UROLOGICAL ONCOLOGY

Outcome of Surgery for Clinical Unilateral T3a Prostate Cancer: A Single-Institution Experience
Hsu CY, Joniau S, Oyen R, Roskams T, Van Poppel H
Department of Urology, University Hospitals KULeuven, Leuven, Belgium
Eur Urol. 2007; 51: 121-8; discussion 128-9

• Objectives: The optimal management of locally advanced prostate cancer (cT3) is still a matter of debate. The objective of this study is to present 10-year outcomes of radical prostatectomy (RP) in unilateral cT3a disease.
• Patients and Methods: Between 1987 and 2004, 2273 patients underwent RP at our institution. Two hundred and thirty-five (10.3%) patients were assessed as unilateral cT3a disease by digital rectal examination. Thirty-five patients who received neoadjuvant treatment before surgery were excluded from further analysis. Mean follow-up was 70.6 months. Kaplan-Meier survival analysis was used to calculate the biochemical progression-free survival (BPFS), clinical progression-free survival (CPFS), cancer-specific survival (CSS), and overall survival (OS) rates. Cox uni- and multivariate regression analyses were used to identify predictive factors in BPFS and CPFS.
• Results: Clinical overstaging (pT2) occurred in 23.5%. One hundred and twelve (56%) patients received adjuvant or salvage therapy. OS at 5 and 10 years was 95.9% and 77.0%, respectively, and CSS was 98.7% and 91.6%. BPFS at 5 and 10 years was 59.5% and 51.1%, respectively, and CPFS was 95.9% and 85.4%. Margin status was a significant independent predictor in BPFS; cancer volume was a significant independent predictor in CPFS.
• Conclusions: Clinically advanced prostate cancer is still frequently overstaged. In a well-selected patient group with locally advanced prostate cancer, RP—with adjuvant or salvage treatment when needed—can yield very high long-term cancer control and survival rates. Margin status and cancer volume are significant predictors of outcome after RP.
  
  
• Editorial Comment
  The outcomes of clinically unilateral T3 cancer after surgical treatment are presented. In 22% the patients received adjuvant and in 34% they received salvage hormonal or radiation treatment.
  Generally the outcomes are relatively good with only 10% cancer mortality after 10 years. The authors claim a high rate of overstaging in 23.5 % which leaves some doubt in the preoperative staging procedures, e.g. was TRUS performed preoperatively? Further aspects still might be debatable and are also addressed in the comments to this paper. At least one point of debate might be added. What happened to bilateral T3 patients and why were these excluded? The authors compare their results with radiotherapy results from historical trials but I do not remember this exclusion criterion in these radiotherapy trials.
  In conclusion, both surgical and radiation therapy approaches seem justified in the treatment of locally advanced prostate cancer.

Dr. Andreas Bohle
Professor of Urology
HELIOS Agnes Karll Hospital
Bad Schwartau, Germany