**6. Survival**

142 Prostate Cancer – Diagnostic and Therapeutic Advances

This approach has been facilitated by recent anatomical descriptions of the periprostatic

Dissection of the neurovascular bundles can be done in an intrafascial plane (directly adjacent to the prostatic capsule; complete nerve sparing), an interfascial plane (within the lateral prostatic fascia; partial nerve sparing) and extrafascial plane (outside the lateral

Deep dissection beneath Denonvilliers' fascia posteriorly should be performed routinely, as few nerves are present in this area and deep dissection will reduce the incidence of

Large, high-grade cancers, near the base of the prostate, or in the anterior transition zone often invade the bladder neck. For anterior cancers, begin division of the bladder neck a centimeter or more from its junction with the prostate. For large posterior tumors or those with seminal vesicle invasion, include the posterior bladder distal to the interureteral ridge

For patients with low risk disease, PLND is not necessary and is not recommended, because

For patients with high and intermediate risk disease, extended PLND at least for external iliac, obturator and hypogastric lymph nodes should be performed during radical prostatectomy. Removing at least 10 lymph nodes is recommended to detect LNI. (52) Prostate cancer lymphatic spread ascends from the pelvis up to the retroperitoneum invariably through common iliac lymph nodes. PC lymphatic spread can be divided in two

So the technique try to remove all lymphatic tissue between the external iliac vein and hypogastric vein above and below the obturator nerve, including the hypogastric and

Therefore may assert that an eLND should be performed in all high-risk cases, as the

However, despite the above, some authors like Bubley are not so categorical in affirming this. Although it is generally accepted that eLND provides important information for prognosis (number of nodes involved, tumour volume within the lymph node, capsular perforation of the node) that cannot be matched by any other current procedure, consensus has not been reached as to when eLND is indicated and to what extent it should be performed. When making such decisions, many physicians rely on nomograms based on pre-operative

As stated earlier, currently, a multimodal treatment is chosen to increase survival and

The EORTC Trial 22911 included 1,005 patients with positive surgical margins or pT3 disease (extracapsular extension and seminal vesicle involvement) and randomized them to adjuvant EBRT (50 Gy to the prostatic fossa and periprostatic tissue plus a 10–14 Gy

reduce biochemical progression. In this sense the RT play an important role.

main levels: pelvic and common iliac plus retroperitoneal lymph nodes. (53)

estimated risk for positive lymph nodes will be in the range 15-40%. (10)

anatomy. (51)

prostatic fascia; nerve resection)

**5. Pelvic lymph node dissection** 

biochemical markers and biopsies. (54)

**Indications for RT after RP** 

**5.1 Role of RT in high risk prostate cancer** 

There are two important studies about this:

the chance of metastasis is low.

obturator lymph nodes.

posterolateral margins.

in the specimen. (48)

Regarding cancer-specific survival rate, and the overall survival rate, there are many studies, with different results (table 4).

First, in terms of morbidity, Berglund and colleagues (58) showed, that recovery from surgery, duration of catheterization, and the overall return of continence were essentially similar to those observed in the low-risk population.

Another important factor to consider when analyzing survival, is the overstaging sometimes happens in the T3. Therefore, Ward et al report a long-term experience with radical surgery in patients presenting with locally advanced (cT3) prostate cancer, as the best management of such patients remains a problem. They found that, significantly many patients with cT3 prostate cancer were over-staged (pT2) in the PSA era, and RP as part of a multimodal treatment strategy for patients with cT3 disease offers cancer control and survival rates approaching those achieved for cT2 disease. (31)

For short term survival, Loeb et al (35) reported a complication rate of 11% in 288 consecutive high-risk patients treated by RP, which was not different from the rate in a previous study from the same group that included 3,477 consecutive patients with prostate cancer (59) when analyzing intermediate-term cancer control, and quality-of-life outcomes after radical retropubic prostatectomy (RRP), and concluded that RRP offers excellent intermediate-term cancer control for selected men, of all ages, who present with high-risk or locally advanced disease. Both, continence and potency, were preserved in most patients, although the potency rates were significantly greater for the younger men. RRP with appropiate postoperative radiotherapy and/or hormonal therapy is a reasonable treatment option for selected men with high-risk or locally advanced disease. (35) (Table 4)

Radical Prostatectomy in High Risk Prostate Cancer 145

**organ** 

Gleason 8-10 274 35 53 88 PSA > 20 275 33 56 91 T3c(\*year 1992) 144 22 49 89

5 years ≤50% 391 28 53 92

ng/mL/year 952 63 80 97

Gleason 8-10 957 43 68 93

Gleason 8-10 1752 51 73 95

Local control, main objective with both techniques, is better achieved with surgery. Local relapse rates between 3-30%(63-65) Depends on clinical stage (pT2: 2-7%; negative margins 7%; pT3-4: 40%; positive margin 27%) While with Radiotherapy, local recurrence rate is for

The rate of positive biopsies is between 20-70%, although is difficult to classify its meaning, they highlight disease and progression. It depend on clinical stage (B=17%, C=59%) and

Frequency of positive prostate biopsies on patients whom underwent radiotherapy, is

In the study (66) with 100 patients, with biopsy every 6 months showed following results T-

There is no doubt regarding its prognostic value. Although the pioneers showing these results were Rhamy (1972) and Sewel (1975) Scardino has been reporting, and highlighting its value (67). At Baylor-Collegue (Houston) 147 patients treated with Au 198 and external bean radiotherapy, clinical stage A2, B, C with pelvic lymphadenectomy. They had a positive biopsy rate of 42%, 36%, 28% at 6, 12 and 18 months. The chance of local recurrence at 5 years for positive and negative biopsies is around 52% and 12%, and at 10 years of 72% and 30%.

Many cancers, categorized clinically as high risk, are actually pathologically confined to the prostate, and most men with such cancers who undergo RP, are free of additional therapy

For men with high-risk, clinically localized prostate cancer, decisions on whether to elect surgery as local definitive therapy should be based on the best available clinical evidence

rather than on an individual practitioner's experiences and biases.

Gleason score. A valuable biopsy is at 18 months after finishing treatment.

**% free survival in 5 years** 

**% cancer specific survival in 10 years** 

**Criterion R Nº patients % confined** 

T1: 17-22% (Standford); 4.6% (Schelhamer); T2: 19%-35%.

Nomogram PFP

PSA velocity >2

PSA≥ 20 o ≥T2c o

PSA≥15 o T2Bc o

**7. Local control** 

around 38% on average.

**8. Conclusions** 

long after surgery.

1b: 21%; en T-2a: 24%; en T-2b-c: 28%.

Table 5.


BR: Bioquimical recurrence NR: No results.

Table 4.

For long term survival, Van Poppel (60) showed in 2006, that in patients with locally advanced disease, the cancer-specific survival rate after RP at 5- and 10-years of follow-up, was 85-100% and 57-91.6%, respectively. The overall survival rate at 5 and 10 yr was, 75% and 60%, respectively. In patients with high-grade prostate cancer (Gleason score> or =8), the biochemical recurrence-free survival, after RP at 5 and 10 yr of follow-up was, 51% and 39%, respectively.

Van Der Ouden et al. determined the progression and survival rates, and investigate subgroups of patients who may not benefit from this treatment. Defining that Radical prostatectomy as monotherapy, in patients with locally advanced non-metastatic prostate cancer (T3) produces acceptable results, in those with well or moderately differentiated tumors. The results of progression and survival, are not significantly different from those patients with organ confined prostate cancer. (29)

Yossepowitch describe the results of RP in their patient's serie, classify patients in risk groups: (61) he studied pathological and clinical outcomes among high-risk patients treated with RP. To identify high-risk subsets, eight definitions from the medical literature were applied. Depending on the criteria, high-risk patients comprised 3% to 38% of the entire study population, highlighting the immense variability among available high-risk definitions.

High-risk patients were more likely to exhibit adverse pathological features (35%–71% with extra capsular extension, 10%–33% with seminal vesicle invasion, and 7%–23% with lymph node involvement), but roughly one third (22%–63%) had organ-confined cancers and nearly half (41%–74%) remained progression-free 10 years after surgery alone. (Table 5)

More recently the group from the Mayo Clinic, has reported their long-term result after radical prostatectomy versus external bean radiotherapy for patients with high-risk prostate cancer. (62) The 10-year cancer specific survival rate was 92%, 92% and 88% after RRP, EBRT plus ADT and EBRT alone. After adjusting for case mix, no significant differences in the risks of systemic progression or prostate cancer death were observed between patients who received EBRT plus ADT and patients who underwent RRP. However, the risk of all causes of mortality was greater, and statistically significant, after EBRT plus ADT than after RRP.


Table 5.

144 Prostate Cancer – Diagnostic and Therapeutic Advances

**% 5 years BR free survival**

8-10 281 65 NR

or PSA ≥15 o T3 288 39-53 70-93

Gleason ≤7 32 3mo:90 NR

For long term survival, Van Poppel (60) showed in 2006, that in patients with locally advanced disease, the cancer-specific survival rate after RP at 5- and 10-years of follow-up, was 85-100% and 57-91.6%, respectively. The overall survival rate at 5 and 10 yr was, 75% and 60%, respectively. In patients with high-grade prostate cancer (Gleason score> or =8), the biochemical recurrence-free survival, after RP at 5 and 10 yr of follow-up was, 51% and

Van Der Ouden et al. determined the progression and survival rates, and investigate subgroups of patients who may not benefit from this treatment. Defining that Radical prostatectomy as monotherapy, in patients with locally advanced non-metastatic prostate cancer (T3) produces acceptable results, in those with well or moderately differentiated tumors. The results of progression and survival, are not significantly different from those

Yossepowitch describe the results of RP in their patient's serie, classify patients in risk groups: (61) he studied pathological and clinical outcomes among high-risk patients treated with RP. To identify high-risk subsets, eight definitions from the medical literature were applied. Depending on the criteria, high-risk patients comprised 3% to 38% of the entire study population, highlighting the immense variability among available high-risk definitions. High-risk patients were more likely to exhibit adverse pathological features (35%–71% with extra capsular extension, 10%–33% with seminal vesicle invasion, and 7%–23% with lymph node involvement), but roughly one third (22%–63%) had organ-confined cancers and nearly half (41%–74%) remained progression-free 10 years after surgery alone. (Table 5) More recently the group from the Mayo Clinic, has reported their long-term result after radical prostatectomy versus external bean radiotherapy for patients with high-risk prostate cancer. (62) The 10-year cancer specific survival rate was 92%, 92% and 88% after RRP, EBRT plus ADT and EBRT alone. After adjusting for case mix, no significant differences in the risks of systemic progression or prostate cancer death were observed between patients who received EBRT plus ADT and patients who underwent RRP. However, the risk of all causes of mortality was greater, and statistically significant, after EBRT plus ADT than after RRP.

**% 10 years cancer especif survival** 

**Patients** 

Ouden (29) T3 clínic 136 39 72 Hsu (26) T3 clínic 235 60 92 Ward (20) T3 clínic 841 58 90; 15 y 79 Lau (23) Gleason 8-10 407 49 85

**<sup>↑</sup>Risk Nº** 

Van de

Van Poppel (27)

NR: No results.

39%, respectively.

Table 4.

BR: Bioquimical recurrence

Berglund (19) PSA ≥15 or Gleason

Loeb (21) T2 and Gleason 8-10

T3a y PSA ≤20 and

patients with organ confined prostate cancer. (29)
