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Treatment Options for Patients With Stage D1 (T0-3,N1-2,MO) Adenocarcinoma of Prostate
ONCOLOGY AND CHEMOTHERAPY
Radical Prostatectomy for Stage Dl Prostate Can.cer: Prognostic Variables and Results of Treatment M. GOLIMBU, J. PROVET, 8. AL-ASKARI AND P. MORALES, Department of Urology, New York University School of Medicine, New York, New York Urology, 30: 427-435 (Nov.) 1987 Surgical extirpation of the primary tumor together with the involved regional nodes has been considered ineffective treatment for locally disseminated prostatic carcinoma. We retrospectively reviewed our experience with 42 patients with Stage disease who underwent radical prostatectomy and bilateral pelvic lymphadenectomy and who had a follow-up of one to thirteen years (mean 5 years). The following variables affecting survival and tumor progression were analyzed: (1) tumor grade and local extent; (2) number of positive lymph nodes, and (3) therapy. The overall five- and ten-year survival was 79.5 per cent and 28 per cent compared with the expected survival of an age-matched control group of 88 per cent and 68 per cent, respectively. The degree of tumor differentiation had no effect on prognosis, but local tumor bulk and the number of involved lymph nodes significantly changed the disease progression and survival rate. Patients with low local tumor bulk and one positive node survived as long as the age-matched male population group. Our data suggest that radical prostatectomy may represent a valuable treatment in selected patients with Dl prostate carcinoma. Authors' abstract 6 figures, 2 tables, 30 references
DI
Editorial comment. This is a well balanced, honest and valuable assessment of the long-term experience at New York University using radical prostatectomy in patients with stage prostatic cancer. The over-all 5 and 10-year survival rates were far lower than the expected survival for an age-matched control population of men. Although tumor differentiation was not helpful to predict prognosis local tumor bulk, invasion of the seminal vesicles and the number of involved lymph nodes correlated well with long-term survival. Indeed, patients with low tumor bulk and only 1 positive node survived as long as an age-matched male population. Adjuvant hormonal or radiation did not influence survival. This study deserves close evaluation and the results may be helpful to select the favorable subset of patients who may benefit most from radical prostatectomy. For some time I have been performing radical prostatectomy in patients with microscopic involvement of 1 pelvic lymph node. To date in my hands the morbidity of the procedure has been low and patients have been pleased to have the ,w·,=, tumor eliminated. Long-term evaluation will be necessary to confirm the wisdom of this plan based upon the interval of survival free of symptoms and freedom from local recurrence. 0 ~"
Patrick C. Walsh, M.D. Baltimore, Maryland
Treatment Options for Patients With Stage D 1 (T03 ,N 1-2 ,MO) Adenocarcinoma of Prostate
H. ZINCKE, D. C. UTZ, P. M. THULE AND W. F. TAYLOR, Department of Urology and the Section of Medical Research Statistics, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
1381
Urology, 30: 307-315 (Oct.) 1987 Three hundred six patients with adenocarcinoma of the prostate underwent pelvic lymphadenectomy and had Stage D, (T0-3,Nl-2,MO) disease; 171 patients underwent radical retropubic prostatectomy with or without immediate adjuvant therapy (hormonal or radiation or both) or conservative (hormonal or radiation or both) treatment alone (n = 135). Follow-up was one-half to eighteen and one-half years (mean, 5 yrs). Immediate adjuvant orchiectomy significantly (P = 0.01) impwved survival (87.4% at 10 years) and nonprogression rates for patients who underwent radical prostatectomy, but not for those who had lymphadenectomy. Overall patient survival was significantly better (P = 0.005) after prostatectomy than lymphadenectomy. Residual disease (n = 43) in patients who underwent prostatectomy and received adjuvant treatment (orchiectomy or radiation or both) did not affect disease outcome. Bilateral pelvic lymphadenectomy and radical prostatectomy with immediate adjuvant orchiectomy provided survival comparable to the expected survival; conservative treatment alone was associated with rapid disease progression and poor survival and significantly (P = 0.02) higher local morbidity. Authors'
abstract 7 figures, 2 tables, 10 references
Editorial comment. These authors from the Mayo Clinic claim that the survival (87 per cent at 10 years) of men with stage Dl disease who are treated with radical prostatectomy and immediate orchiectomy is the same as the expected survival of an age-matched control group of patients. Why are these results superior to the findings of Golimbu and associates from New York University (Urology, 30: 427, 1987)? One must assume that the selection of candidates has some role. The Mayo Clinic study is not randomized but rather treatment reflects the prejudice of the individual caring for the patient. Thus, it is difficult to make comparisons between patients who underwent lymphadenectomy alone (possibly because they had higher bulk tumor) and those in whom radical prostatectomy was performed. It also is difficult to compare the Mayo Clinic patients who underwent radical prostatectomy to those from New York University because bulk of tumor and seminal vesicle involvement were not mentioned. In the Mayo Clinic study 45 per cent of the patients who underwent radical prostatectomy had only 1 positive node compared to 33 per cent of those treated at New York University. This is an indication that the selection of patients at the Mayo Clinic was better. Most importantly, in the Mayo Clinic series there was no significant difference in the survival of patients who underwent radical prostatectomy with immediate orchiectomy from the survival of patients who underwent radical prostatectomy with orchiectomy delayed until the occurrence of symptoms. This important information is buried in the article and does not receive sufficient comment. Hormonal therapy does not cure the patients, it only affects the hormone-sensitive cell population. Patients with advanced prostatic cancer ultimately die of the androgeninsensitive cell population that is not influenced by hormonal therapy. Thus, there is no reason why adjuvant hormonal therapy should improve survival. This agrees with the findings from New York University. One must assume then that the excellent results from the Mayo Clinic reflect their ability to select the best patients for treatment. Again, if the criteria established at New York University are applied it may be possible for all of us to identify this favorable subset of patients. Patrick C. Walsh, M.D. Baltimore, Maryland
Radical Prostatectomy for Stage Dl Prostate Can.cer: Prognostic Variables and Results of Treatment M. GOLIMBU, J. PROVET, 8. AL-ASKARI AND P. MORALES, Department of Urology, New York University School of Medicine, New York, New York Urology, 30: 427-435 (Nov.) 1987 Surgical extirpation of the primary tumor together with the involved regional nodes has been considered ineffective treatment for locally disseminated prostatic carcinoma. We retrospectively reviewed our experience with 42 patients with Stage disease who underwent radical prostatectomy and bilateral pelvic lymphadenectomy and who had a follow-up of one to thirteen years (mean 5 years). The following variables affecting survival and tumor progression were analyzed: (1) tumor grade and local extent; (2) number of positive lymph nodes, and (3) therapy. The overall five- and ten-year survival was 79.5 per cent and 28 per cent compared with the expected survival of an age-matched control group of 88 per cent and 68 per cent, respectively. The degree of tumor differentiation had no effect on prognosis, but local tumor bulk and the number of involved lymph nodes significantly changed the disease progression and survival rate. Patients with low local tumor bulk and one positive node survived as long as the age-matched male population group. Our data suggest that radical prostatectomy may represent a valuable treatment in selected patients with Dl prostate carcinoma. Authors' abstract 6 figures, 2 tables, 30 references
DI
Editorial comment. This is a well balanced, honest and valuable assessment of the long-term experience at New York University using radical prostatectomy in patients with stage prostatic cancer. The over-all 5 and 10-year survival rates were far lower than the expected survival for an age-matched control population of men. Although tumor differentiation was not helpful to predict prognosis local tumor bulk, invasion of the seminal vesicles and the number of involved lymph nodes correlated well with long-term survival. Indeed, patients with low tumor bulk and only 1 positive node survived as long as an age-matched male population. Adjuvant hormonal or radiation did not influence survival. This study deserves close evaluation and the results may be helpful to select the favorable subset of patients who may benefit most from radical prostatectomy. For some time I have been performing radical prostatectomy in patients with microscopic involvement of 1 pelvic lymph node. To date in my hands the morbidity of the procedure has been low and patients have been pleased to have the ,w·,=, tumor eliminated. Long-term evaluation will be necessary to confirm the wisdom of this plan based upon the interval of survival free of symptoms and freedom from local recurrence. 0 ~"
Patrick C. Walsh, M.D. Baltimore, Maryland
Treatment Options for Patients With Stage D 1 (T03 ,N 1-2 ,MO) Adenocarcinoma of Prostate
H. ZINCKE, D. C. UTZ, P. M. THULE AND W. F. TAYLOR, Department of Urology and the Section of Medical Research Statistics, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
1381
Urology, 30: 307-315 (Oct.) 1987 Three hundred six patients with adenocarcinoma of the prostate underwent pelvic lymphadenectomy and had Stage D, (T0-3,Nl-2,MO) disease; 171 patients underwent radical retropubic prostatectomy with or without immediate adjuvant therapy (hormonal or radiation or both) or conservative (hormonal or radiation or both) treatment alone (n = 135). Follow-up was one-half to eighteen and one-half years (mean, 5 yrs). Immediate adjuvant orchiectomy significantly (P = 0.01) impwved survival (87.4% at 10 years) and nonprogression rates for patients who underwent radical prostatectomy, but not for those who had lymphadenectomy. Overall patient survival was significantly better (P = 0.005) after prostatectomy than lymphadenectomy. Residual disease (n = 43) in patients who underwent prostatectomy and received adjuvant treatment (orchiectomy or radiation or both) did not affect disease outcome. Bilateral pelvic lymphadenectomy and radical prostatectomy with immediate adjuvant orchiectomy provided survival comparable to the expected survival; conservative treatment alone was associated with rapid disease progression and poor survival and significantly (P = 0.02) higher local morbidity. Authors'
abstract 7 figures, 2 tables, 10 references
Editorial comment. These authors from the Mayo Clinic claim that the survival (87 per cent at 10 years) of men with stage Dl disease who are treated with radical prostatectomy and immediate orchiectomy is the same as the expected survival of an age-matched control group of patients. Why are these results superior to the findings of Golimbu and associates from New York University (Urology, 30: 427, 1987)? One must assume that the selection of candidates has some role. The Mayo Clinic study is not randomized but rather treatment reflects the prejudice of the individual caring for the patient. Thus, it is difficult to make comparisons between patients who underwent lymphadenectomy alone (possibly because they had higher bulk tumor) and those in whom radical prostatectomy was performed. It also is difficult to compare the Mayo Clinic patients who underwent radical prostatectomy to those from New York University because bulk of tumor and seminal vesicle involvement were not mentioned. In the Mayo Clinic study 45 per cent of the patients who underwent radical prostatectomy had only 1 positive node compared to 33 per cent of those treated at New York University. This is an indication that the selection of patients at the Mayo Clinic was better. Most importantly, in the Mayo Clinic series there was no significant difference in the survival of patients who underwent radical prostatectomy with immediate orchiectomy from the survival of patients who underwent radical prostatectomy with orchiectomy delayed until the occurrence of symptoms. This important information is buried in the article and does not receive sufficient comment. Hormonal therapy does not cure the patients, it only affects the hormone-sensitive cell population. Patients with advanced prostatic cancer ultimately die of the androgeninsensitive cell population that is not influenced by hormonal therapy. Thus, there is no reason why adjuvant hormonal therapy should improve survival. This agrees with the findings from New York University. One must assume then that the excellent results from the Mayo Clinic reflect their ability to select the best patients for treatment. Again, if the criteria established at New York University are applied it may be possible for all of us to identify this favorable subset of patients. Patrick C. Walsh, M.D. Baltimore, Maryland