UROLOGICAL ONCOLOGY

Outcome of prostate cancer patients with initial PSA> or =20 ng/ml undergoing radical prostatectomy
Zwergel U, Suttmann H, Schroeder T, Siemer S, Wullich B, Kamradt J, Lehmann J, Stoeckle M
Department of Urology and Pediatric Urology, University of Saarland, Hamburg/Saar, Germany
Eur Urol. 2007; 52: 1058-65

• Objectives: To retrospectively assess the outcome of patients with initial PSA of 20 ng/ml or higher undergoing radical prostatectomy (RP) for prostate cancer (pCA).
• Methods: Between January 1986 and June 2005, 275 patients with preoperative PSA> or =20 ng/ml underwent RP for pCA at our institution. Overall, disease-specific and biochemical progression-free survival rates for the entire cohort and for particular subgroups were determined.
• Results: Median patient age at time of surgery was 64 yr (range: 44-75). Fifty-seven patients (20.7%) had pT2 stage, 206 (74.9%) pT3, and 10 (3.7%) pT4; 78 (28.4%) presented with local nodal metastases (pN+). To date, 40 patients have died (14.5%), 22 of pCA and 18 of other causes. Biochemical progression occurred in 92 patients (33.5%). Overall (and disease-specific) survivals at 5, 10, and 15 yr were 87% (93%), 70% (83%), and 58% (71%), respectively. These survival rates did not significantly differ between patients receiving immediate versus deferred hormonal therapy (in case of progression). Five-year PSA progression-free survival in patients on surveillance (receiving deferred hormonal treatment at the onset of rising PSA values) was 53%. For patients on immediate hormonal treatment following RP, the 5-yr hormone-refractory PSA progression rate was 76%.
• Conclusions: According to long-term follow-up results in this high-risk cohort of patients with preoperative PSA > or = 20 ng/ml, RP can be considered a viable therapeutic option. With regard to combining immediate hormonal therapy with surgery, the optimal treatment following RP remains to be defined.
  
  
• Editorial Comment
  The authors report on a series of 275 prostate cancer patients who received radical prostatectomy (RP) with a preoperative PSA of > 20 ng/ml. The patients had bone scans preoperatively, but MRI or CT was offered only in case of clinically suspected metastatic disease. Only 20.7% of patients had organ-confined disease, whereas 74.9 % had pT3 cancer (with pT3b in 43.9%). Only 7.6% had Gleason sum score of 5 and 6 whereas Gleason 7 was seen in 43,3% and Gleason 9 in 28.1 %. Interestingly, even in this high-risk group of patients, cancer-specific survival after 5, 10 and 15 years was 93%, 83% and 71%, respectively. No difference was seen between cohorts receiving immediate versus deferred hormon-ablative therapy. These data support active therapy in patients with high-risk cancer.

Dr. Andreas Bohle
Professor of Urology
HELIOS Agnes Karll Hospital
Bad Schwartau, Germany
E-mail: boehle@urologie-bad-schwartau.de