Remarkable long-term survival rates have recently been reported in locally advanced prostate cancers treated with radical prostatectomy . Similar findings have emerged in a large retrospective series of patients with prostate-specific antigen (PSA) over 20 ng/ml receiving surgery with or without adjuvant therapy . Prostate cancer patients with a PSA more than 100 ng/ml harbour a very high risk of bone metastatic disease  and therefore would not be elected for surgery. In a retrospective analysis of two institutional radical prostatectomy databases, we identified 26 patients with a preoperative PSA ≥ 100 ng/ml. All patients had a negative preoperative bone scan, with or without clinically node positive disease, and underwent a wide radical prostatovesiculectomy with pelvic lymph node dissection. Adjuvant or salvage treatment was administered according to institutional protocols. Follow-up data with regular PSA testing, clinical examination, and imaging studies usually performed at the time of biochemical failure or at the onset of clinical progression, were available for all cases. The Kaplan-Meier method and Log Rank test were used for the outcome analysis. Median PSA was 140 ng/ml (range 100–630), median age 66 (53–78). Clinically locally advanced disease was seen in 18/26 (69.2%), with 6/26 (23.1%) presenting with clinical nodal involvement. Pathological staging showed locally advanced disease in 24/26 (92.3%) with pN+ in 12/26 (46.2%). Median pathological Gleason score was 8 (range 6–10). Positive surgical margins were found in 22/26 (84.6%). Adjuvant and/or salvage treatment was given in 20/26 (76.9%) and 16/26 (61.5%) patients respectively, with most of the patients (22/26; 84.6%) receiving hormonal treatment at some stage during follow-up. Median follow-up was 75 mo (range 12–158). Data on the 10-yr projected biochemical and clinical disease free survivial, cancer specific survival, and overall survival are reported for all patients and categorized for pN+ and pN0 disaese in Table 1. Surprisingly, more than half of these patients were pathological N0, which showed to be the most significant outcome predictor in all cancer related outcomes.
10-yr projected biochemical and clinical disease free survivial, cancer specific survival, and overall survival of 26 radical prostatectomy patients with a preoperative prostate-specific antigen (PSA) level ≥ 100 ng/ml
|10-yr projected survival||All patients (n = 26)||pN0 (n = 14)||pN1 (n = 12)||p-value|
|BDFS (PSA < 0.2 ng/ml)||11.3%||18.7%||8.3%||0.132|
|CDFS (local–distant recurrence)||47.5%||84.6%||9.7%||0.0003|
BDFS, biochemical disease free survival; CDFS, clinical disease free survival; CSS, cancer specific survival; OS, overall survival.
The finding of an 88% 10-yr projected cancer specific survival in this selected very high-risk prostate cancer population where radical surgery was administered alone or as part of a multimodal treatment is intriguing and deserves attention. While the beneficial role of surgery cannot be proven by our study design, the poor utility of PSA alone to predict the disease prognosis would seem clearly emphasized in this selected series. On the other hand, in the light of the known high probability of metastatic disease for PSA level above 100 ng/ml , one could speculate that a significant proportion of our patients may harbour systemic disease undetectable by bone scan but potentially diagnosable by more sensitive imaging techniques currently in use, such us PET/CT . Under this perspective, the current data raise the compelling possibility, for which only speculative evidence currently exists , that removing the prostate in men with metastatic prostate cancer might result in a more complete and durable response to adjuvant treatment and ultimately favourably impact on survival.
Conflicts of interest: The authors have nothing to disclose.
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a University of Torino, Department of Urology, Torino, Italy
b University Hospital Leuven, Department of Urology, Leuven, Belgium
Corresponding author. Dipartimento di Discipline Medico Chirurgiche, University of Turin, Urologia 1, San Giovanni Battista Hospital, C.so Dogliotti, 14, Torino, Italy. Tel./Fax: +39 011 6335581; Mobile: 347 8600447.
© 2008 European Association of Urology, Published by Elsevier B.V.