Surgical Prospectives in High-Risk Prostate Cancer

Dr. Benson from Columbia University discussed radical prostatectomy (RP) in the treatment of high-risk CaP. Risk assessment is critical and he uses RP as a lumpectomy with adjuvant therapy based upon pathology. Dr. Benson stated that the goal of the RP is to remove the prostate with negative margins.

Pelvic lymphadenectomy may have a role in improved outcomes. 5% of men with localized CaP have occult positive lymph nodes (LN) in one study. The number of patients having a pelvic lymphadenectomy has decreased form 92% to 80% over a 10 year period. This may represent stage migration and changing surgical trends.

He showed an example of not doing a pelvic lymphadenectomy for a low risk patient who turned out to be high risk on final pathology. In one study, 20% of men have positive lymph nodes in the area along the internal iliac vessels, which is not incorporated in the standard LN dissection. 

In a Hopkins series, an extended LN dissection resulted in a better disease free progression and other studies support that 20-50% of patients may have therapeutic benefit from a pelvic LN dissection. In the Columbia series, the time from PSA recurrence to death was 4 years.

In the Atrasentan trial, a previous RP correlated with better probability of survival. This might suggest that controlling the primary tumor is important for survival. This prompted a review of 2,522 RP patients at Columbia and 208 were high risk. Six of the 208 high-risk patients died from CaP at a mean of 7 years. There was lack of correlation between biochemical recurrence and survival. He pointed out that due to stage migration; a single as opposed to multiple positive lymph nodes are more likely than it was 20 years ago. With a single positive LN, 20% did not have a recurrence despite not receiving ADT. Thus, despite the low incidence of positive LNs, removing them is highly effective in controlling CaP and adjuvant treatment can be given based on pathology or avoided in 20% who are cured by surgery alone.

Presented by Mitchell Benson, MD at the American Society of Clinical Oncology (ASCO) - 2008 Genitourinary Cancers Symposium - A Multidisciplinary Approach - February 14-16, 2008 San Francisco, California, USA

Written by Christopher P. Evans, MD, a Contributing Editor with UroToday

Source: UroToday

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