Long-term survival after radical prostatectomy versus external-beam radiotherapy for patients with high-risk prostate cancer

BACKGROUND:

The long‐term survival of patients with high‐risk prostate cancer was compared after radical prostatectomy (RRP) and after external beam radiation therapy (EBRT) with or without adjuvant androgen‐deprivation therapy (ADT).

METHODS:

In total, 1238 patients underwent RRP, and 609 patients received with EBRT (344 received EBRT plus ADT, and 265 received EBRT alone) between 1988 and 2004 who had a pretreatment prostate‐specific antigen (PSA) level ≥ 20 ng/mL, a biopsy Gleason score between 8 and 10, or clinical tumor classification ≥ T3. The median follow‐up was 10.2 years, 6.0 years, and 7.2 years after RRP, EBRT plus ADT, and EBRT alone, respectively. The impact of treatment modality on systemic progression, cancer‐specific survival, and overall survival was evaluated using multivariate Cox proportional hazard regression analysis and a competing risk‐regression model.

RESULTS:

The 10‐year cancer‐specific survival rate was 92%, 92%, and 88% after RRP, EBRT plus ADT, and EBRT alone, respectively (P = .06). After adjustment for case mix, no significant differences in the risks of systemic progression (hazard ratio [HR], 0.78; 95% confidence interval [CI], 0.51‐1.18; P = .23) or prostate cancer death (HR, 1.14; 95% CI, 0.68‐1.91; P = .61) were observed between patients who received EBRT plus ADT and patients who underwent RRP. The risk of all‐cause mortality, however, was greater after EBRT plus ADT than after RRP (HR, 1.60; 95% CI, 1.25‐2.05; P = .0002).

CONCLUSIONS:

RRP alone and EBRT plus ADT provided similar long‐term cancer control for patients with high‐risk prostate cancer. The authors concluded that continued investigation into the differing impact of treatments on quality‐of‐life and noncancer mortality will be necessary to determine the optimal management approach for these patients. Cancer 2011. © 2011 American Cancer Society.     

A randomized trial comparing radical prostatectomy plus endocrine therapy versus external beam radiotherapy plus endocrine therapy for locally advanced prostate cancer: results at median follow-up of 102 months

BACKGROUND: To investigate the optimal treatment of locally advanced prostate cancer, a prospective randomized trial was conducted to compare radical prostatectomy plus endocrine therapy versus external beam radiotherapy plus endocrine therapy. METHODS: One hundred patients with T2b-3N0M0 prostate cancer were enrolled and 95 were evaluated. Of 95 cases, 46 underwent radical prostatectomy with pelvic lymph node dissection and 49 were treated with external beam radiation by linear accelerator with 40-50 Gy to the whole pelvis and 20-Gy boost to the prostatic area. For all patients, endocrine therapy was initiated 8 weeks before surgery or radiotherapy and continued thereafter. The long-term outcome and morbidity were examined. RESULTS: Median follow-up period was 102 months. At 10 years overall survival rates in the surgery group were better than the radiation group (76.2% versus 71.1% for biochemical progression-free rates; P=0.25, 83.5% versus 66.1% for clinical progression-free rates; P=0.14, 85.7% versus 77.1% for cause-specific survival rates; P=0.06, and 67.9% versus 60.9% for overall survival rates; P=0.30), although none of them reached statistical significance. Erectile dysfunction was recognized in almost all patients as a result of continuous endocrine therapy. Incontinence requiring more than one pad per day was observed more frequently in the surgery group than the radiation group (P<0.01). CONCLUSIONS: For the treatment of patients with locally advanced prostate cancer, when combined with endocrine therapy, either radical prostatectomy or external beam radiotherapy demonstrated favorable long-term outcomes. The radiation dose of 60-70 Gy might not be enough for the local treatment of locally advanced prostate cancer.     

Retropubic versus perineal radical prostatectomy in early prostate cancer: eight-year experience

BACKGROUND: Prostate cancer is the most common malignancy in men and the second leading cause of cancer death. A randomized study was performed on patients with localized prostate cancer and treated with radical prostatectomy using the perineal or the retropubic approach comparing oncological outcomes, cancer control, and functional results. STUDY DESIGN: Between 1997 and 2004, in a randomized study 200 patients underwent a radical prostatectomy performed by retropubic (100 patients) or perineal (100 patients) approach. RESULTS: Differences between hospital stay, duration of catheter drainage, intraoperative blood loss, and transfusion requirements were statistically significant in favor of perineal prostatectomy. Differences between positive surgical margins and urinary continence in the two groups were not statistically significant at 6 and 24 months. Differences between erectile function at 24 months were statistically significant in favor of retropubic prostatectomy. CONCLUSIONS: Radical perineal prostatectomy is an excellent alternative approach for radical surgery in the treatment of early prostate cancer.     

Association between the polygenic liabilities for prostate cancer and breast cancer with biochemical recurrence after radical prostatectomy for localized prostate cancer

Prostate and breast cancers are hormone-related malignancies and are characterized by a complex interplay of hundreds of susceptibility loci throughout the genome. Prostate cancer could be inhibited by eliminating androgens through castration or estrogen administration, thus facilitating long-term treatment of prostate cancer; however, the role of estrogen in prostate cancer remains unclear. This study aimed to determine whether polygenic risk scores (PRSs) comprising combinations of genome-wide susceptibility variants influence the clinical outcomes of prostate cancer patients. The study subjects were recruited from four medical centers in Taiwan, and genome-wide genotyping data were obtained from 643 prostate cancer patients. We derived the PRS for prostate cancer (PRS-PC) and for breast cancer (PRS-BC) for each patient. The association between the PRS-PC/PRS-BC at the age of prostate cancer onset and recurrence within seven years was evaluated using a regression model adjusted for population stratification components. A higher PRS-PC was associated with an earlier onset age for prostate cancer (beta in per SD increase in PRS = -0.89, P = 0.0008). In contrast, a higher PRS-BC was associated with an older onset age for prostate cancer (beta = 0.59, P = 0.02). PRS-PC was not associated with the risk of recurrence (hazard ratio = 1.03, P = 0.67), whereas a higher PRS-BC was associated with a low recurrence risk (hazard ratio = 0.86, P = 0.03). These results indicate that the genetic predisposition to breast cancer is associated with a low risk of prostate cancer recurrence. Further studies are warranted to explore the role of breast cancer susceptibility variants and estrogen signaling in prostate cancer progression.     

Undetectable ultrasensitive PSA after radical prostatectomy for prostate cancer predicts relapse-free survival

Radical retropubic prostatectomy is considered by many centres to be the treatment of choice for men aged less than 70 years with localized prostate cancer. A rise in serum prostate-specific antigen after radical prostatectomy occurs in 10-40% of cases. This study evaluates the usefulness of novel ultrasensitive PSA assays in the early detection of biochemical relapse. 200 patients of mean age 61. 2 years underwent radical retropubic prostatectomy. Levels < or = 0.01 ng ml-1 were considered undetectable. Mean pre-operative prostate-specific antigen was 13.3 ng ml-1. Biochemical relapse was defined as 3 consecutive rises. The 2-year biochemical disease-free survival for the 134 patients with evaluable prostate-specific antigen nadir data was 61.1% (95% CI: 51.6-70.6%). Only 2 patients with an undetectable prostate-specific antigen after radical retropubic prostatectomy biochemically relapsed (3%), compared to 47 relapses out of 61 patients (75%) who did not reach this level. Cox multivariate analysis confirms prostate-specific antigen nadir < or = 0.01 ng ml-1 to be a superb independent variable predicting a favourable biochemical disease-free survival (P < 0.0001). Early diagnosis of biochemical relapse is feasible with sensitive prostate-specific antigen assays. These assays more accurately measure the prostate-specific antigen nadir, which is an excellent predictor of biochemical disease-free survival. Thus, sensitive prostate-specific antigen assays offer accurate prognostic information and expedite decision-making regarding the use of salvage prostate-bed radiotherapy or hormone therapy.     

Open radical retropubic prostatectomy 2007: the true minimally invasive surgery for localized prostate cancer?

The introduction of robotic laparoscopic assisted prostatectomy at our institution and nationwide has been a great advancement and has caused us to focus and fine-tune our goal for improvements in prostate cancer outcomes whether the patient elects for robotic laparoscopic assisted prostatectomy or open minimally invasive radical retropubic prostatectomy. While these authors favor the open technique performed by highly skilled urologic surgical oncologists, the lessons we have learned to date suggest that it is the skill of the surgeon that determines outcome, regardless of whether or not the operation is performed by an open or robotic laparoscopic technique. The concepts we have articulated here are related to resection and avoidance of positive margins, limited intraoperative blood loss and pain control, which allow equivalence in these outcome areas, regardless of technique.     

pT0 prostate cancer after radical prostatectomy

The purpose of our study was to perform a literature review of current data to determine the frequency and correlates of pT0 prostate cancer after radical prostatectomy alone. A comprehensive search was made of MEDLINE and PUBMED. Seven studies were identified involving 18,135 patients with 74 reported pT0 cases. The most frequent correlates from our pooled data of patients with pT0 specimens include preoperative PSA <10 ng/ml, only one positive core biopsy, and Gleason score <7. J. Surg. Oncol. 2010;102:331–333. © 2010 Wiley‐Liss, Inc.     

Prostate cancer-specific mortality after radical prostatectomy or external beam radiation therapy in men with 1 or more high-risk factors

BACKGROUND: Estimates of prostate cancer-specific mortality (PCSM) were determined after radical prostatectomy (RP) or radiation therapy (RT) in men with >or=1 high-risk factors. METHODS: The study cohort comprised 948 men who underwent RP (N = 660) or RT (N = 288) for localized prostate cancer between 1988 and 2004 and had at least 1 of the following high-risk factors: a prostate-specific antigen (PSA) velocity >2 ng/mL/year during the year before diagnosis, a biopsy Gleason score of >or=7, a PSA level of >or=10 ng/mL, or clinical category T2b or high disease. Grays regression was used to evaluate whether the number and type of high-risk factors were associated with time to PCSM. RESULTS: Multiple determinants of high risk were found to be significantly associated with a shorter time to PCSM after RP (P < .001) or RT (P 2 ng/mL/year was associated with an increased risk of PCSM after RP (hazards ratio [HR] of 7.3; 95% confidence interval [95% CI], 1.0-59 [P = .05]) or RT (HR of 12.1; 95% CI, 1.4-105 [P = .02]) when compared with men with any other single high-risk factor. CONCLUSIONS: Men with a PSA velocity >2 ng/mL/year had a significantly higher risk of PCSM compared with men who had any other single high-risk factor. These men should be considered for randomized trials evaluating the impact on PCSM from adding systemic agents to standards of care for men with high-risk PC.     

机器人辅助前列腺癌根治术治疗大体积前列腺癌的临床应用研究

目的:评估大体积前列腺癌行机器人辅助前列腺癌根治术（RALP）的疗效和安全性,探讨前列腺体积对手术难度的影响。方法:回顾性分析2013年1月至 2017年3月应用机器人辅助前列腺癌根治术治疗大体积前列腺癌35例患者临床资料（前列腺体积≥100 ml）,tPSA水平为6.5~58.5 ng/ml,平均（19.5±8.7） ng/ml,Gleason评分≤6分4例,7分19例（3+4分8例,4+3分11例）,8分7例,9~10分5例。3例有经尿道前列腺电切手术史,5例术前行新辅助内分泌治疗。手术方式均采用经腹膜内入路机器人辅助腹腔镜前列腺癌根治术,高危患者同时行扩大盆腔淋巴结清扫并术后辅助内分泌治疗12~18个月。结果:35例患者均顺利完成手术,无中转开放、直肠损伤及输血病例。手术时间为86~191 min,平均（154±19.8） min;术中出血量45~330 ml,平均（132±60.5） ml;住院时间5~9 d,平均（6.5±0.8） d。术后病理切缘阳性3例（8.6%）;盆腔淋巴结阳性2例（5.7%）。术后漏尿1例,术后2周停止。1例吻合口狭窄,经尿道扩张后排尿通畅。术后1~12个月复查,无生化复发病例,术后3个月有不同程度尿失禁9例（25.7%）,1年内控尿满意33例（94.3%）。结论:大体积前列腺癌手术难度明显增大,需在具备丰富手术经验的前提下完成,采取合理的技术优化可以明显降低手术难度。     

Psychological distress and lifestyle disruption in low-risk prostate cancer patients: Comparison between active surveillance and radical prostatectomy

Objective: To quantify distress in men treated with radical prostatectomy (RP) or active surveillance (AS). Methods: In a retrospective cross-sectional design, we assessed men through questionnaire and investigator-designed questions. Results: RP patients worried more about cancer spread than AS patients. RP patients were influenced by friends for treatment decision, whereas AS patients were influenced by urologists. RP group report declines in intimacy and instrumental. AS men worried more about future health and dying than post-RP men. Conclusion: Fear of disease progression may be a motivating factor in choosing RP. AS patients adhere to their treatment decision in spite of distress.     

Preoperative hypogonadism is not an independent predictor of high-risk disease in patients undergoing radical prostatectomy

BACKGROUND:

A study was undertaken to assess the association between either preoperative serum total testosterone (TT) or hypogonadism (defined as TT <3 ng/mL) with high‐risk prostate cancer (PCa) (defined as patients with pathological extracapsular extension [ECE], seminal vesicle invasion [SVI], or Gleason grades ≥4 + 3 [high‐grade PCa]) at radical prostatectomy (RP).

METHODS:

A cohort of 673 consecutive Caucasian‐European patients who underwent RP at a single institute was used. None of the patients had taken any hormonal neoadjuvant treatment or other hormonal preparations during the previous 12 months. Serum TT was measured the day before surgery (8‐10 AM ) in all cases. Logistic regression models tested the associations among predictors (eg, prostate‐specific antigen, clinical stage, biopsy Gleason sum, body mass index, and TT) and ECE, SVI, and high‐grade PCa.

RESULTS:

Median TT was 4.5 ng/mL (mean, 4.5; range, 0.02‐13.6). Hypogonadism was found in 144 (21.4%) patients, and severe hypogonadism (defined as TT <1 ng/mL) was observed in 37 (5.5%) men. Extracapsular extension, SVI, and high‐grade PCa were found in 96 (14.6%), 88 (13.1%), and 153 (22.7%) patients, respectively. Patients with high‐risk PCa had median TT comparable to those with low‐risk disease. At multivariate analysis, TT did not achieve independent predictor status for ECE, SVI, and high‐grade PCa. Only circulating TT <1 ng/mL was an independent predictor of SVI (odds ratio, 3.11; P = .006).

CONCLUSIONS:

In contrast with previous reports, preoperative circulating TT levels were not associated with high‐risk PCa. Likewise, hypogonadism did not achieve independent predictor status for high‐risk PCa. Cancer 2011;. © 2011 American Cancer Society.     

Biochemical recurrence after radical prostatectomy for prevalent versus incident cases of prostate cancer : implications for management

BACKGROUND.

Among screened populations, it is unknown whether men with prostate cancer (PC) diagnosed at the initial screening (prevalent cases) have a different outcome than men who are diagnosed at subsequent screenings (incident cases) after adjusting for known prognostic factors.

METHODS.

The current study cohort was comprised of 1923 men from a prospective PC screening study who underwent radical prostatectomy (RP) between September 19, 1989 and May 22, 2002. Cox regression multivariate analysis was used to determine whether having prevalent PC versus incident PC was associated with the time to prostate‐specific antigen (PSA) failure after RP after adjusting for PSA level, Gleason score, clinical tumor (T) classification, and year of RP.

RESULTS.

Men with prevalent PC had higher PSA levels (P < .001) and more advanced clinical T classification (P < .001) than men with incident PC. After a median follow‐up of 6.1 years, factors that were associated with a significantly shorter time to PSA failure after RP were prevalent PC (adjusted hazard ratio [AHR], 1.8; 95% confidence interval [95% CI], 1.3‐2.6; P = .0005), baseline PSA (AHR, 1.07; 95%CI, 1.04‐1.09; P < .001), Gleason 7 disease (AHR, 2.5; 95% CI, 1.9‐3.3; P < .001), Gleason 8 to 10 disease (AHR, 2.3; 95%CI, 1.5‐3.5; P < .001), and the year of RP (AHR, 0.92; 95%CI, 0.86‐0.97; P = .003). Men with prevalent PC also had worse outcomes after adjusting for their more advanced pathologic features.

CONCLUSIONS.

After adjusting for known prognostic factors, men with prevalent PC had a poorer outcome after RP than men with incident PC. The authors believe that this finding should be taken into consideration when weighing the risk of recurrence and treatment options for men who are diagnosed with PC on their initial screening. Cancer 2008. © 2008 American Cancer Society.     

Circulating estradiol, but not testosterone, is a significant predictor of high-grade prostate cancer in patients undergoing radical prostatectomy

BACKGROUND:

The objective of this study was to assess the association between preoperative circulating levels of 17β‐estradiol (E₂) and high‐grade prostate cancer (HGPCa) (Gleason grade ≥4 + 3) at the time patients underwent radical retropubic prostatectomy (RRP).

METHODS:

Serum total testosterone (tT), sex hormone‐binding globulin (SHBG), and E₂ levels were measured the day before surgery (8‐10 AM ) in a cohort of 655 consecutive Caucasian‐ European patients who underwent RRP at a single institution. Logistic regression models were used to test the association between predictors (including age, body mass index, prostate‐specific antigen [PSA], clinical tumor classification, biopsy Gleason sum, tT, SHBG, and E₂) and HGPCa. Serum E₂ was included in the model as both a continuous variable and a categorized variable (according to the most informative cutoff: 50 pg/mL).

RESULTS:

Pathologic HGPCa was identified in 156 patients (23.8%). Patients with HGPCa had significantly higher PSA, clinical tumor classification, and biopsy Gleason sum than those without HGPCa (all P < .001). No other significant differences were observed between groups. At univariate analysis, continuously coded E₂ was not associated significantly with HGPCa (odds ratio [OR], 1.009; P = .25), whereas patients with E₂ levels ≥50 pg/mL had a 3.24‐fold increased risk of HGPCa (P < .001). At multivariate analysis, E₂ was associated significantly with HGPCa both as a continuous predictor (OR, 1.02; P = .04) and as a categorical predictor (OR, 3.94; P < .001) after accounting for other variables. Conversely, tT and SHBG levels were not associated significantly with HGPCa.

CONCLUSIONS:

E₂ was associated significantly with pathologic HGPCa, whereas SHBG and tT failed to demonstrate any association with HGPCa in patients who underwent RRP. Cancer 2011;. © 2011 American Cancer Society.     

Analysis of pathologic extent of disease for clinically localized prostate cancer after radical prostatectomy and subsequent use of adjuvant radiation in a national cohort

BACKGROUND:

The Surveillance, Epidemiology, and End Results database was analyzed to explore the pathologic extent of disease for clinically localized prostate cancer after radical prostatectomy as well as the use of adjuvant radiation in this population.

METHODS:

Identified were patients from 2004 to 2006 with clinically staged T1c‐2cNx‐0M0 prostate adenocarcinoma who underwent radical prostatectomy. All patients had complete clinical and pathologic data. The use of postoperative radiation was recorded. Logistic regression analysis was performed to identify unadjusted and adjusted predictors for extraprostatic disease or positive surgical margins and for adjuvant radiation use.

RESULTS:

A total of 35,642 patients were identified. For those patients with Gleason 7 (4 + 3) and a prostate‐specific antigen (PSA) level of ≥10.1 ng/mL or Gleason 8 to 10 with any PSA level, the rate of organ‐confined disease with negative surgical margins was found to be <50%. Of those with indications for adjuvant radiation, 11.1% received the treatment.

CONCLUSIONS:

This large population‐based study detailed the risk of extraprostatic extension and positive surgical margins in a broad setting across multiple regions and communities, as well as the use of adjuvant radiation for these patients. As of 2006, 11.1% of patients who had indications for adjuvant radiation received this treatment, providing a useful baseline for future patterns of care studies. Cancer 2010. © 2010 American Cancer Society.