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PROGNOSTIC FACTORS FOR PATIENTS WITH LOCALLY ADVANCED PROSTATIC CANCER WHO UNDERWENT RADICAL PROSTATECTOMY
761
762
TREATMENT OF CLINICAL STAGE T3 PROSTATE CANCER: A SURGICAL DISEASE?
NEOADJUVANT CHEMOHORMONAL THERAPY IN POOR-PROGNOSIS LOCALISED PROSTATE CANCER Zisman A.1, Yarom N.2, Stav K.2, Leibovici D.2, Lindner A.2, Sella A.3 1 Assaf Harofeh MC, Urology, Ness Ziona, Israel, 2Assaf Harofeh MC, Urology, Zeriffin, Israel, 3Assaf Harofeh MC, Pathology, Zeriffin, Israel INTRODUCTION & OBJECTIVES: We designed a trial of neoadjuvant chemohormonal therapy followed with radical prostatectomy (RPX) for patients with poor prognosis localised CAP (PSA > 20 ng/ml, Gleason score > 8 and clinical stage > T2c) who are not candidates for routine radical surgery. MATERIAL & METHODS: Therapy included 4 cycles of Emcyt 280 mg TID days 1-5 and Docetaxel 70 mg/m2 day 2 Q 21 days combined with androgen blockage and low dose Coumadin. RPX was performed no later than 7 weeks from initiation of 4th cycle. Androgen suppression was maintained for node positive patients. RESULTS: Since 4/2002 we recruited 13 patients. Patients’ characteristics included (median values): age 61 (54-69) years, PSA 13.2 (3.2-50) ng/ml and Gleason score 7 (4-9). Clinical stage: T2b or T2c - 2 (14.2%) patients each, T3a - 6 (42.8%), T3b - 1 (7.1%) patient and T3c – 2 (14.2%) patients. We delivered 42 cycles to 11 patients. Grade 3-4 toxicity per cycles included neutropenia 9 (21/4%), infections 6 (14.2%), metabolic, nausea, vomiting and liver toxicity - 2 episodes each (4.7%). Ten Pt’s underwent surgery at 6.5 (3.8-7.7) weeks from last therapy. Their postoperative characteristics included PSA 0.25 (0.05-0.5) ng/ml. Viable disease was found in all specimens. Median Gleason score was 7. The rate of organ and specimen confined disease was 6 (60%), seminal vesicle disease in 4 (40%) and lymph node involvement in 3 (30%) patients. To date at a median follow-up of 23 months all Pt’s are alive. One patient experienced biochemical progression. Operative time was 210 (135-225) minutes, nadir Hb 9.0 (8.6-9.8) gr/dL, and hospital stay 12 (7-17) days. Analgesia was required for 4 (2-11) days. Wound drainage was removed on POD 6 (4-8) and the catheter was removed on day 12 (10-17). Surgical difficulties encountered were severe adhesions in 4 patients each, difficulty in SV dissection, pelvic haematoma and rectal injury (primary suturing) each in 1 patient. Four patients had wound infection, no cardiovascular or thromboembolic events were noted. All patients but one are fully continent. Although nerve sparing was attempted all patients did not regain potency. CONCLUSIONS: Neoadjuvant chemohormonal approach is feasible in poor prognosis localised prostate cancer. Initial results appear promising.
Joniau S.1, Van Baelen A.1, Hsu C.Y.1, Oyen R.2, Roskams T.3, Van Poppel H.1 1 University Hospital Leuven, Urology, Leuven, Belgium, 2University Hospital Leuven, Uro-radiology, Leuven, Belgium, 3University Hospital Leuven, Histopathology, Leuven, Belgium
INTRODUCTION & OBJECTIVES: The value of surgery as monotherapy in clinical stage T3 prostate cancer (cT3 PCa) is still subject to debate. The aim of this study was to examine the technical feasibility of radical prostatectomy for cT3 PCa. MATERIAL & METHODS: We reviewed the records of 139 patients who underwent a radical retropubic prostatectomy (RRP) with pelvic lymphadenectomy for cT3 PCa from January 1997 to December 2003. The files were critically reviewed and all data related to surgical and peri-operative complications were collected. Additionally, continence and erectile function were assessed at 12 months postoperatively. Data were compared to series of RRP in patients with clinically localised disease. RESULTS: There was no peri-operative mortality. No ureteral or large vessel injury occurred. Rectal injury and injury of the obturator nerve occurred both in 0.7% of cases. No serious in-hospital complications were noted and no reintervention was needed. Lymphorrhea was noted in 2.2% of patients and 1.4% experienced prolonged drainage of urine. In 7.2%, wound related problems occurred. Anastomotic stricture occurred in 2.9%. At 12 months, complete continence was 87.8%. Erectile function fully recovered in 6% of patients who underwent a non-nerve-sparing procedure and in 10% of patients who underwent a unilateral nerve-sparing procedure. Positive surgical margin rate was only 13.7%. CONCLUSIONS: In cT3 PCa, RRP is technically feasible with morbidity comparable to RRP in clinically localised PCa. Prospective randomised trials are needed to clearly define the place of surgery in the treatment of cT3 PCa.
763
764
OUTCOME FOR CLINICAL UNILATERAL T3A PROSTATE CANCER: A SINGLE-INSTITUTION EXPERIENCE
PROGNOSTIC FACTORS FOR PATIENTS WITH LOCALLY ADVANCED PROSTATIC CANCER WHO UNDERWENT RADICAL PROSTATECTOMY
Hsu C.Y.1, Joniau S.1, Oyen R.2, Roskams T.3, Van Poppel H.1 1
University Hospital Leuven, Urology, Leuven, Belgium, 2University Hospital Leuven, Radiology, Leuven, Belgium, 3University Hospital Leuven, Histopathology, Leuven, Belgium
INTRODUCTION & OBJECTIVES: An estimated 12-25% of prostate cancers are clinical stage T3 (cT3). The management of cT3 disease is still mater of debate. The purpose of this study is to present 10-year outcomes of radical prostatectomy (RP) in unilateral cT3a prostate cancer. MATERIAL & METHODS: Between 1987 and 2004, two hundred patients with unilateral cT3a prostate cancer underwent RP and bilateral pelvic lymphadenectomy. Mean followup was 70.6 months (range 7 to 177). The mean serum PSA was 14.88 ng/ml (range 1.0 to 127.0). Median surgical Gleason score was 7(range 4 to 9). The pathological stages were recorded according to the 2002 TNM classification. Kaplan-Meier survival analysis was used to calculate the overall survival (OS), cancer specific survival (CSS), biochemical progression free survival (BPFS) and clinical progression free survival (CPFS) rate. Multivariate Cox proportional hazard analysis was used to determine independent prognostic indicators of cancer progression. RESULTS: Forty-seven patients (23.5%) were confirmed with organ confined disease (pT2); 145 (72.5%) were pT3 including 113 (56.5%) with extraprostatic extension only (pT3a) and 32 (16%) with seminal vesicle invasion (pT3b); 8 (4%) had adjacent structure invasion (pT4). Seventeen patients (8.5%) had lymph node involvement. Sixty-seven patients (33.5%) were found with positive surgical margin. One hundred and twelve (56%) patients received adjuvant or salvage therapy. The OS, CSS, BPFS and CPFS at 5 and 10 years were: 5 years
10 years
Overall survival
95.9%
77.0%
Cancer specific survival
98.7%
91.6%
Biochemical progression free survival
59.5%
51.1%
Clinical progression free survival
95.9%
85.4%
Margin status and preoperative PSA were identified as strong independent factors predicting BPFS. Surgical Gleason score and pelvic lymph node status were not withheld as independent factors in predicting CCS, BPFS and CPFS. Pathological stage was a significant independent predictor in CSS. There were no significant difference between pT2 and pT3a-b in CSS, BPFS and CPFS. CONCLUSIONS: RP is a valuable treatment option in unilateral cT3a prostate cancer, yielding very high 10-year overall and cancer specific outcomes. More than half of the patients might need adjuvant or salvage treatment.
Tomita K., Tsurumaki Y., Kume H., Takahashi S., Takeuchi T., Kitamura T. Faculty of Medicine, University of Tokyo, Urology, Tokyo, Japan INTRODUCTION & OBJECTIVES: Locally advanced prostatic cancer (clinical stage C) is not commonly curable by radical prostatectomy. On the other hand, approximately 20% patients with clinical stage C prostatic cancer who underwent radical prostatectomy diagnosed as pathological localised cancer (pT2) practically. Several urologists occasionally recommend the patients with clinical stage C prostatic cancer to receive radical prostatectomy with hormone therapy. We estimate the correlation between clinicopathological factors and prognosis in patients with clinical stage C prostatic cancer who underwent radical prostatectomy. MATERIAL & METHODS: We evaluated 95 patients with clinical stage C out of 348 patients with prostatic cancer who underwent radical prostatectomy between 1984 and 2004. The mean age at operation was 66.7 years (ranged from 52 to 77). Total follow-up ranged from 5to 148 months (mean 51.4 months). We estimate the correlation between clinicopathological factors and prognosis in the patients on univariate and multivariate analyses. RESULTS: Average of preoperative PSA level was 27.4ng/ml (2.3-154). 22 (23.2%) out of 95 patients was pathologically localised prostatic cancer (pT2). 37 patients (38.9%) received neoadjuvant androgen deprivationtherapy and 71 (74.7%) received adjuvant androgen deprivationtherapy. 10 years cause specific survival rate was 83.2% in the all patients.éThe ratio of 10-years survival rate for each variable and p value on univariate analysis were as follows: PSA level (<10: 71.3%, 10-20:85.7%, >20: 85.9%, p=0.006), pT stage (pT2: 100%, pT3: 78.1%, p=0.103), lymph node metastasis (negative: 79.4%, positive: 90.0%, p=0.603), Gleason score (4-6: 100%, 7: 81.7%, >7: 79.6%, p=0.193), seminal vesicle invasion (negative: 83.3%, positive: 79.5%, p=0.216), lymph or vessel invasion (negative: 84.1%, positive: 81.4%, p=0.258) and surgical margin (negative: 100%, positive: 78.6%, p=0.100). The proportional hazard regression model revealed pT stage and seminal vesicle invasion as the significant prognostic factors for patients with stage C prostate cancer who underwent radical prostatectomy (p=0.007, p=0.049). CONCLUSIONS: Our data revealed preoperative low PSA level was a worse prognostic factor compared to high PSA level, and pathological T stage and seminal vesicle invasion are good prognostic factors for patients with stage C prostate cancer who underwent radical prostatectomy.
Eur Urol Suppl 2006;5(2):213
762
TREATMENT OF CLINICAL STAGE T3 PROSTATE CANCER: A SURGICAL DISEASE?
NEOADJUVANT CHEMOHORMONAL THERAPY IN POOR-PROGNOSIS LOCALISED PROSTATE CANCER Zisman A.1, Yarom N.2, Stav K.2, Leibovici D.2, Lindner A.2, Sella A.3 1 Assaf Harofeh MC, Urology, Ness Ziona, Israel, 2Assaf Harofeh MC, Urology, Zeriffin, Israel, 3Assaf Harofeh MC, Pathology, Zeriffin, Israel INTRODUCTION & OBJECTIVES: We designed a trial of neoadjuvant chemohormonal therapy followed with radical prostatectomy (RPX) for patients with poor prognosis localised CAP (PSA > 20 ng/ml, Gleason score > 8 and clinical stage > T2c) who are not candidates for routine radical surgery. MATERIAL & METHODS: Therapy included 4 cycles of Emcyt 280 mg TID days 1-5 and Docetaxel 70 mg/m2 day 2 Q 21 days combined with androgen blockage and low dose Coumadin. RPX was performed no later than 7 weeks from initiation of 4th cycle. Androgen suppression was maintained for node positive patients. RESULTS: Since 4/2002 we recruited 13 patients. Patients’ characteristics included (median values): age 61 (54-69) years, PSA 13.2 (3.2-50) ng/ml and Gleason score 7 (4-9). Clinical stage: T2b or T2c - 2 (14.2%) patients each, T3a - 6 (42.8%), T3b - 1 (7.1%) patient and T3c – 2 (14.2%) patients. We delivered 42 cycles to 11 patients. Grade 3-4 toxicity per cycles included neutropenia 9 (21/4%), infections 6 (14.2%), metabolic, nausea, vomiting and liver toxicity - 2 episodes each (4.7%). Ten Pt’s underwent surgery at 6.5 (3.8-7.7) weeks from last therapy. Their postoperative characteristics included PSA 0.25 (0.05-0.5) ng/ml. Viable disease was found in all specimens. Median Gleason score was 7. The rate of organ and specimen confined disease was 6 (60%), seminal vesicle disease in 4 (40%) and lymph node involvement in 3 (30%) patients. To date at a median follow-up of 23 months all Pt’s are alive. One patient experienced biochemical progression. Operative time was 210 (135-225) minutes, nadir Hb 9.0 (8.6-9.8) gr/dL, and hospital stay 12 (7-17) days. Analgesia was required for 4 (2-11) days. Wound drainage was removed on POD 6 (4-8) and the catheter was removed on day 12 (10-17). Surgical difficulties encountered were severe adhesions in 4 patients each, difficulty in SV dissection, pelvic haematoma and rectal injury (primary suturing) each in 1 patient. Four patients had wound infection, no cardiovascular or thromboembolic events were noted. All patients but one are fully continent. Although nerve sparing was attempted all patients did not regain potency. CONCLUSIONS: Neoadjuvant chemohormonal approach is feasible in poor prognosis localised prostate cancer. Initial results appear promising.
Joniau S.1, Van Baelen A.1, Hsu C.Y.1, Oyen R.2, Roskams T.3, Van Poppel H.1 1 University Hospital Leuven, Urology, Leuven, Belgium, 2University Hospital Leuven, Uro-radiology, Leuven, Belgium, 3University Hospital Leuven, Histopathology, Leuven, Belgium
INTRODUCTION & OBJECTIVES: The value of surgery as monotherapy in clinical stage T3 prostate cancer (cT3 PCa) is still subject to debate. The aim of this study was to examine the technical feasibility of radical prostatectomy for cT3 PCa. MATERIAL & METHODS: We reviewed the records of 139 patients who underwent a radical retropubic prostatectomy (RRP) with pelvic lymphadenectomy for cT3 PCa from January 1997 to December 2003. The files were critically reviewed and all data related to surgical and peri-operative complications were collected. Additionally, continence and erectile function were assessed at 12 months postoperatively. Data were compared to series of RRP in patients with clinically localised disease. RESULTS: There was no peri-operative mortality. No ureteral or large vessel injury occurred. Rectal injury and injury of the obturator nerve occurred both in 0.7% of cases. No serious in-hospital complications were noted and no reintervention was needed. Lymphorrhea was noted in 2.2% of patients and 1.4% experienced prolonged drainage of urine. In 7.2%, wound related problems occurred. Anastomotic stricture occurred in 2.9%. At 12 months, complete continence was 87.8%. Erectile function fully recovered in 6% of patients who underwent a non-nerve-sparing procedure and in 10% of patients who underwent a unilateral nerve-sparing procedure. Positive surgical margin rate was only 13.7%. CONCLUSIONS: In cT3 PCa, RRP is technically feasible with morbidity comparable to RRP in clinically localised PCa. Prospective randomised trials are needed to clearly define the place of surgery in the treatment of cT3 PCa.
763
764
OUTCOME FOR CLINICAL UNILATERAL T3A PROSTATE CANCER: A SINGLE-INSTITUTION EXPERIENCE
PROGNOSTIC FACTORS FOR PATIENTS WITH LOCALLY ADVANCED PROSTATIC CANCER WHO UNDERWENT RADICAL PROSTATECTOMY
Hsu C.Y.1, Joniau S.1, Oyen R.2, Roskams T.3, Van Poppel H.1 1
University Hospital Leuven, Urology, Leuven, Belgium, 2University Hospital Leuven, Radiology, Leuven, Belgium, 3University Hospital Leuven, Histopathology, Leuven, Belgium
INTRODUCTION & OBJECTIVES: An estimated 12-25% of prostate cancers are clinical stage T3 (cT3). The management of cT3 disease is still mater of debate. The purpose of this study is to present 10-year outcomes of radical prostatectomy (RP) in unilateral cT3a prostate cancer. MATERIAL & METHODS: Between 1987 and 2004, two hundred patients with unilateral cT3a prostate cancer underwent RP and bilateral pelvic lymphadenectomy. Mean followup was 70.6 months (range 7 to 177). The mean serum PSA was 14.88 ng/ml (range 1.0 to 127.0). Median surgical Gleason score was 7(range 4 to 9). The pathological stages were recorded according to the 2002 TNM classification. Kaplan-Meier survival analysis was used to calculate the overall survival (OS), cancer specific survival (CSS), biochemical progression free survival (BPFS) and clinical progression free survival (CPFS) rate. Multivariate Cox proportional hazard analysis was used to determine independent prognostic indicators of cancer progression. RESULTS: Forty-seven patients (23.5%) were confirmed with organ confined disease (pT2); 145 (72.5%) were pT3 including 113 (56.5%) with extraprostatic extension only (pT3a) and 32 (16%) with seminal vesicle invasion (pT3b); 8 (4%) had adjacent structure invasion (pT4). Seventeen patients (8.5%) had lymph node involvement. Sixty-seven patients (33.5%) were found with positive surgical margin. One hundred and twelve (56%) patients received adjuvant or salvage therapy. The OS, CSS, BPFS and CPFS at 5 and 10 years were: 5 years
10 years
Overall survival
95.9%
77.0%
Cancer specific survival
98.7%
91.6%
Biochemical progression free survival
59.5%
51.1%
Clinical progression free survival
95.9%
85.4%
Margin status and preoperative PSA were identified as strong independent factors predicting BPFS. Surgical Gleason score and pelvic lymph node status were not withheld as independent factors in predicting CCS, BPFS and CPFS. Pathological stage was a significant independent predictor in CSS. There were no significant difference between pT2 and pT3a-b in CSS, BPFS and CPFS. CONCLUSIONS: RP is a valuable treatment option in unilateral cT3a prostate cancer, yielding very high 10-year overall and cancer specific outcomes. More than half of the patients might need adjuvant or salvage treatment.
Tomita K., Tsurumaki Y., Kume H., Takahashi S., Takeuchi T., Kitamura T. Faculty of Medicine, University of Tokyo, Urology, Tokyo, Japan INTRODUCTION & OBJECTIVES: Locally advanced prostatic cancer (clinical stage C) is not commonly curable by radical prostatectomy. On the other hand, approximately 20% patients with clinical stage C prostatic cancer who underwent radical prostatectomy diagnosed as pathological localised cancer (pT2) practically. Several urologists occasionally recommend the patients with clinical stage C prostatic cancer to receive radical prostatectomy with hormone therapy. We estimate the correlation between clinicopathological factors and prognosis in patients with clinical stage C prostatic cancer who underwent radical prostatectomy. MATERIAL & METHODS: We evaluated 95 patients with clinical stage C out of 348 patients with prostatic cancer who underwent radical prostatectomy between 1984 and 2004. The mean age at operation was 66.7 years (ranged from 52 to 77). Total follow-up ranged from 5to 148 months (mean 51.4 months). We estimate the correlation between clinicopathological factors and prognosis in the patients on univariate and multivariate analyses. RESULTS: Average of preoperative PSA level was 27.4ng/ml (2.3-154). 22 (23.2%) out of 95 patients was pathologically localised prostatic cancer (pT2). 37 patients (38.9%) received neoadjuvant androgen deprivationtherapy and 71 (74.7%) received adjuvant androgen deprivationtherapy. 10 years cause specific survival rate was 83.2% in the all patients.éThe ratio of 10-years survival rate for each variable and p value on univariate analysis were as follows: PSA level (<10: 71.3%, 10-20:85.7%, >20: 85.9%, p=0.006), pT stage (pT2: 100%, pT3: 78.1%, p=0.103), lymph node metastasis (negative: 79.4%, positive: 90.0%, p=0.603), Gleason score (4-6: 100%, 7: 81.7%, >7: 79.6%, p=0.193), seminal vesicle invasion (negative: 83.3%, positive: 79.5%, p=0.216), lymph or vessel invasion (negative: 84.1%, positive: 81.4%, p=0.258) and surgical margin (negative: 100%, positive: 78.6%, p=0.100). The proportional hazard regression model revealed pT stage and seminal vesicle invasion as the significant prognostic factors for patients with stage C prostate cancer who underwent radical prostatectomy (p=0.007, p=0.049). CONCLUSIONS: Our data revealed preoperative low PSA level was a worse prognostic factor compared to high PSA level, and pathological T stage and seminal vesicle invasion are good prognostic factors for patients with stage C prostate cancer who underwent radical prostatectomy.
Eur Urol Suppl 2006;5(2):213