Prostatectomy in patients with PSA > 20 ng/ml

Some years have passed since D’Amico and colleagues developed their risk classification system for newly diagnosed prostate cancer patients which placed any patient with a PSA > 20 ng/ml into the high-risk category. And since the introduction of that classification system, we are aware of limited data on the long-term outcomes of surgical treatment of men who fall into that category.

Nguyen et al. have now reviewed data from a select group of patients treated between 1995 and 2006 at one French teaching hospital to assess the cancer control afforded by radical prostatectomy (RP) in patients with PSA values > 20 ng/ml. Biochemical recurrence in these patients was defined as a single rise in PSA levels over 0.2 ng/ml after surgery.

The results of this study are as follows:

  • 41 patients met the study inclusion criteria.
  • The mean age of the patients was 62 ± 6.43 years.
  • The mean PSA of these patients was 27.39 ± 13.57 ng/ml (range: 20.3 to 80 ng/ml).
  • Post-surgical pathological analysis showed that
    • The cancer was organ-confined in 21/41 cases (51.2 percent) and locally advanced in 20/41 cases (48.8 percent).
    • Positive surgical margins were detected in 15/41 cases (36.5 percent).
    • 5/41 patients (12 percent) had lymph node involvement.
    • The mean prostate volume was 58 ± 28.9 cm3.
  • The mean length of post-surgical follow-up was 94 ±37 months.
  • The median time to biochemical recurrence was 44.6 ± 22 months.
  • 24/41 patients (58.5 percent) experienced a biochemical recurrence.
  • The 5-year biochemical recurrence-free survival rate was 53 percent.

The pathological stage, the biopsy and pathological Gleason scores, and positive margin status were all individually and significantly associated with recurrence on univariate analysis. However, only margin status and pathological Gleason score were significant in multivariate analysis.

The authors conclude that RP can still be recommended as a viable first-line treatment option in carefully selected, high-risk patients with preoperative PSA values > 20 ng/ml. Patients with any evidence of Gleason grade 4 or 5 disease and clinical stage T2c or higher would seem unlikely to be appropriate candidates for such treatment on the basis of these data.

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