Locally Advanced Prostate Cancer

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Locally Advanced Prostate Cancer

• Debate on Current Management

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Prostatectomy
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• Prostate cancer which extends beyond the
  confines of the prostate gland on clinical
  assessment is designated a clinical stage T3
  tumour.

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Risk extent
dAmico et al 1998
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Estimated 5-year biochemical failure-free rates
dAmico et al 1998
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Predicting metastases-free rates from PSA rise
after Radical prostatectomy if not treated

• Gleason PSA failure PSA DT
  Metastases-free rate ()
• Score (years) (months)
  3 years 5 years 7 years
• --------------------------------------------------
  -----------------------------------------------
• gt 2
  lt 10 95 86
  82
• 5 - 7
  gt 10 82 69
  60
• lt 2
  lt 10 79 76
  59
• 
  gt 10 81 31
  15
• gt 8 gt 2
  77 60
  47
• lt 2
  53 31
  21
• --------------------------------------------------
  -----------------------------------------------

• Estimates at 3,5 and 7y from time of initial PSA
  rise.
• Gleason score is of the surgical specimen

Pound et al 1999
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• Surgical treatment of patients with clinical
  stage T3 prostate cancer has not been widely
  accepted
• Potential for incomplete excision of the primary
  tumour.
• High incidence of lymph node metastasis.
• Poor prognosis as most patients already have
  occult metastasis
• Lymph node ve 30 50
• S V invasion 67

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• Still, selected patients with small T3 cancers
  may benefit from surgery.

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• The goal of therapy should include
• Prolongation of survival
• Control of local tumour progression
  with its associated improvement in QOL

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• The success of radical prostatectomy for T3
  prostate cancer relies on the removal of all
  local tumour bearing tissue. Tumours originating
  in the peripheral zone are more likely to extend
  in to the postero-lateral and rectal
  peri-prostatic soft tissue.

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• Consequently
• The neurovascular bundles are usually excised
  widely (on the side of the cancer).
• The posterior plane of excision should be deep
  enough to Denonvilliers fascia to reduce the
  risk of positive surgical margin.

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Mayo Clinic

• Lerner SE, Blute ML, Iocca AJ,Zinke H Primary
  surgery for clinical stage T3 adenocarcinoma of
  the prostate.In Vogelzang NJ,Scardino PT, Shipley
  WU, Coffey DS (eds) Comrehensive Textbook of
  Genitourinary Oncology. 2d ed. Philadelphia.
  Lippincott Williams Wilkins. 2000, pp 789-799.

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Radical prostatectomy

• 1090 T3a patients.
• Criteria
• Low morbidity.
• 10 y life expectancy.
• No significant extension to the pelvic side wall
  or involvement of the bladder base or trigone.
• No metastases (M0).

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• 26 Organ confined disease.
• 30 ve Lymph nodes.
• Adjuvant hormonal therapy in 28.

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• Overall clinical non progression
• 10y
  67
• 15y
  61
• Serum PSA inclusion as a sign of progression
• 10y
  47
• 15y
  41

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Conclusion
Patients with limited but unequivocal clinical
stage T3 disease can be successfully treated
surgically with minimal operative morbidity.
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Salvage Radical Prostatectomy

• The American Society for Therapeutic Radiology
  and Oncology Consensus Panel in a consensus
  statement in 1997 agreed the guidelines for using
  PSA end points for reporting success or failure
  after irradiation.
• Three consecutive increases in PSA is a
  reasonable definition of biochemical failure.
• However, biochemical failure is not equivalent to
  clinical failure and it is not a justification
  per se to initiate additional treatment.

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Biopsy evaluation

• Histological clearance of tumour after
  radiotherapy is difficult to interpret and may
  take 18 months or longer to occur owing to
  ongoing tumour cell death.
• The question remains whether recurrent cancer
  after irradiation is caused by growth of
  incompletely eradicated tumour, progression from
  incompletely eradicated PIN or represents a new
  tumour de novo.
• Gleason grading was designed for untreated
  prostate cancer and thus should be avoided as it
  may not be appropriate or applicable to post
  radiotherapy biopsies.

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Selection criteria for salvage prostatectomy

• Young healthy motivated patients who were good
  candidates for primary prostatectomy and have a
  life expectancy gt 10 years.
• Overall they should have minimal medical
  co-morbidities.
• The results from a bone scan, chest X ray and CT
  scan of abdomen and pelvis should provide no
  evidence of systemic disease or pelvic
  lymphadenopathy.
• Minimal to tolerable urinary symptoms are
  expected in a large number of candidates
  following irradiation but beware in candidates
  suffering symptoms of overactive detrusor.
• A clear and frank discussion explaining the
  significant potential of peri-operative morbidity
  and post operative outcome, particularly
  incontinence and impotence.

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Preoperative prognostic factors

• Patients who could benefit most from salvage
  prostatectomy with regards to long term disease
  free survival would include
• Pre-radiation PSA lt4 ng./ml.
• Pre-radiation clinical stage T1-T2.
• Pre-operative favourable parameters
• - PSA lt10 ng/ml.
• - Biopsy Gleason score lt7
• - Clinical stage T1c.
• - Diploid DNA.

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• Radical prostatectomy has a place in primary
  management of locally advanced prostate cancer
  and as a means of salvage following primary
  radiotherapy treatment modality.
• The key for a satisfactory outcome is
  meticulous patient selection as well as surgical
  expertise.

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