Urological oncology

Bohle, Andreas

doi:10.1590/S1677-55382005000100021

UROLOGICAL SURVEY

Urological oncology

Cancer progression and survival rates following anatomical radical retropubic prostatectomy in 3,478 consecutive patients: long-term results

Roehl KA, Han M, Ramos CG, Antenor JA, Catalona WJ

Department of Psychiatry, School of Medicine, Washington University, St. Louis, Missouri, USA

J Urol. 2004; 172: 910-4

PURPOSE: We updated a long-term cancer control outcome in a large anatomical radical retropubic prostatectomy (RRP) series. We also evaluated the perioperative parameters that predict cancer specific outcomes following surgery.

MATERIALS AND METHODS: From May 1983 to February 2003, 1 surgeon (WJC) performed RRP in 3,478 consecutive men. Patients were followed with semiannual serum prostate specific antigen (PSA) tests and annual digital rectal examinations. We used Kaplan-Meier product limit estimates to calculate actuarial 10-year probabilities of biochemical progression-free survival, cancer specific survival and overall survival. Multivariate Cox proportional hazards models were used to determine independent perioperative predictors of cancer progression.

RESULTS: At a mean followup of 65 months (range 0 to 233) actuarial 10-year biochemical progression-free, cancer specific and overall survival probabilities were 68%, 97% and 83%, respectively. On multivariate analysis biochemical progression-free survival probability was significantly associated with preoperative PSA, clinical tumor stage, Gleason sum, pathological stage and treatment era. Cancer specific survival and overall survival rates were also significantly associated with clinicopathological parameters.

CONCLUSIONS: RRP can be performed with excellent survival outcomes. Favorable clinicopathological parameters and treatment in the PSA era are associated with improved cancer control.

Editorial Comment

This paper is very valid as it describes the long-term outcome of a very large cohort of patients after radical prostatectomy. Notably, all patients have been operated by a single surgeon (W. Catalona), thus certifying best results by a high-volume urologist. The most interesting results are given as PSA progression-free survival data (defined as detectable PSA > 0.2 ng/mL) and are therefore comparable to other, especially nonsurgical data (see following comment). Biochemical progression was 20% at 5 and 32% at 10 years. A closer look into the Kaplan Meier curves reveals more truth: in very low-risk patients with PSA < 2.6 ng/mL around 10% showed PSA progression after 150 months, for PSA 2.6 - 4 ng/mL roughly 20% and PSA 4 -10 ng/mL roughly 25% had biochemical progression after 150 months. Notably, these patients are considered low risk. With PSA > 10 less than 50% of patients remained progression free after 150 months. Another look is worthwhile on the curve showing Gleason grades and biochemical progression. In Gleason 2-6 around 20% of patients have failed after 100 months of follow-up, with a continuously decreasing curve. Altogether these data give a clear view on the advantages and especially, the limits of radical prostatectomy and should be considered if this procedure is advocated to men with prostate cancer.

Dr. Andreas Bohle

Professor of Urology

HELIOS Agnes Karll Hospital

Bad Schwartau, Germany

Prostate cancer in a large prostate is associated with a decreased prostate specific antigen failure rate after brachytherapy

Lehrer S, Stone NN, Stock RG

Department of Radiation Oncology and Urology, Mount Sinai Medical Center, New York, NY 10029, USA

J Urol. 2005; 173: 79-81

PURPOSE: A large prostate has been found to correlate with improved prostate cancer survival in men undergoing radical prostatectomy. In the current study we analyzed the relationship of prostate size and prostate specific antigen (PSA) failure in men undergoing brachytherapy for localized prostate cancer.

MATERIALS AND METHODS: We studied data on 613 men who had undergone I radioactive seed implantation. Average patient age +/- SD was 65 +/- 7.2 years. Average prostate volume ultrasonically measured at seed insertion was 40 +/- 15 ml. All patients had a minimum of 2 years of followup.

RESULTS: Men with a large prostate had increased freedom from failure compared to men with a small prostate. Failure time in men with an intermediate size prostate was between that for large and small prostates. This difference in failure rates was significant (log rank test p = 0.0002). We further analyzed our data with Cox regression. Large prostate size significantly correlated with increased time to PSA failure (p = 0.013) and it was independent of the significant effects of Gleason score, PSA, disease stage (p < 0.001), minimal radiation dose covering 90% of prostate volume (p = 0.008) and hormone treatment, including androgen ablation (p = 0.001).

CONCLUSIONS: Some investigators have postulated that paracrine signals acting to regulate epithelial proliferation in benign prostatic hypertrophy have beneficial influences on coexistent prostate cancer. Our finding that the effect of prostate size is independent of Gleason score, PSA and disease stage supports the paracrine signal mechanism. If a circulating substance, such as a cytokine, might be responsible for improved survival, this substance might be useful for treating prostate cancer. Moreover, since we found that prostate size is independent of PSA, Gleason score and tumor stage for predicting outcome, we hypothesize that patients with a small prostate treated with brachytherapy might benefit from hormone treatment and larger radiation doses. These measures are now generally reserved for men with more advanced tumors, higher PSA and increased Gleason scores.

Editorial Comment

On first approach the data on the treatment of prostates of different sizes by brachytherapy are given. In a closer look this paper bears outcome data of one of the largest cohorts of permanent interstitial seed (LDR) brachytherapy treated patients with a long term follow up of 140 months. Therefore, this paper should be read carefully and be compared to the above cited on.

Again, outcomes for low, intermediate and high-risk patients are given as PSA-progression-free survival data (defined as 3 consecutive PSA increases, ASTRO criteria).

In low-risk patients around 95% had no progression after 140 months. For intermediate risk patients roughly 12% and for high-risk patients roughly 45% had biochemical progression after 140 months. Interestingly, the curves do not show any further decrease and remain linear 75 months after treatment. With these 2 papers in mind, brachytherapy can no longer be considered an inferior therapeutic option to radical prostatectomy in men with localized prostate cancer.