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Introduction: The aim of this study is to evaluate the use of androgen deprivation therapy (ADT) with post-prostatectomy radiotherapy (PPRT) in a population-based cohort of Australian men.Methods: This is a prospective cohort of men with localised prostate cancer captured in the Prostate Cancer Outcomes Registry Victoria (PCOR-Vic), who received PPRT between January 2010 and December 2015. The primary outcome was ADT use with PPRT. Multivariate logistic regressions were used to identify patient, tumour and institutional factors influencing ADT use.Results: 485 men were included in this study - 115 (24%) had pT2 disease, 231 (48%) pT3a, 134 (28%) pT3b and 5 (1%) pT4. Eighteen (4%) men had ISUP grade 1 disease, 139 (29%) ISUP grade 2, 170 (35%) ISUP grade 3 and 158 (33%) ISUP grade 4/5, while 267 (64%) men had positive surgical margins. Median time from prostatectomy to PPRT was 8.1 months (IQR = 5.3-13.9). Sixty-six (14%) patients had ADT with PPRT. In multivariate analyses, men who had increased age (OR = 1.06; 95% CI = 1.01-1.11), seminal vesicle involvement (OR = 3.81; 95% CI = 1.63-8.91) and underwent treatment in regional centres (OR = 2.17; 95% CI = 1.08-4.33) were more likely to have ADT with PPRT.Conclusion: We reported that 14% of men treated with PPRT received ADT in a population-based cohort of Australian men, which was less than half of the proportion of ADT use with PPRT in the US. It will be of interest to evaluate the uptake of ADT with PPRT in the coming years following recent publications of level 1 evidence confirming overall survival benefits of ADT with PPRT. [ABSTRACT FROM AUTHOR]

Background: Men with locally advanced prostate cancer (LAPCa) or regionally advanced prostate cancer (RAPCa) are at high risk for death from their disease. Clinical guidelines support multimodal approaches, which include radical prostatectomy (RP) followed by radiotherapy (XRT) and XRT plus androgen deprivation therapy (ADT). However, there are limited data comparing these substantially different treatment approaches. Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, this study compared survival outcomes and adverse effects associated with RP plus XRT versus XRT plus ADT in these men.Methods: SEER-Medicare data were queried for men with cT3-T4N0M0 (LAPCa) or cT3-T4N1M0 (RAPCa) prostate cancer. Propensity score methods were used to balance cohort characteristics between the treatment arms. Survival analyses were analyzed with the Kaplan-Meier method and Cox proportional hazards models.Results: From 1992 to 2009, 13,856 men (≥65 years old) were diagnosed with LAPCa or RAPCa: 6.1% received RP plus XRT, and 23.6% received XRT plus ADT. At a median follow-up of 14.6 years, there were 2189 deaths in the cohort, of which 702 were secondary to prostate cancer. Regardless of the tumor stage or the Gleason score, the adjusted 10-year prostate cancer-specific survival and 10-year overall survival favored men who underwent RP plus XRT over men who underwent XRT plus ADT. However, RP plus XRT versus XRT plus ADT was associated with higher rates of erectile dysfunction (28% vs 20%; P = .0212) and urinary incontinence (49% vs 19%; P < .001).Conclusions: Men with LAPCa or RAPCa treated initially with RP plus XRT had a lower risk of prostate cancer-specific death and improved overall survival in comparison with those men treated with XRT plus ADT, but they experienced higher rates of erectile dysfunction and urinary incontinence. [ABSTRACT FROM AUTHOR]

Abstract: Locally advanced prostate cancer is regarded as a very high‐risk disease with a poor prognosis. Although there is no definitive consensus on the definition of locally advanced prostate cancer, radical prostatectomy for locally advanced prostate cancer as a primary treatment or part of a multimodal therapy has been reported. Robot‐assisted radical prostatectomy is currently carried out even in high‐risk prostate cancer because it provides optimal outcomes. However, limited studies have assessed the role of robot‐assisted radical prostatectomy in patients with locally advanced prostate cancer. Herein, we summarize and review the current knowledge in terms of the definition and surgical indications of locally advanced prostate cancer, and the surgical procedure and perisurgical/oncological outcomes of robot‐assisted radical prostatectomy and extended pelvic lymphadenectomy for locally advanced prostate cancer. [ABSTRACT FROM AUTHOR]

Purpose To identify the ability of multiple variables to predict prostate cancer specific mortality ( PCSM) in a whole of population series of all radical prostatectomies ( RP) performed in Victoria, Australia. Materials & Methods A total of 2154 open RPs were performed in Victoria between July 1995 and December 2000. Subjects without follow up data, Gleason grade, pathological stage were excluded as were those who had pT4 disease or received neoadjuvant treatment. 1967 cases (91.3% of total) met the inclusion criteria for this study. Tumour characteristics were collated via a central registry. We used competing hazards regression models to investigate associations. Results At median follow up of 10.3 years pT stage of RP ( P < 0.001) and high Gleason score of the RP specimen ( P < 0.001 for ≥8 [Subhazard ratio ( SHR) 11.19] and 4 + 3 = 7 [ SHR 7.10]) compared with Gleason score 6 disease were strong predictors of progression to PCSM. Gleason score 3 + 4 = 7 was not at this time a significant predictor of PCSM ( P = 0.08, SHR 1.84). Predictors of PCSM, independent of stage and grade, included rural residency ( P = 0.003), primary surgeon contributing less than 40 cases (low-volume) to the VRPR ( P = 0.025) and the involvement of a trainee surgeon in the operation ( P = 0.031). Conclusion The significant prediction of PCSM by pT cancer stage, Gleason score and primary Gleason pattern at RP in this whole of population study suggests a need to avoid understaging/grading in the process of cancer diagnosis and active surveillance protocols. Multi-modality therapy is likely to have a greater impact on PCSM in higher stage and Gleason grade disease. Identification of increased PCSM with rural residency and with involvement of a trainee urologist, and reduction in PCSM with higher surgeon volume all suggest potential for improved PC outcomes to be achieved with changes to surgical training and service delivery. [ABSTRACT FROM AUTHOR]

Objective To describe the survival benefit associated with radical prostatectomy ( RP), as compared with initial observation, in patients with locally advanced prostate cancer ( PCa). Patients and Methods Overall, 1382 patients with locally advanced PCa treated with RP or initial observation between 1995 and 2009 were identified from the Surveillance, Epidemiology and End Results Medicare insurance programme-linked database. Patients were matched using propensity-score methodology, then 10-year cancer-specific mortality ( CSM) rates were estimated and the number needed to treat ( NNT) was calculated. Competing-risks regression analyses tested the relationship between treatment type and CSM. Results Overall, the 10-year CSM rates were 11.8 and 19.3% for patients treated with RP and initial observation, respectively ( P < 0.001). The corresponding 10-year NNT was 13. The 10-year CSM rates for the same treatment groups were 8.9 vs 13.9%, respectively, for Gleason score ≤7, 16.8 vs 27.8%, respectively, for Gleason score 8-10, 10.1 vs 15.8%, respectively, for clinical stage T3a, and 17.0 vs 29.3%, respectively, for T3b/ T4, respectively (all P ≤ 0.04). The corresponding NNTs were 20, 9, 17 and 8, respectively. In multivariable analyses, RP was an independent predictor of more favourable CSM rates in all categories (all P ≤ 0.04). In separate sensitivity analyses, no differences were recorded when patients treated with radiotherapy were compared with those receiving RP ( P = 0.4). Conversely, patients undergoing initial observation had a higher risk of CSM compared with those treated with radiotherapy ( P = 0.03). Conclusions RP leads to a significant survival advantage compared with observation in patients with locally advanced disease. The highest benefit was observed in patients with T3b/ T4 and Gleason score 8-10 disease. [ABSTRACT FROM AUTHOR]

Australian and New Zealand radiation oncologists with an interest in uro-oncology were invited to undertake a pattern of practice survey dealing with issues encountered in the management of high-risk prostate cancer in the post-prostatectomy setting. Responses from practitioners revealed a lack of consensus regarding the optimal timing of radiation therapy, the use of whole pelvic radiation therapy and the use of androgen deprivation therapy. A review of the literature outlining the current body of knowledge and the clinical studies that will inform future practice is presented. [ABSTRACT FROM AUTHOR]

BACKGROUND: The current trial evaluated 2 common therapies for patients with advanced prostate cancer, docetaxel and hormonal ther-apy (HT), in the surgical adjuvant setting. METHODS: TAX-3501 was a randomized, phase 3, adjuvant study post-radical prostatectomy (RP) In high-risk patients with prostate cancer (n = 228) comparing 18 months of HT with (CHT) without docetaxel chemotherapy either Immediately (I) or deferred (D). High-risk disease was defined as a 5-year freedom-from-disease-progression rate of <60% as predicted by a post-RP nomogram. Progression-free survival (PFS), Including prostate-specific antigen disease recurrence, was the primary end-point. The authors also assessed the accuracy of the nomogram and analyzed testosterone recovery in 108 patients treated with HT who had at least 1 posttreatment testosterone value. RESULTS: Between December 2005 and September 2007, 228 patients were randomized between the treatment cohorts. TAX-3501 was terminated prematurely because of enrollment challenges, leaving it underpowered to detect differences in PFS. After a median follow-up of 3.4 years (interquartile range, 2.3-3.8 years), 39 of 228 patients (17%) demon-strated PSA disease progression, and metastatic disease progression occurred in 1 patient. The median time to baseline testosterone recov-ery after the completion of treatment was prolonged at 487 days (95% confidence interval, 457-546 days). The nomogram's predicted versus observed freedom from disease progression was significantly different for the combination D(HT) and D(CHT) group (P<.00001). CONCLUSIONS: TAX-3501 illustrated several difficulties involved in conducting postoperative adjuvant systemic trials In men with high-risk prostate cancer: the lack of consensus regarding patient selection and treatment, the need for long follow-up time, nonvalidated Intermedi-ate endpolnts, evolving standard approaches, and the need for long-term research support. Except for selected patients at very high-risk of disease recurrence and death, surgical adjuvant trials in patients with prostate cancer may not be feasible. [ABSTRACT FROM AUTHOR]

Background To evaluate the impact of adjuvant hormonal therapy after radical prostatectomy on overall survival in high-risk prostate cancer patients, stratified by comorbidity status. Methods We identified 1247 patients who underwent radical prostatectomy from 1988 to 2004 for high-risk prostate cancer, as defined by National Comprehensive Cancer Network classification. Comorbidity status was stratified by Charlson Comorbidity Index as 0, 1 or >2, as well as by the presence or absence of cardiovascular disease. Overall survival was estimated by the Kaplan- Meier method, and compared within each comorbidity category/adjuvant hormonal therapy strata with the log-rank test. Results Median patient age was 65 years, and the median postoperative follow up was 11.2 years. In total, 419 patients (34%) received adjuvant hormonal therapy. The distribution of Charlson Comorbidity Index was 0, 1 and ≥2 in 861 (69%), 244 (20%) and 142 (11%) patients, respectively. The 10-year overall survival for patients who received adjuvant hormonal therapy versus those who did not was 75% versus 82% ( P = 0.54) for patients with Charlson Comorbidity Index = 0, 72% versus 76% ( P = 0.83) with Charlson Comorbidity Index = 1, and 70% versus 68% ( P = 0.33) with Charlson Comorbidity Index ≥2. Meanwhile, 155 (12%) patients had cardiovascular disease, and the 10-year overall survival for patients with cardiovascular disease who received adjuvant hormonal therapy was 72%, compared with 76% without adjuvant hormonal therapy ( P = 0.97). On multivariate analysis, receipt of adjuvant hormonal therapy was not associated with non-prostate cancer mortality ( P = 0.24). Conclusions Adjuvant hormonal therapy after radical prostatectomy for high-risk prostate cancer does not increase non-prostate cancer mortality, even among patients with multiple comorbidities. Additional studies are warranted to determine optimal multimodal treatment approach for high-risk patients. [ABSTRACT FROM AUTHOR]

One consistent finding in the studies regarding treating men with prostate cancer is that men with high-risk disease have the most to gain from treatment with curative intent. Men with high-risk or locally-advanced prostate cancer require treatment to the primary cancer or risk dying prematurely from their disease. Increasingly, combined androgen deprivation therapy + radiation treatment is seen as the standard treatment as a result of prospective studies in this space, and the perceived increased morbidity of radical prostatectomy in the setting of a 'low' cure rate as monotherapy. In the absence of a well-conducted randomized trial, there is no definite evidence that one treatment is superior to the other. The advantages of radical prostatectomy are that it provides excellent local control of the primary tumor without an increase in morbidity, accurately stages the disease to guide further therapy, and removes benign sources of prostate-specific antigen so that failures can be promptly identified and subsequent treatment can be initiated in a timely manner. Although several guidelines recommend radiation treatment over radical prostatectomy as first-line treatment, there is no evidence that surgery is inferior and radical prostatectomy should remain part of any informed discussion regarding treatment options for men with high-risk prostate cancer. [ABSTRACT FROM AUTHOR]

What's known on the subject? and What does the study add? Laparoscopic radical prostatectomy ( LRP) has shown good oncological short-term and mid-term outcomes, but long-term outcomes are still lacking., We present long-term oncological outcomes of LRP in a large cohort of patients operated on in one of the pioneering European centres. The data from the present study show high rates of biochemical and clinical recurrence-free survival and low cancer-specific mortality compared with open series., Objectives To investigate long-term oncological outcomes after laparoscopic radical prostatectomy ( LRP)., To identify parameters influencing recurrence-free survival in a single-institution series., Patients and Methods All patients underwent LRP using the transperitoneal retrograde Heilbronn technique. High-risk patients received adjuvant treatment according to an institutional algorithm based on prostate-specific antigen ( PSA), Gleason score, tumour-node-metastasis stage, margin status and tumour volume., Data were collected prospectively on operative and postoperative parameters beginning in 1999. Complete follow-up data of 370 of the first 500 consecutive patients are available., Biochemical recurrence was defined as two consecutive PSA levels <0.2 ng/mL within the follow-up period., Kaplan- Meier estimates and Cox regression were applied to examine recurrence-free survival times., Results The estimated biochemical recurrence-free survival ( BCRFS) rates 10 years after LRP were 80.2% in patients staged pT2, 47.4% in those staged pT3a and 49.8% in those staged pT3b/4, confirming a better prognosis in patients with organ-confined disease ( P < 0.001)., In the multivariate Cox regression analysis, only Gleason score and pT stage significantly influenced BCRFS., The 10-year clinical progression-free survival rates were 97.2% ( pT2), 84.4% ( pT3a) and 78.1% ( pT3b/4), and prostate cancer-specific survival estimates were 100% ( pT2), 97.3% ( pT3a) and 90.6% ( pT3b/4)., Conclusions The 10-year biochemical and clinical progression-free survival after LRP combined with a risk-adapted concept of adjuvant therapy is high, while prostate-cancer specific mortality is low. Our data shows no negative impact of laparoscopic techniques on oncologic outcomes compared to large series after retropubic radical prostatectomy., In a multivariate Cox regression, only Gleason score and pT stage had significant impact on BCRFS. [ABSTRACT FROM AUTHOR]

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Despite a lack of randomised controlled trials, most men with locally advanced prostate cancer are recommended to undergo external beam radiotherapy (EBRT), often combined with long-term androgen-deprivation therapy (ADT). Many of these men are not offered radical prostatectomy (RP) by their treating urologist. Additionally, it is know that EBRT with long-term ADT does provide good cancer control (88% at 10 years). We have previously published intermediate-term follow-up of a large series of men treatment with RP for cT3 prostate cancer. We report long-term follow-up of a large series of men treated with RP as primary treatment for cT3 prostate cancer. Our study shows that with long-term follow-up RP provides excellent oncological outcomes even at 20 years. While most men do require a multimodal treatment approach, many men can be managed successfully with RP alone. OBJECTIVE To present long-term survival outcomes after radical prostatectomy (RP) for patients with cT3 prostate cancer, as the optimal treatment for patients with clinical T3 prostate cancer is debated., PATIENTS AND METHODS We identified 843 men who underwent RP for cT3 tumours between 1987 and 1997., Survival was estimated using the Kaplan-Meier method., Cox proportional hazards regression models were used to evaluate the association of clinicopathological features with outcome, RESULTS The median (range) postoperative follow-up was 14.3 (0.1-23.5) years., Down-staging to pT2 disease occurred in 26% (223/843) at surgery., Local recurrence-free, systemic progression-free and cancer-specific survival for men with cT3 prostate cancer after RP was 76%, 72%, and 81%, respectively, at 20 years., On multivariate analysis, increasing RP Gleason score (hazard ratio [HR] 1.8; P= 0.01), non-diploid chromatin content (HR 1.8; P= 0.01), positive surgical margins (HR 2.1; P= 0.007), and seminal vesicle invasion (HR 2.1; P= 0.005) were associated with a significant risk of prostate cancer death, while a more recent year of surgery was associated with a decreased risk of cancer-specific mortality (HR 0.88; P= 0.01), CONCLUSIONS RP affords accurate pathological staging and may be associated with durable cancer control for cT3 prostate cancer, with 20 years of follow-up presented here., RP as part of a multimodal treatment strategy therefore remains a viable treatment option for patients with cT3 tumours. [ABSTRACT FROM AUTHOR]

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). [ABSTRACT FROM AUTHOR]

BACKGROUND: Pelvic lymph node dissection (PLND) is an important component of prostate cancer staging and treatment, especially for surgical patients who have high-risk tumor features. It is not clear how the shift from open radical prostatectomy (ORP) to minimally invasive radical prostatectomy (MIRP) has affected the use of PLND. The objectives of this study were to identify predictors of PLND and to assess the impact of surgical technique in a contemporary, population-based cohort. METHODS: In Surveillance, Epidemiology, and End Results (SEER) cancer registry data linked with Medicare claims, the authors identified men who underwent ORP or MIRP for prostate cancer during 2003 to 2007. The impact of surgical approach on PLND was evaluated, and interactions were examined between surgical procedure, prostate-specific antigen (PSA), and Gleason score with the analysis controlled for patient and tumor characteristics. RESULTS: Of 6608 men who underwent ORP or MIRP, 70% (n = 4600) underwent PLND. The use of PLND declined over time both overall and within subgroups defined by procedure type. PLND was 5 times more likely in men who underwent ORP than in men who underwent MIRP when the analysis was controlled for patient and tumor characteristics. Elevated PSA and biopsy Gleason score, but not clinical stage, were associated with a greater odds of PLND in both the ORP group and the MIRP group. However, the magnitude of the association between these factors and PLND was significantly greater for patients in the ORP group. CONCLUSIONS: PLND was less common among men who underwent MIRP, independent of tumor risk factors. A decline in PLND rates was not fully explained by an increase in MIRP. The authors concluded that these trends may signal a surgical approach-dependent disparity in prostate cancer staging and therapy. Cancer 2011;. © 2011 American Cancer Society. [ABSTRACT FROM AUTHOR]

According to the literature, the current preferred treatment for T3 prostate cancer is a combination of radiotherapy and extended hormone therapy. The preoperative staging based on digital rectal examination results alone now appears obsolete from the investigated series, in which 20% of T3 prostate cancer is over-staged during physical examination. Prostatic magnetic resonance imaging is becoming increasingly necessary to evaluate extraprostatic extension during the preoperative evaluation. European Association of Urology guidelines recommend the use of radical prostatectomy only in selected patients with cT3a who have a PSA <20 ng/mL and a biopsy Gleason score ≤8. The cancer control obtained after the implementation of radical prostatectomy is variable from one series to another, with PSA-free survival rates at 5, 10 and 15 years ranging from 45 to 62%, 43 to 51% and 15 to 49%, respectively. The specific survival rates at 5, 10 and 15 years are between 84 and 98%, 84 and 91% and 76 and 84%, respectively. The surgical margins rate varies from 22% to 61% depending on the specific operative technique used and the surgeon's own experience level. Regarding urinary continence, functional outcomes are in line with those of prostatectomy for localized prostate cancer. Upon consideration of erectile dysfunction, the rates are linked with the type of surgery performed, which can at times be fairly extensive. There is no impact on the overall or specific survival rate of neoadjuvant treatments. One of the problems currently depends on the efficacy of early adjuvant treatment after prostatectomy, especially regarding the use of adjuvant external beam radiotherapy. Radical prostatectomy can be considered in selected cases as a viable alternative to the first-line treatment option. However, patients must be counselled that they may undergo complementary treatments during the postoperative course of the disease. [ABSTRACT FROM AUTHOR]

Study Type - Prognosis (retrospective cohort) Level of Evidence 2b OBJECTIVE To analyse the relationship between African American (AA) race and obesity in men with prostate cancer. PATIENTS AND METHODS In all, 4196 patients who underwent radical prostatectomy from 1988 to 2008 were identified in the Duke Prostate Center database. A subset of 389 (AA 20.9% and non-AA 79.1%) patients with a body mass index (BMI) of ≥30 kg/m2, T1c disease and a prostate-specific antigen (PSA) level of <10 ng/mL were stratified by race and analysed. Age at surgery, race, surgical margin status, pathological tumour stage (pT2, pT3/4), pathological Gleason sum (<7, 3 + 4, 4 + 3, >7), extracapsular extension (ECE), seminal vesicle invasion and tumour percentage were assessed by univariate analysis followed by Cox regression analysis. RESULTS In the entire cohort, 143 (38.1%) AA men were obese, compared to 509 (25.0%) of the non-AA men. AA men had a significantly higher tumour percentage (15% vs 10%, P= 0.002), and a greater proportion of pT3/4 disease (45.1% vs 26.2%, P= 0.039), pathological Gleason sum ≥7 (70.7% vs 50.5%, P= 0.003), positive ECE (37.8% vs 23.1%, P= 0.007), and positive surgical margin (52.4% vs 36.8%, P= 0.010) than non-AA men. AA men had a greater risk of PSA recurrence on Kaplan Meier ( P= 0.004) and Cox regression analysis ( P= 0.040, hazard ratio 1.72) CONCLUSION A greater proportion of AA men was obese in this cohort. Obese AA with impalpable cancer and a PSA level of <10 ng/mL have a higher risk of pathological features than obese non-AA men, as well as a higher risk of PSA recurrence. Obesity might be responsible for the racial disparity seen in prostate cancer. [ABSTRACT FROM AUTHOR]

• Laparoscopic retroperitoneal lymph node dissection (L-RPLND) was first introduced in 1992, initially as a staging procedure. • With advances in instrumentation and laparoscopic techniques, as well as improved understanding of laparoscopic anatomy, L-RPLND has developed to duplicate open RPLND. • Unlike the relatively rapid adoption of laparoscopy for other applications including nephrectomy and prostatectomy, L-RPLND has been slow to be universally accepted. • The limited numbers of patients requiring RPLND and technical challenges in performing the dissection have undoubtedly contributed to its delayed reception. • This review will present available data on this technique and discuss issues potentially inhibiting acceptance by traditional surgeons. [ABSTRACT FROM AUTHOR]

Study Type – Therapy (case series) Level of Evidence 2b OBJECTIVE To present the outcomes of cT3N0M0 prostate cancer after radical prostatectomy (RP) and determine the prognostic factors in biochemical progression-free survival (BPFS), clinical progression-free survival (CPFS), cancer-specific survival (CSS) and overall survival (OS) after long-term follow-up of 10 years. PATIENTS AND METHODS In all, 164 patients who were assessed as clinical T3 prostate cancer by digital rectal examination (DRE), underwent RP and bilateral pelvic lymphadenectomy at Erasmus MC between 1977 and 2004 without neoadjuvant treatment. Preoperative staging computed tomography showed no signs of metastasis. Kaplan–Meier curves were constructed to show BPFS, CPFS, CSS and OS. Cox proportional hazard analysis was used to determine prognostic indicators of disease progression. RESULTS The mean (range) follow-up was 100 (1–291) months. At 5, 10 and 15 years, BPFS was 50.4%, 43.0% and 38.3%, respectively, CPFS was 79.7%, 68.7% and 63.5%, CSS was 93.4%, 80.3% and 66.3%, and OS was 87.1%, 67.2% and 37.4%. Multivariate Cox proportional hazard analysis showed that surgical tumour grade, margin and node status were significant factors in CPFS and CSS. Surgical tumour grade, node status and preoperative PSA level were significant factors in BPFS CONCLUSION RP for clinically locally advanced prostate cancer may produce acceptable long-term BPFS, which is comparable with published results of radiotherapy with adjuvant endocrine therapy. Pathological tumour grade and node status were significant predicting factors in BPFS and CPFS, as well as tumour-specific survival after 100 months follow-up. [ABSTRACT FROM AUTHOR]

Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE To report the oncological outcome of 106 patients who had locally advanced prostate cancer with microscopic bladder neck invasion, identified in a series of 1129 patients surgically treated with retropubic radical prostatectomy over a 12-year period. PATIENTS AND METHODS All specimens were reviewed. Microscopic bladder neck invasion was defined as the presence of neoplastic cells within the smooth muscle bundles of the bladder neck, with no accompanying prostatic glandular tissue on the corresponding slide. Survival was analysed for different subgroups in relation to several variables. RESULTS The follow-up (median 7.2 years, mean 6.68, range 0.3–14) was available for 106 patients with microscopic bladder neck invasion. Seminal vesicle invasion was present in 69.8% of the cases, lymph node involvement in 29.2%, apex infiltration in 31.8%, and positive surgical margins in 23.6%. Biochemical progression occurred in 61 (57.5%) patients, and 25 of them died from cancer. The mean (sd) biochemical progression-free survival was 0.68 (0.05), 0.59 (0.05), 0.40 (0.05) and 0.38 (0.05) at 1, 2, 5 and 10 years, respectively. Age, Gleason score and lymph node invasion were independent prognostic factors on multivariate analysis. Overall and cancer-specific survival rates were 0.75 (0.04) and 0.80 (0.04) at 5 years and 0.57 (0.04) and 0.75 (0.04) at 10 years, respectively. Univariate analysis showed that seminal vesicle invasion, lymph node involvement and surgical Gleason score ≥8 significantly increased the risk of death. On multivariate analysis only the surgical Gleason score had an independent prognostic role with regard to overall survival ( P = 0.01; odds ratio 2.82, 95% confidence interval 1.2–6.4) and cancer-specific survival ( P < 0.001; 8.6, 2.5–28.8). CONCLUSIONS In this series, overall and cancer-specific survival rates were comparable to those reported for surgically treated cT3 prostate cancers. The lack of need for external urinary diversion during the entire follow-up significantly contributed to the patients’ quality of life. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

OBJECTIVE To determine the effectiveness of cancer control afforded by radical prostatectomy (RP) in patients with clinical stage T3 prostate cancer. PATIENTS AND METHODS We retrospectively reviewed data for patients treated by RP for clinical stage T3 prostate cancer between 1995 and 2005. The following case characteristics were analysed: patient age, clinical presentation, preoperative prostate-specific antigen (PSA) level, Gleason score, tumour stage (2002 Tumour-Node-Metastasis), surgical procedure, pathological data, margin and lymph node status, and recurrence. Biochemical recurrence was defined as an increase in PSA level of >0.2 ng/mL after surgery. Kaplan-Meier survival curves were generated, and prognostic factors were evaluated. RESULTS Overall, 100 patients were included; only 79% of them had pT3 disease based on the pathological specimen. The median follow-up after RP was 69 months. The RP was open in 77 and laparoscopic in 23, with no significant difference between these approaches ( P = 0.38). The 5-year PSA-free survival after surgery was 45%, and 5-year cancer-specific survival was 90%. On univariable analysis, Gleason score >7 ( P = 0.01), pathological stage (pT2-T3a vs T3b) ( P < 0.001), positive lymph node ( P < 0.001), and positive margin ( P < 0.001) were associated with recurrence. On multivariable analysis, lymph node, margin status and Gleason score were also significant ( P < 0.05). CONCLUSIONS RP can be recommended as an alternative primary treatment that results in acceptable cancer control for clinical stage T3 prostate cancer in selected cases. However, the patient should be warned that surgery alone might not be sufficient to control the cancer, and that adjuvant therapy might be needed during the course of the disease. [ABSTRACT FROM AUTHOR]

Background: The authors evaluated the long-term outcomes of men with prostate cancer and very high (> or =50 ng/mL) preoperative serum prostate-specific antigen (PSA) values that were treated with radical prostatectomy.Methods: This study included 236 men with preoperative serum PSA values > or =50 ng/mL who underwent radical retropubic prostatectomy between 1987 and 2004. For comparison, the study cohort was divided into 2 groups: patients with PSA levels between 50 and 99 ng/mL and patients with PSA levels > or =100 ng/mL. Biochemical recurrence was defined as a single postoperative serum PSA value of 0.4 ng/mL or greater. Systemic disease progression was defined as the development of a local recurrence or systemic metastases, and any death resulting from prostate cancer or its treatment was defined as a cancer-specific mortality.Results: Biochemical recurrence-free survival rates in the groups of patients with a PSA level 50 to 99 ng/mL and > or =100 ng/mL were 43% and 36% at 10 years, respectively. Systemic progression-free survival rates in the PSA 50 to 99 ng/mL and PSA > or =100 ng/mL groups were 83% and 74% at 10 years, respectively. Estimated overall cancer-specific survival was 87% at 10 years.Conclusions: Patients with prostate cancer and a serum PSA level > or =50 ng/mL have very high-risk prostate cancer that carries a high likelihood of being pathologically advanced. Although the probability of realizing long-term survival in these high-risk patients is less than in patients with more favorable disease, 10-year survival outcomes remain excellent and argue for aggressive management of these cases. [ABSTRACT FROM AUTHOR]

Men with clinical stage T3a disease are at high risk and are often encouraged to undergo radiation therapy with concomitant hormonal therapy. The long‐term outcomes among men treated with radical prostatectomy for clinical stage T3a disease were examined.Among 3397 men treated by radical prostatectomy by 1 surgeon between 1987 and 2003, 62 (1.8%) men were identified who had clinical stage T3a disease. Among the 56 men not treated with neoadjuvant or adjuvant therapies before prostate‐specific antigen (PSA) recurrence, the long‐term outcomes of PSA‐free survival, metastasis‐free survival, and prostate cancer specific survival were examined. Median and mean follow‐up after surgery were 10.3 and 13 years, respectively (range, 1–17).Ninety‐one percent of men in this group had pathological T3 disease. PSA‐free survival at 15 years after surgery was 49%. Metastasis‐free survival and cause‐specific survival at 15 years after surgery were 73% and 84%, respectively. Among men with a PSA recurrence, 46% received secondary therapy before metastasis. The only preoperative or pathological feature that predicted risk of prostate cancer death was lymph node metastasis (hazard ratio [HR]: 9.22, 95% confidence interval [CI]: 1.06–80.02, P = .044). Among the 28 men with a PSA recurrence, PSA doubling time (PSADT) data were available for 23, of which 11 (48%) has a PSADT ≥9 months. No patient with a PSADT ≥9 months died of prostate cancer. A PSADT <9 months was significantly associated with increased risk of prostate cancer death (log‐rank, P = .004).In a select cohort of men with clinical stage T3a disease, radical prostatectomy alone provides long‐term cancer control in about half of the men and results in a prostate cancer‐specific survival of 84%. Among men with a PSA recurrence, PSADT at the time of recurrence is a useful determinant of risk of prostate cancer death. Cancer 2007. © 2007 American Cancer Society. [ABSTRACT FROM AUTHOR]