ONCOLOGIC OUTCOMES FOLLOWING RADICAL PROSTATECTOMY IN MEN WITH LOCALLY ADVANCED DISEASE

Introduction & Objectives: The role of surgery in the management of clinically locally advanced prostate cancer is unclear. We review our long term experience with radical prostatectomy and selective adjuvant radiation treatment in patients with clinical stage T3 prostate cancer and negative lymph nodes to better understand the role of surgery in these high-risk patients Material & Methods: Among the 2226 men underwent radical prostatectomy from 1983 to 2000 at our institution, we identified all 104 men with cT3 disease at the time of surgery. An additional 214 men with cT2c disease matched to age, PSA, Gleason score and stage were identified as a potential control group. Forty-six (44%) of the cT3 patients and 56 (26%) of the cT2 patients were excluded from further analysis when they were found to have positive lymph nodes at the time of surgery. Overall survival, clinical recurrence-free survival, and biochemical recurrence-free survival were analyzed using appropriate survival analytic techniques. Appropriate univariate and multivariable analyses were performed to examine the risk factors for clinical outcomes. Results: Median follow-up was 14 years (Range: 0.6 to 20.5 years). There were no significant differences in overall survival between cT2c, cT3a and cT3b/c patients. Clinical recurrencefree survival at 14 years for cT2c, cT3a, and cT3b/c patients was 86.5%, 85.3% and 64.3% respectively (p<0.001,. PSA recurrence-free survival at 14 years was similar, with disease-free rates of 58.9%, 54.1% and 42.3% for cT2c, cT3a and cT3b/c patients respectively (p<0.001). After controlling for other potential confounding variables, Cox proportional hazards analyses revealed that men with cT3b/c disease were 4.2 (95% CI: 1.4-12.6) times more likely to experience clinical recurrence, and 4.5 (95% CI: 2.0-9.9) times more likely to experience a biochemical failure when compared to cT2c cases. Men with cT3a disease were statistically no more likely to experience these adverse outcomes than men with cT2c disease in the multivariable analysis. Finally, adjuvant radiation therapy did not appear to be an independent predictor for disease progression or biochemical failure. Conclusions: The results of the current analysis indicate that, in men with clinically advanced disease (cT3) and negative lymph nodes, outcomes between those with cT3a and cT2c are similar when controlling for other potential confounding factors. However, this is not true for men with cT3b/c disease, who appear to perform worse. These findings imply that there may be a role for radical prostatectomy in men with locally advanced disease, although it is likely that men who have more advanced disease (cT3b/c) or positive lymph nodes will require adjuvant therapy.