Radical prostatectomy in very high-risk localized prostate cancer: long-term outcomes and outcome predictors.

Objective: The objective of this study was to present the long-term outcomes and determine outcome predictors in very high-risk (cT3b-T4) prostate cancer (PCa) after radical prostatectomy (RP).

Material and methods: Between January 1989 and December 2004, 51 patients with cT3b-T4 PCa underwent RP. Kaplan-Meier survival analysis was used to calculate the biochemical progression-free survival (BPFS), clinical progression-free survival (CPFS), cancer-specific survival (CSS) and overall survival (OS) rate. Multivariate Cox proportional hazard models were used to determine the predictive power of clinical and pathological variables in BPFS and CPFS.

Results: Median follow-up was 108 months [interquartile range (IQR) 73.5-144.5]. The median serum prostate-specific antigen (PSA) was 16.9 ng/ml (IQR 7-37.2). Median biopsy and pathological Gleason (pGS) score were both scored as 7 (range 4-10 and 5-9, respectively). Overstaging was frequent (37.2%); four patients (7.8%) had organ-confined stage pT2, while 15 (29.4%) had extracapsular extension only (pT3a). Another 23 (45.1%) were confirmed with seminal vesicle invasion (pT3b) and nine (17.7%) had adjacent structure invasion (pT4). Eleven patients (21.6%) had lymph-node involvement. Thirty-two patients (62.7%) had positive surgical margins. The BPFS, CPFS, CSS and OS at 5 and 10 years were 52.7%, 45.8%;78.0%, 72.5%; 91.9%, 91.9% and 88.0%, 70.7%. In the multivariate Cox proportional hazard models, pathological stage was an independent predictor of BPFS while preoperative PSA and pGS was an independent predictor of CPFS.

Conclusions: The management of cT3b-T4 PCa typically consists of a multimodality treatment in which RP is a valuable first step. Overstaging was frequent (37.2%), and almost one-quarter of the patients remained free of additional treatments. Long-term cancer-related outcomes were very satisfactory.