UROLOGICAL ONCOLOGY

doi: 10.1590/S1677-55382010000600027

Outcome predictors of radical prostatectomy in patients with prostate-specific antigen greater than 20 ng/ml: A European multi-institutional study of 712 patients
Spahn M, Joniau S, Gontero P, Fieuws S, Marchioro G, Tombal B, Kneitz B, Hsu CY, Van Der Eeckt K, Bader P, Frohneberg D, Tizzani A, Van Poppel H
University Hospital Würzburg, Department of Urology and Pediatric Urology, Germany; Community Hospital Karlsruhe, Department of Urology, Karlsruhe, Germany
Eur. Urol. 58: 1-7, 2010

• Background: Prostate cancer (PCa) patients with pretreatment prostate-specific antigen (PSA) >20 ng/ml have a high risk of biochemical and clinical failure and even cancer-related death after local therapy. Pretreatment predictors of outcome after radical prostatectomy (RP) in this patient group are necessary.
  Objective: Our aim was to assess how the use of additional high-risk factors (biopsy Gleason score [bGS] >/=8 or clinical stage 3-4) can improve prediction of treatment failure and cancer-related death after RP in patients with PSA >20.
  Design, Setting, and Participants: In a retrospective multicentre cohort study from six European centres between 1987 and 2005, 712 patients with PSA >20 ng/ml underwent RP and bilateral pelvic lymphadenectomy.
  Measurements: Subgroups were analysed to determine the relationship between the number of high-risk factors and histopathology, biochemical progression-free survival, clinical evidence of progressive disease, prostate cancer-specific mortality (PCSM), and overall mortality. Kaplan-Meier analysis with log-rank test and Cox multivariable analysis were applied.
  Results and Limitations: Median follow-up was 77 mo. The number of high-risk factors was significantly associated with unfavourable histopathology. Among patients with only PSA >20 ng/ml, 33% had pT2 PCa, 57.9% had bGS <7, 54% had negative surgical margins, and 85% were lymph node negative (pN0), whereas among patients with all three high-risk factors, 4.5% had pT2 PCa, 2.3% had bGS <7, 20.5% had negative margins, and 49% were pN0 (p<0.001). The strongest predictor of progression and mortality was bGS. PSA >20 ng/ml associated with bGS </=7 resulted in 10-yr PCSM of 5%; when associated with bGS >/=8, PCSM was 35%. The main limitations of the study were retrospective design and varying treatment modalities.
  Conclusions: PCa patients with PSA >20 ng/ml have varying risk levels of disease progression and PCSM. Considering additional risk factors further stratifies this group into four subgroups that can guide the clinician in preoperative patient counselling.

• Editorial Comment
  Surgical therapy in patients with prostate cancer and a PSA >20 ng/ml is a matter of debate. Most patients are considered high-risk and receive either hormonal therapy alone or are referred to external beam radiation therapy. The authors from this multi-institutional study analyze their 712 patients with PSA >20 ng/ml who underwent radical prostatectomy. Of this group, roughly 40% had Gleason score > 7, 50% had positive surgical margins and 15% were node-positive. The combination of these factors was predictive for patient’s outcome.
  Interestingly, even in this special group of patients death of disease was a rare event, with high cancer-specific survival rates of 90% and 85% after 5 and 10 years, respectively, whereas biochemical progression-free rates in the same group were as low as 65% at 5 years and 52% at 10 years.
  The combination of several risk factors, expectedly, led to reduced progression-free and survival rates. In summary, radical prostatectomy is a viable option even for high-risk patients.

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