% to 30% depending on the risk constellation, while their overall survival rate over the same period ranges from 58% to 89%.

A population-based analysis of the effect of marital status on overall and cancer-specific mortality in patients with squamous cell carcinoma of the penis

PURPOSE

The association between marital status and tumor stage and grade, as well as overall mortality (OM) and cancer-specific mortality (CSM) received little attention in patients with squamous cell carcinoma of the penis (SCCP).

METHODS

We relied on the surveillance, epidemiology, and end results (SEER) 17 database to identify patients diagnosed with primary SCCP. Logistic and Cox regression models, respectively, addressed the effect of marital status on the rate of locally advanced disease and its effect on OM and CSM. Covariates consisted of age, race, socioeconomic status, year of surgery, and SEER registries.

RESULTS

Between 1988 and 2006, 1,884 patients with SCCP were identified. At surgery, 1,192 (63.3 %) were married and 966 (51.3 %) had locally advanced disease. In multivariable logistic regression models predicting locally advanced disease at surgery, unmarried men had a 1.5-fold higher (p < 0.001) risk than others. In multivariable Cox models predicting CSM, marital status had no effect [hazard ratio (HR) = 1.3, p = 0.1]. Finally, in multivariable Cox models predicting OM, unmarried men had a 1.3-fold higher (p = 0.001) risk than others.

CONCLUSION

Unmarried men tend to present with less favorable disease stage at SCCP. Moreover, unmarried men tend to live less long than their married counterparts. However, marital status has no effect on CSM.

Younger age is an independent predictor for poor survival in patients with signet ring prostate carcinoma

Objective. The aim of this study was to examine the epidemiology, natural history, treatment pattern, and predictors of long-term survival of signet ring prostate carcinoma (SRPC) patients based on the analysis of the national Surveillance, Epidemiology, and End Results (SEER) database. Methods & Results. Between 1980 and 2004, a total of 93 patients with pathologically confirmed SRPC were identified. The mean age was 70 ± 11 years old. 82.8% of the patients had poorly or undifferentiated histology grade. 13.9% patients presented with metastatic disease. The 1-, 3-, and 5-year cancer-specific survival rates were 94.6%, 89.6%, and 83.8%, respectively. Using multivariate Cox proportional hazard model, younger age (40-50 versus age >70 yrs, P = .01), advanced tumor stage (distant versus local/regional, P = .02), and earlier diagnosis year (before 1995 versus after 1995, P = .01) were predictors of worse cancer specific survival. Conclusions. Despite more aggressive cancer therapy, younger SRPC patients had a worse cancer specific survival. This information could be useful when counseling these patients and emphasizes the need for new strategies and molecular-based therapeutic approaches for younger patients with SRPC.

Locally advanced prostate cancer: a population-based study of treatment patterns

Study Type--Therapy (practice patterns). Level of Evidence 2b. What's known on the subject? And what does the study add? The treatment of locally advanced prostate cancer varies widely even though there is level one evidence supporting the use of multimodality therapy as compared with monotherapy. This study defines treatment patterns of locally advanced prostate cancer within the United States and identifies predicators of who receives multimodality therapy rather than monotherapy.

OBJECTIVE

• To identify treatment patterns and predictors of receiving multimodality therapy in patients with locally advanced prostate cancer (LAPC).

PATIENTS AND METHODS

• The cohort comprised patients ≥66 years with clinical stage T3 or T4 non-metastatic prostate cancer diagnosed between 1998 and 2005 identified from the Surveillance, Epidemiology and End Results (SEER) cancer registry records linked with Medicare claims. • Treatments were classified as radical prostatectomy (RP), radiation therapy (RT) and androgen deprivation therapy (ADT) received within 6 and 24 months of diagnosis. • We assessed trends over time and used multivariable logistic regression to identify predictors of multimodality treatment.

RESULTS

• Within the first 6 months of diagnosis, 1060 of 3095 patients (34%) were treated with a combination of RT and ADT, 1486 (48%) received monotherapy (RT alone, ADT alone or RP alone), and 461 (15%) received no active treatment. • The proportion of patients who received RP increased, exceeding 10% in 2005. • Use of combined RT and ADT and use of ADT alone fluctuated throughout the study period. • In all 6% of patients received RT alone in 2005. • Multimodality therapy was less common in patients who were older, African American, unmarried, who lived in the south, and who had co-morbidities or stage T4 disease.

CONCLUSIONS

• Treatment of LAPC varies widely, and treatment patterns shifted during the study period. • The slightly increased use of multimodality therapy since 2003 is encouraging, but further work is needed to increase combination therapy in appropriate patients and to define the role of RP.

Surgery for high-risk localized prostate cancer

Treatment of men with high-risk prostate cancer (PCa) remains challenging for urologists. The complex natural history of high-risk PCa and the lack of specific and accurate definitions for high-risk disease impede treatment decision making. Historically, surgery in this patient group has been avoided based on the perception of ostensibly higher complication rates associated with inferior functional and oncological outcomes. To date, no randomized data comparing different therapy approaches have been made available. Several investigators have reported that continence rates in patients after radical prostatectomy (RP) for high-risk disease seem to be unaffected. Similarly, in a large proportion of these men, a nerve-sparing procedure can be performed without a significant negative impact on surgical margin rates and with comparable potency results. Moreover, extended pelvic lymph node dissection (EPLND) contributes to accurate pathological staging with a marginal effect on perioperative morbidity. With regards to the benefits of RP on local recurrence and cure rates, realistic expectations regarding the success of RP alone or in the context of a multimodal approach should be provided during patient counseling.

Evolution of the clinical presentation of men undergoing radical prostatectomy for high-risk prostate cancer

OBJECTIVE

To investigate the outcomes and potential effect of improved longitudinal screening in men presenting with high-risk (advanced clinical stage [>T2b], Gleason score 8-10 or prostate-specific antigen [PSA] level >20 ng/mL) prostate cancer (PC).

PATIENTS AND METHODS

The Institutional Review Board approved, Institutional Radical Prostatectomy Database (1992-2010) was queried for men with high-risk PC based on D'Amico criteria. Year of surgery was divided into two cohorts: the Early PSA Era (EPE, 1992-2000) and the Contemporary PSA Era (CPE, 2001-2010). PC features and outcomes were evaluated using appropriate comparative tests.

RESULTS

In total, 667 men had high-risk PC in the EPE and 764 in the CPE. In the EPE, 598 (89.7%) men presented with one high-risk feature; 173 (29.0%) men had a Gleason score of 8-10 on biopsy. In the CPE, 717 (93.9%) men presented with one high-risk feature (P = 0.004) and 494 (68.9%) men had a Gleason score of 8-10. At 10 years, biochemical-free survival (BFS) was 44.1% and 36.4% in the EPE and CPE, respectively (P = 0.04); metastases-free survival (MFS) was 77.1% and 85.1% (P = 0.6); and PC-specific survival (CSS) was 83.3% and 96.2% (P = 0.5). BFS, MFS and CSS were worse for men with more than one high-risk feature in both eras.

CONCLUSIONS

Over the PSA era, an increasing percentage of men with high-risk PC were categorized by a biopsy Gleason score of 8-10. The accumulation of multiple high-risk features increases the risk of biochemical recurrence, the development of metastases and death from PC. BFS, MFS and CSS are stable over the PSA era for these men. The balance between a greater proportion of men having high Gleason disease and a greater proportion with small, less advanced tumours may explain the stability in MFS and CSS over time.

Radical prostatectomy for high-risk prostate cancer defined by preoperative criteria: oncologic follow-up in national multicenter study in 813 patients and assessment of easy-to-use prognostic substratification

OBJECTIVE

To estimate the effect of predictive factors for oncologic outcomes after radical prostatectomy (RP) for high-risk prostate cancer (PCa).

METHODS

A total of 813 patients underwent RP for high-risk PCa in a national retrospective multi-institutional study. High-risk PCa was defined as follows: prostate-specific antigen (PSA) level>20 ng/mL, Gleason score 8-10, and/or clinical Stage T2c-T4 disease. The preoperative criteria of high-risk PCa were studied in a logistic regression model to assess the correlations with the pathologic findings in the RP specimens. The predictive factors isolated or combined in scores were assessed by Cox multivariate and Kaplan-Meier analyses in predicting PSA failure (recurrence-free survival [RFS]) and overall survival (OS).

RESULTS

The median follow-up was 64 months. Organ-confined disease was reported in 36.5%. The 5-year RFS, metastasis-free survival, and OS rate was 74.1%, 96.1%, and 98.6%, respectively. Each preoperative criteria of high-risk PCa was an independent predictor of PSA failure. The PSA failure risk was increased by 1.5- and 2.8-fold in men with 2 and 3 criteria, respectively. The RFS, but not the OS, was significantly different according to the preoperative score (P<.001). The postoperative score was significantly predictive for RFS and OS (P<.001 and P<.035, respectively). The risk of PSA failure was significantly increased with an increasing postoperative score (2-4.6-fold).

CONCLUSION

National data support evidence that RP can result in encouraging midterm oncologic outcomes for the management of high-risk PCa. At 5 years after surgery, 75% of patients remain disease free. Our easy-to-use risk stratification might help clinicians to better predict the clinical and PSA outcomes of high-risk patients after surgery.

Multimodal approaches to high-risk prostate cancer

Widespread use of testing for prostate-specific antigen (PSA) has led to a migration in the stage and grade of prostate cancer (PCa), with most men presenting with localized disease. However, 20%-35% of patients still present with high-risk disease (PSA > 20 ng/mL, biopsy Gleason score 8-10, or clinical stage T3). Despite advances in various treatment modalities, patients with high-risk disease have a significant chance of recurrence and death after surgery, often because of the presence of early occult metastasis at time of diagnosis. The optimal management of high-risk pca remains controversial. The present article aims to discuss the traditional approaches and the more recent evolution toward multimodal therapies.

High-risk prostate cancer: the role of radical prostatectomy for local therapy

The management of high-risk prostate cancer can pose a unique challenge to the urologic oncologist. High-risk prostate cancer remains a real entity, especially in the inner-city urban population centers with high-risk ethnic groups. Although the role of radical prostatectomy is well defined for localized, low-to-intermediate-risk prostate cancer, its role in high-risk disease is more controversial. This is compounded by a lack of a universally accepted definition for ‘high-risk’ disease and the stage migration that has occurred in prostate cancer in the PSA era, rendering some historical perspectives less relevant. However, what has been accepted is the role of multimodal therapy in the management of this challenging group of patients. This article offers the reader an up-to-date detailed review of this topic, with specific emphasis on the role of radical prostatectomy in this clinical setting, including surgical considerations and outcomes. The advantages in terms of accurate pathologic staging with radical prostatectomy are presented. The role of robotic radical prostatectomy, which is increasingly utilized in the USA for the surgical treatment of prostate cancer in this clinical scenario, is discussed. In addition, we address the shortcomings of adequate clinical staging in this group of patients and discuss advances in imaging that might improve our capabilities in the future.

Radical prostatectomy for high-risk clinically localized prostate cancer: a prospective single institution series

OBJECTIVE

The objective of this paper is to report on the pathologic and biochemical progression-free outcomes of patients who underwent radical prostatectomy for high-risk localized prostate cancer.

METHODS

Data was collected prospectively from 299 patients who underwent radical prostatectomy for high-risk clinically localized prostate cancer by 2 surgeons at a single institution. High risk was defined as 1 or more of 3 adverse factors: prostate-specific antigen (PSA) >20, biopsy Gleason score 8 to 10 and clinical stage T3. PSA recurrence was defined as PSA >0.4 ng/mL or any salvage therapy.

RESULTS

Median age was 63.3 years (46.1-75.9). Median follow-up was 4.7 years (range 0.5-17.3 years). PSA at diagnosis was >20 ng/mL in 31.4%. Biopsy Gleason score was 8 to 10 in 66.9%. Clinical stage was T3 in 24.4%. 81.6% of patients had a single baseline risk factor, 15.7% had 2 risk factors and 2.7% had all 3 risk factors. Neoadjuvant therapy was administered to 184 patients (61.5%). Pathologic stage was organ-confined in 39.6%, specimen-confined in 26%, non-specimen-confined in 26.4%, and 8% had lymph node positive disease. Overall survival, cancer-specific survival and biochemical progression-free survival was 99%, 99.67% and 70.2%, respectively. Univariate analysis showed that PSA at diagnosis, percentage of cores positive and number of risk factors were predictors of PSA recurrence (p < 0.05). Multivariate analysis showed that PSA at diagnosis was an independent predictor of PSA recurrence (p < 0.05).

CONCLUSION

Radical prostatectomy is associated with favourable biochemical progression-free, clinical and overall survival in selected men with high-risk localized prostate cancer, and should therefore be considered an option in these patients. Baseline PSA >20 ng/mL is a significant independent predictor of PSA recurrence.

What is the optimal management of high risk, clinically localized prostate cancer?

OBJECTIVES

To summarize the presentations and debate regarding the optimal treatment of localized high-risk prostate cancer as presented at the 2009 Spring Meeting of the Society of Urologic Oncology.

MATERIALS AND METHODS

The debate was centered on presentations arguing for radical prostatectomy (RP) or radiotherapy as the optimal treatment for this condition. The meeting presentations are summarized by their respective presenters herein.

RESULTS

Dr. James Eastham presents the varied definitions for "high-risk" prostate cancer as strongly influencing which patients end up in this cohort. Based upon this, between 3% and 38% of patients with high-risk features could be defined as "high-risk". Despite that, these men do not have a uniformly poor prognosis after RP, and attention to surgical principles as outlined improve outcomes. Disease-specific survival at 12 years is excellent and up to one-half of these men may not need adjuvant or salvage therapies, depending on their specific disease characteristics. Adjuvant or salvage radiotherapies improve outcomes and are part of a sequential approach to treating these patients. Dr. Anthony Zietman presented radiotherapy as the gold-standard based upon large, randomized clinical trials of intermediate- and high-risk prostate cancer patients. Compared with androgen deprivation alone, the addition of radiotherapy provided a 12% cancer-specific survival advantage and 10% overall survival advantage. Dose escalation seems to confer further improvements in cancer control without significant escalation of toxicities, with more data forthcoming.

CONCLUSIONS

There are no randomized trials comparing RP to radiotherapy for any risk category. In high-risk prostate cancer patients, both approaches have potential benefits and cumulative toxicities that must be matched to disease characteristics and patient expectations in selecting a treatment course.

High-risk localized prostate cancer: role of radical prostatectomy

PURPOSE OF REVIEW

The paucity of randomized trials comparing curative management strategies for high-risk prostate cancer makes treatment decisions in this patient population difficult. Although in the past, high-risk patients have primarily been sent for radiation therapy due to concerns that surgery was not likely to be curative and associated with high side-effect profile, there is renewed interest in radical prostatectomy as the primary treatment for high-risk disease.

RECENT FINDINGS

Multiple case series have recently been reported that demonstrate the long-term efficacy of radical prostatectomy in a high-risk population with 15-year prostate cancer-specific survival of over 80%. Comparisons of different treatment options using nonrandomized trials demonstrate improved outcomes with surgery compared with watchful waiting or radiation therapy.

SUMMARY

Radical prostatectomy is an acceptable treatment alterative, which provides long-term durable disease control for men with high-risk prostate carcinoma.

What are the outcomes of radical prostatectomy for high-risk prostate cancer?

OBJECTIVES

To examine the long-term survival following radical prostatectomy in the population with high-risk prostate cancer. Despite considerable stage migration associated with widespread prostate-specific antigen screening, as many as one-third of incident prostate cancers have high-risk features. These patients are often treated with combined radiation and androgen deprivation therapy, and less is known about the long-term survival in this population after radical prostatectomy (RP).

METHODS

Between 1992 and 2008, 175 men underwent RP by a single surgeon with D'Amico high-risk prostate cancer (clinical stage ≥T2c, biopsy Gleason score 8-10, or prostate-specific antigen >20 ng/mL). In this population, we examined the rates and predictors of biochemical progression, metastatic disease, and cancer-specific mortality.

RESULTS

Among 175 high-risk patients, 63 (36%) had organ-confined disease in the RP specimen. At 10 years, biochemical recurrence-free survival was 68%, metastasis-free survival was 84%, and prostate cancer-specific survival was 92%. The 10-year rate of freedom from any hormonal therapy was 71%. Of the high-risk criteria, a biopsy Gleason score of 8-10 (vs ≤7) was the strongest independent predictor of biochemical recurrence, metastases, and prostate cancer death.

CONCLUSIONS

National data suggest that RP may be underutilized for the management of high-risk clinically localized prostate cancer. Our data suggest that surgical treatment can result in long-term progression-free survival in a subset of carefully selected high-risk men. Further prospective studies are warranted to directly compare the outcomes of RP vs combined radiation and hormonal therapy in high-risk patients.

Robotic radical prostatectomy for patients with locally advanced prostate cancer is feasible: results of a single-institution study

OBJECTIVES

The aim of this study was to compare the outcomes of robotic prostatectomy (RP) in patients with clinically localized or locally advanced prostate cancer (PC).

PATIENTS AND METHODS

Between July 2005 and February 2008, we performed RP in 357 patients by using the da Vinci robot system and a transperitoneal approach. We defined locally advanced PC as cases with a clinical T-stage >/=T3a with any serum prostate-specific antigen (PSA) or Gleason score. Among the 321 men not treated with neoadjuvant hormonal therapy, 200 patients had clinically localized PC and 121 patients had locally advanced PC. We compared perioperative variables and early surgical outcomes between the two groups.

RESULTS

Although advanced PC patients had significantly higher mean preoperative PSA levels, prostatectomy Gleason scores, and extracapsular extension rates, there were no significant differences in mean operation time, estimated blood loss, duration of bladder catheterization, hospital stay, or initiation of a regular postoperative diet between the two groups. Except for some early cases, a bilateral extended lymphadenectomy was performed without difficulty in both groups. Although both the frequency of lymph node invasion and the positive surgical margin rates were higher in the advanced PC patients, the positive surgical margin rate (48.8%) in the present study was similar to those of open radical retropubic prostatectomy in other studies. The overall complication rate did not differ between the two groups. Two intraoperative rectal injuries occurred in patients with locally advanced PC and were closed primarily without specific problems, except for 1 case.

CONCLUSIONS

Our results suggest that RP may be performed safely on patients with locally advanced PC.

Locally advanced prostate cancer: the role of surgical management

Among the heterogeneous population of patients with prostate cancer, a high-risk group with locally advanced prostate cancer (LAPC) present a diagnostic and therapeutic dilemma. Although the incidence of LAPC has decreased with screening since the introduction of prostate-specific antigen (PSA) testing, significantly many patients are still diagnosed with LAPC. These patients are by definition at higher risk of metastatic disease and worse outcomes. The role of radical prostatectomy (RP) in this population has been debated, as the combination of radiotherapy and hormonal therapy is becoming used more frequently for LAPC. Unfortunately, the clinical staging and evaluation of LAPC is a challenge that results in possibly understaging or overstaging these patients. This further complicates therapeutic decision-making, and as a result no established standard treatment has been proposed. Like other patients with prostate cancer, individualized therapeutic choices are essential and depend on a multitude of factors. Herein we examine the role of RP for managing LAPC and attempt to emphasize how the risk of distant disease and difficulty with clinical staging might favour incorporating a surgical approach as part of the therapy for patients with LAPC.

[Clinical study of radical prostatectomy for prostate cancer from a single institution]

PURPOSE

To investigate the outcomes for single institution with prostate cancer treated with radical prostatectomy (RP).

MATERIALS AND METHODS

A retrospective analysis was performed on 406 patients who underwent RRP from January 1991 to December 2005 for cT1-3N0M0 prostate cancer. To evaluate the change of the patient background, we divided the 15 years into the 5 periods whose span was 3 years each and examined. Biochemical recurrence was defined as a prostate-specific antigen (PSA) of > or = 0.2 ng/ml. Clinical recurrence was defined as metastases or local recurrence. Actual probability of cancer specific mortality was estimated using the Kaplan-Meier method. The Log rank test was used to determine statistical difference between actual curves. Preoperative parameters analyzed were patient age, preoperative PSA, clinical stage, Gleason score, and Neoadjuvant hormonal therapy. Multivariate analyses (logistic regression and Cox proportional hazard model) for the dependent variables (organ-confined prostate cancer, clinical recurrence free survival and cancer specific mortality) were performed. Perioperative complications between cT1/2 with cT3 were compared.

RESULTS

The number of the operation increased every period. High recurrence risk group and cT3 were tended to decrease. Median follow-up and median patient age were 55 month and 69 year. Of the 406 men, 35 (8.6%) developed clinical recurrence, 15 men (3.7%) died from prostate cancer within the follow-up period. For pT0/2, pT3a, pT3b and pN +, the 10-yr cancer specific survival rate was 100%, 92%, 81% and 67%, respectively. Preoperative PSA (p < 0.0001), clinical stage (p = 0.004), Gleason score (p < 0.0001) and neoadjuvant hormone therapy (p = 0.0003) are predictive variables for organ confined prostate cancer. Preoperative PSA (p = 0.002) and clinical stage (p = 0.03) are prognostic variables for cancer specific mortality. There was significant difference in surgery time (p = 0.04) and blood loss (p = 0.0007) in cT1/2 cases compared with cT3 cases.

CONCLUSION

The number of the operation increased every period. High recurrence risk group and cT3 were tended to decrease. Neoadjuvant hormone therapy prior to prostatectomy was a significant improvement in the organ confined rates. However neoadjuvant hormone therapy did not improve patient prognosis. Preoperative PSA and clinical stage are prognostic variable for cancer specific mortality.

The clinical significance and therapeutic implications of extraprostatic invasion

Invasion of the prostatic margin by cancer establishes a higher risk of disease progression and treatment failure depending upon its extent and other clinical factors. Pathological stage is the most important single prognostic indicator, but determined reliably only in patients having radical prostatectomy. Tumour beyond the prostatic margin or its invasion into the seminal vesicle defines the local stage category as T3, and when confirmed by pathological examination the extent of prostatic margin involvement has prognostic significance. Prediction of extraprostatic invasion may influence therapeutic decisions, but can be difficult to determine for the individual patient prior to treatment. In some individuals having radical prostatectomy, the finding of extraprostatic invasion is unsuspected, and fortunately for the majority of these men the treatment remains curative. On the other hand, when extraprostatic invasion is suspected prior to or at surgery, wide excision may be necessary to achieve negative surgical margins, with other factors contributing independently to the likelihood of subsequent progression. Radiotherapy is an effective alternative treatment for clinical stage T3 and high-risk clinically localized cancer. Recent technological advances and use of combination modality treatment with radiation and hormone manipulation have improved survival outcomes and reduced side-effects. Radiation also has its place as adjuvant treatment following radical prostatectomy in high-risk disease, or as salvage following PSA recurrence, with ongoing trials evaluating potential benefit and toxicity. For clinically localised stage T3 prostate cancer, treatment with surgery or radiotherapy may be highly effective, but multimodality interventions are increasingly being used for primary treatment where clinical assessment indicates that there would otherwise be a high risk for disease progression and therapeutic failure.

[The role of surgery in locally advanced prostate cancer]

Recent retrospective monocentric studies have demonstrated favorable 15-year cancer-specific survival (CSS) rates of up to 86% using radical prostatectomy as part of multimodal treatment in locally advanced prostate cancer (T3-4, N0, M0). Patients most likely to benefit from surgery include those with a biopsy Gleason score < or =8, a prostate-specific antigen level <20 ng/ml, and cT3a cancer. Patients must be informed that additional treatment after prostatectomy might be necessary (30-70%; radiotherapy, hormonal therapy). Urinary incontinence may occur in up to 20%, and severe incontinence (more than two pads per day) is observed in up to 6%.Adjuvant radiotherapy should be considered individually and is not routinely recommended. Extended pelvic lymphadenectomy should be performed, although it has only a minor impact on survival. However, even in patients with lymph node micrometastasis, 10-year CSS can be achieved in 85.6% with the use of additional hormonal therapy. Cancer progression can possibly be delayed by surgical excision of the primary tumor, even in patients with metastasis. The existing data must be checked in prospective randomized trials.

Role of radical prostatectomy in the treatment of high-risk prostate cancer

Controversy remains regarding the preferred therapy for high-risk, clinically localized prostate cancer. High-risk prostate cancer represents a diverse disease entity for which accurate risk assessment is critical to informed counseling and clinical decision making. For men with high-risk features, electing surgery as a local definitive therapy should be based on the best available evidence rather than a surgeon's bias and experience. Patients classified with high-risk prostate cancer by common definitions do not have a uniformly poor prognosis after radical prostatectomy. Many cancers that are clinically categorized as high risk are actually pathologically confined to the prostate, and most of these men do not require additional long-term therapy after surgery. For some high-risk patients, an integrated approach combining local and systemic therapy may be advantageous. Available studies using adjuvant and neoadjuvant strategies have their individual strengths and weaknesses; unfortunately, none has provided persuasive evidence to dictate the standard of care in the high-risk setting. Therefore, results are eagerly anticipated from ongoing randomized trials exploring the merits of perioperative chemohormonal therapy in high-risk patients. This review discusses current limitations and challenges in accurately identifying high-risk patients and focuses on radical prostatectomy alone or as part of multimodal therapy for men with high-risk prostate cancer.

Trends in radical prostatectomy

The surgical treatment of prostate cancer ideally removes the entire cancer, avoids excessive blood loss or serious perioperative complications, and results in complete recovery of continence and potency. To achieve this, the surgeon must excise sufficient periprostatic tissue to cure the cancer while preserving the cavernosal nerves required for erectile function and the neuromusculature required for normal urinary and bowel function. Here we will examine recent trends in radical prostatectomy, focusing on surgical technique.

Intermediate-Term Potency, Continence, and Survival Outcomes of Radical Prostatectomy for Clinically High-Risk or Locally Advanced Prostate Cancer

OBJECTIVES

Controversy exists about the preferred treatment of patients with high-risk or locally advanced prostate cancer. We examined the intermediate-term cancer control and quality-of-life outcomes after radical retropubic prostatectomy (RRP) in selected patients.

METHODS

From 1984 to 2003, 288 men with Stage cT2b (Gleason score 8 to 10 or a prostate-specific antigen level greater than 15 ng/mL) or T3 disease underwent RRP by a single surgeon. The 7 and 10-year actuarial progression-free survival (PFS), cancer-specific survival (CSS), overall survival (OS), potency, and continence rates were recorded.

RESULTS

The actuarial 7-year PFS, CSS, and OS rate after surgery was 39%, 92%, and 91%, respectively. The corresponding actuarial 10-year rates were 35%, 88%, and 74%. Only OS differed significantly by age group. On multivariate analysis, the pathologic stage was a significant independent predictor of progression. Ultimately, 31 men (11%) required hormonal therapy, 58 (20%) underwent postoperative radiotherapy, and 67 (23%) received both. Potency and continence were preserved in 64% and 92%, respectively.

CONCLUSIONS

Overall, RRP offers excellent intermediate-term cancer control for selected men of all ages who present with high-risk or locally advanced disease. The PFS was significantly greater for men with high-risk Stage cT2b than for those with cT3 disease, but the CSS and OS were similar. Both continence and potency were preserved in most patients, although the potency rates were significantly greater for the younger men. RRP with appropriate postoperative radiotherapy and/or hormonal therapy is a reasonable treatment option for selected men with high-risk or locally advanced disease.

[Radiotherapy for prostate cancer]

Depending on tumor-stage and risk-factors, prostate cancer can be treated by Radical Prostatectomy, External Beam Radiotherapy, Brachytherapy, Androgen Ablation or a combination of at least two of them. In clinically localized low-risk cases, the results of radiotherapy and surgery are very similar. Patients with intermediate-risk or high-risk prostate cancer, often not suited for radical prostatectomy, seem to benefit from higher radiation doses and additional Androgen ablation, although questions remain regarding the treatment volume of radiotherapy and the optimal timing and duration of androgen deprivation. Standardised target volume definitions and dose prescriptions for different risk groups and improved patient selection for radiotherapy are required.

Optimal treatment of locally advanced prostate cancer

The treatment of clinically locally advanced prostate cancer (cT3-4) is subject to controversies. Patients with lymph node metastases as well as patients with overstaged localized and thus curable disease fall into this category. Radical prostatectomy, external beam radiotherapy and early or deferred hormonal therapy are possible treatment options. Multimodal treatment (i.e., a combination of these options) is frequently used. After radical prostatectomy, Gleason score-adjusted disease-specific survival does not differ meaningfully between the tumor stages pT2 and pT3-4. In the case of lymph node metastases after radical prostatectomy, but not in node-negative disease, adjuvant hormonal treatment seems to improve survival. Adjuvant radiotherapy may improve biochemical and local control in locally advanced prostate cancer, a survival benefit has, however, not yet been proven. External beam radiotherapy alone provides unfavourable survival rates in locally advanced prostate cancer. Adjuvant hormonal treatment may improve outcome in this setting. When no curative treatment is chosen, early hormonal treatment seems to provide modest benefit compared with deferred therapy.