Radical Prostatectomy-Indication, Surgical Technique, Results

[Locally advanced prostate carcinoma (T2b-T4 N0) without and with clinical evidence of local progression (Tx N+) with lymphatic metastasis. Is radiotherapy for pelvic lymphatic metastasis indicated or not?]

BACKGROUND

There is a greater controversy regarding the indication of radiotherapy of the pelvic lymphatics in patients with suspected lymph node metastases in locally advanced prostate cancer (T2b-4 N0) on the one hand and in patients with pathologically proven lymph node metastases in locoregional advanced prostate cancer (Tx pN+) on the other hand following definitive radiotherapy and radical prostatectomy. This paper investigates the possible indications for radiotherapy of the pelvic lymphatics in the light of data from the literature.

PATIENTS AND METHODS

Because data from several retrospective studies concerning radiotherapy of the pelvic lymphatics indicated a better outcome, the RTOG conducted 2 prospective randomised studies (RTOG 75-06, 77-06) to address these questions. However, the results of these studies showed no better survival or cause specific survival for patients treated for the paraaortal or pelvic lymphatics and therefore, radiotherapy of the pelvic lymphatics was no more advocated. A reanalysis showed several problems of the study design and it was concluded that the studies couldn't prove the question of elective radiotherapy of the pelvic lymphatics. In RTOG 77-06 patients with T1b/T2 tumors were investigated. Therefore, there is no prospective study investigating the elective radiotherapy in patients with T3-tumors, who are at high risk of pelvic lymph node metastases.

RESULTS

Today there is no indication for treating the paraaortal lymphatics in patients with locoregional advanced prostate cancer. Many radiotherapists perform the elective radiotherapy of pelvic lymphatics when the risk of metastases is above 15 to 20% because retrospective data indicate a better outcome. On the other hand, many others don't treat them because RTOG 75-06 and 77-06 didn't demonstrate a better outcome. Laparoscopic lymphadenectomy with low morbidity seems to be helpful as in pN0 patients radiotherapy is not necessary. Where performing laparoscopic pelvine lymphadenectomy is impossible the probability of the frequency of lymph node metastases can be estimated using the clinical tumor stage, the Gleason-score and the pretherapeutic PSA. In case of proven metastases (pN+) some retrospective data indicate that patients with micrometastasis could profit from aggressive treatment. In case of proven metastases and extirpation by lymphadenectomy it seems that patients with hormonal therapy and radiotherapy have a longer tumor-free interval. However, there are no data from randomized trials.

CONCLUSIONS

Every radiotherapist has to make his own decision for radiotherapy of the pelvic lymphatics as there is no standard treatment. Two randomised studies are open and recruiting patients. These are one study of the ARO, investigating patients with histologically proven lymph node metastases and one study of the RTOG (RTOG 9413), investigating patients with an estimated risk of lymph node metastases > 15%. In case of radiotherapy of the pelvic lymphatics a dose of 45 Gy for suspected metastases and 50.4 Gy for proven metastases is recommended.

[Radiotherapy after radical prostatectomy: indications, results and side effects]

BACKGROUND

Radiation therapy following radical prostatectomy in locally progressed prostate carcinoma has become increasingly important in the last few years as both adjuvant therapy in patients with pT3-tumors with or without positive margins and treatment for a PSA increase in local recurrence of disease. The background for this is the knowledge gained by using PSA that up to 60% of the patients with histopathologically confirmed pT3/4 tumors or involvement of the lymph nodes are systemically and/or locally progressive after 3 to 5 years if only surgical or radiation therapy was performed.

RESULTS

A number of studies, albeit exclusively retrospective, substantiated a significantly high local tumor control by radiotherapy after radical prostatectomy. This holds true for adjuvant therapy with a PSA in the "zero range" as well as with a PSA increase from the "zero range", whereby it must be taken into consideration that a certain percentage of treated patients with a PSA in the "zero-range" with or without positive margins actually do not need further therapy. Two retrospective studies demonstrated a significant better lengthening of "freedom from treatment failure" that is local and systemic progression of disease. Lengthening the survival time has, however, not yet been proven. With an increase in the PSA from the "zero range" after radical prostatectomy, there are indications that systemic metastatic spread already occurs with values higher than 2.5 to 4 ng/ml and the radiotherapy no longer has any curative intention.

CONCLUSIONS

Adjuvant RT following radical prostatectomy gives better local control rates and probably better rates of "freedom from treatment failure" in patients with locally advanced prostate cancer with positive margins and probably in patients with negative margins. However, in retrospective studies no advantage in overall survival was shown.

Adjuvant radiotherapy following radical prostatectomy--results of 56 patients

Patients with adenocarcinoma of the prostate with positive surgical margins and/or seminal vesicle invasion after radical prostatectomy (RP) have a high risk of local recurrence or distant spread of disease. Several investigators reported increased local control rates following adjuvant radiotherapy (RT). However, it is unclear whether this procedure, with or without hormonal therapy (HT), improves the outcome. From 1975 to 1987, 56 patients with adenocarcinoma of the prostate underwent adjuvant RT following RP (pathological stage C1, n = 19; stage C2, n = 17; stage D1, n = 20). In 27 of 56 patients an additional immediate orchiectomy was performed. 48 patients received 4000-5000 cGy to the pelvic lymphatics, including the prostatic fossa, followed by a boost to the prostatic fossa to complete 6400-7000 cGy, whereas 8 patients were treated to the prostatic fossa only. With a median follow-up of 89 months, the overall survival rate of patients with stages C1, C2 and D1 did not differ significantly (10-year overall survival rate 84, 74 and 71, respectively). The local control rate for 5- and 10-years was 96 and 90%, respectively. A significant advantage in overall survival (5- and 10-year rate: 92 versus 93% and 92 versus 63%; P < 0.05, respectively) and clinical disease-free survival (5- and 10-year rate: 92 versus 72% and 92 versus 49%; P < 0.05, respectively) was seen in 27 patients with orchiectomy compared with 29 patients without HT. A total of 15 patients (26%) developed at least one form of late toxicity, in most cases a mild proctitis, cystitis, or penile or leg oedema. However, 6 patients (11%) had severe grade 3 or 4 side-effects that necessitated a cystectomy in 2 cases as well as a colostomy in 2 cases. In all patients with grade 3 or 4 side-effects, 70 Gy as a tumour-encompassing isodose were applied. Adjuvant RT, following RP in stage C and D1 prostate cancer with positive surgical margins and/or seminal vesicle invasion increases local control. Whether immediate HT influences the outcome, as seen in this study, should be proven in prospective clinical trials.

Five year follow-up after radical prostatectomy for localized prostate cancer--a study of the impact of different tumor variables on progression

Fifty-one patients with clinically localized prostate cancer stages A and B, who underwent radical prostatectomy have been followed for a minimum of 5 years. The impact of age, stage, capsular penetration, total tumor volume, Gleason score, seminal vesicle invasion and lymph node metastases on progression has been evaluated. Progression free survival was calculated according to the Kaplan-Meier method. Uni- and multivariate analyses were performed according to the Cox proportional hazards model. During the observation period 16 patients (31%) experienced progression. Tumor volume, grade and seminal vesicle invasion emerged as statistically significant predictors of tumor progression in the survival analyses while age at surgery, preoperative stage and different levels of capsular penetration were not statistically significant. The findings in the Cox models were in accordance with those at actuarial survival analyses though tumor volume was the only variable proven to have an independent statistically significant influence on progression.