Radical prostatectomy as a monotherapy for locally advanced (stage T3) prostate cancer

Within a prospective protocol initiated in 1977, 100 patients with locally extensive prostate cancer (stage T3, 1982 tumor, nodes and metastasis classification) were treated by pelvic node dissection and radical prostatectomy as monotherapy. Adjuvant treatment was not given until disease progression. Radical prostatectomy, except for 3 young patients with a single micrometastasis, was not done if positive lymph nodes were found at frozen section. Six patients had positive lymph nodes at permanent sections but not at frozen section. Average followup was 43.9 months (range 1 to 155 months). Histological grade was determined according to the Mostofi system. Progression was determined biochemically (prostate specific antigen elevation) and clinically by evidence of metastatic disease, either histologically proved or evidenced as new hot spots on bone scan or chest x-rays. Of the 100 patients 41 did not undergo radical prostatectomy: 39 because of positive lymph nodes and 2 because of evidence of a stage pT4 tumor at surgical exploration. Of those 59 patients who underwent radical prostatectomy 9 had positive lymph nodes, while 2 had stage pT4, 39 stage pT3 and 9 stage pT2 tumors. Only 1 of the 9 patients with lymph node metastases is free of biochemical or clinical progression. Disease also progressed in both stage pT4, 27 of 39 stage pT3 and none of the 9 stage pT2 cases. A total of 22 patients was free of clinical or biochemical progression. Clinical progression was evidenced in approximately half of the cases as distant and local progression. Data on stage T3 disease were compared to those of 129 patients with stages T0 to T2 disease. There was a significant difference in interval to clinical progression for these 2 groups (p = 0.001). However, if grade 3 cases were excluded from the stage T3 group, this difference disappeared. Prognostic factors analyzed were pretreatment and posttreatment grade, pretreatment prostate specific antigen and prostatic acid phosphatase levels, positive margins, seminal vesicle invasion and nodal status. The analysis allows one to identify groups of patients who may benefit and others who certainly do not benefit from radical prostatectomy in this disease category. In the latter group effective adjuvant treatment is urgently indicated.