Research Article: Radical Prostatectomy: An Option for High-Risk Prostate Cancer

Date Published: October 11, 2012

Publisher: Hindawi Publishing Corporation

Author(s): S. Rausch, C. Schmitt, T. Kälble.


Introduction. High-risk prostate cancer represents a therapeutic challenge. The role of radical prostatectomy (RP) in patients with extreme PSA values is under discussion. Material and Methods. We retrospectively analysed our data of 56 consecutive patients with preoperative PSA ≥ 40 mg/mL undergoing open radical retropubic prostatectomy from 1999 to 2009. Patient survival and time to PSA recurrence were recorded, and the Kaplan-Meier survival analysis was performed. Postoperative quality of life and functional status were investigated using a SF-12 questionnaire and determining the number of pads used per day. Results. Overall 56 patients were available for followup after a median time of 83.84 months. Locally advanced carcinoma was present in 84% while 16% of patients had organ-confined stages. A positive nodal status was observed in 46%. Overall survival was 95% at five and
81% at 10 years. Cancer-specific survival was 100% for five years and 83% for 10 years. Corresponding biochemical recurrence-free survival was low (52% and 11%,
resp.). Quality of life and functional outcomes were favourable. Conclusions. In patients with PSA ≥ 40 mg/mL, RP allows long-term control, exact planning of adjuvant treatment, and identification of curable disease.

Partial Text

Prostate cancer is an important medical issue with a high complexity regarding stage classification and risk-adapted multidisciplinary treatment. As the consensus towards the therapy of localised prostate cancer is broad, radical prostatectomy (RP) is an established surgical approach based on reliable clinical data. High-risk prostate cancer is defined as PSA > 20 ng/mL, Gleason 8–10 or clinical stage ≥ T2c. RP is also considered as first-line treatment for higher-risk strata whereas the scientific evidence for patient outcomes, especially those with elevated PSA values greater than 50 ng/mL, is comparably low [1]. Based on our own single centre experience and the implementation of available published data, our investigation targets this relevant clinical topic.

We retrospectively analysed our data of 56 consecutive patients with an elevated PSA ≥ 40 ng/mL who underwent radical retropubic prostatectomy with iliac lymphadenectomy from 1999 to 2009 with followup to October 2010. The template of LAD consisted in external, internal iliac, and obturatorial lymph nodes. A nerve-sparing procedure was not conducted. We examined patient survival, time to PSA recurrence, and cancer-related survival. Complete followup was available for 54/56 patients (96%). A Kaplan-Meier analysis was performed to analyse overall (OS) and cancer-specific survival (CSS) and time to biochemical recurrence (BCR), which was defined as postoperative PSA ≥ 0.4 ng/mL or PSA rise while receiving androgen deferral treatment. To assess postoperative quality of life, a SF-12 questionnaire was used. For the evaluation of postoperative continence, the number of used pads per day was interrogated using a patient questionnaire.

In our cohort, 56 consecutive patients with a preoperative PSA ≥ 40 ng/mL (median: 54.2 ng/mL) were available for the analysis. Mean age at surgery was 66.81 years. Median followup was 83.3 months (IQR: 37.57 to 109.43). Patient characteristics, the distribution of preoperative staging, biopsy Gleason’s score, and clinical stages are demonstrated in Table 1.

In the PSA era, the proportion of men treated with RP for high-risk prostate cancer has decreased while in contrast the number of patients undergoing surgery for low-risk cancer is increasing. Nevertheless, the currently used risk groups remain predictive of patient outcomes [1]. The pretreatment risk stratification for patients diagnosed with high-risk prostate cancer is commonly based on the classification system of D’Amico et al. which includes PSA value (>20 ng/mL), biopsy Gleason’s score (8–10), and clinical T-stage (cT2c or more) [2]. Based on the same data, for radical prostatectomy risk, stratification is available not only for biochemical recurrence but also for disease progression and survival [3]. This observation is crucial as the impact of biochemical recurrence does not automatically influence clinical progression and overall survival. To improve prostate cancer risk assessment, Cooperberg et al. established a scoring system based on the CaPSURE database which allows the prediction of clinically more relevant endpoints such as development of metastases, cancer-specific mortality, and overall survival [4]. In our cohort, we reviewed patients with a PSA threshold of >40 ng/mL in order to assess the outcome of individuals with an elevated risk profile.

Although RP might be inadequate as solitary therapeutic approach for high-risk prostate cancer in a subset of patients, the procedure allows surgical control with good quality of life and satisfying functional outcome. Accurate pathologic information and improved patient selection for individual adjuvant treatment is possible. Even in individuals presenting with elevated PSA ≥ 40 ng/mL, RP offers not only long-term disease control in general but also a curative approach in at least 16% of patients with organ-confined disease.