Post-surgical outcomes of men with positive seminal vesicles over time

An interesting research question is whether, given the earlier diagnosis, the reduced risk for positive surgical margins, and the reduced likelihood of positive lymph nodes at the time of diagnosis in the contemporary PSA era, there has been any impact on the long-term outcomes of men with pathologic T3b prostate cancer post-surgery.

pT3b prostate cancer is the formal pathologic definition of positive seminal vesicles at the time of surgery. Pierorazio et al. carried out a retrospective analysis of data from the nearly 30-year-long Johns Hopkins database to try to answer this question.

They initially searched the database for men with pT3b disease, finding 989 such patients among the total of 18,505 men treated by radical prostatectomy between 1982 and 2010.

They then divided these 989 patients into three groups by time period:

  • A pre-PSA group (treated between 1982 and 1992)
  • An early PSA group (treated between 1993 and 2000)
  • A contemporary group (treated between 2001 and 2010)

They were first able to show that, based on these 989 men and the total number of men treated (18,505), the incidence of pT3b disease had clearly dropped over time:

  • 7.7 percent in the pre-PSA era
  • 4.3 percent in the early PSA era
  • 3.3 percent in the contemporary era

When they assessed the outcomes of the 989 men with pT3b disease according to time period as defined above, they found the following:

  • 140 men treated in the early PSA and contemporary eras had  positive lymph nodes and were excluded from the study.
  • Of the remaining 732 patients with pT3bN0 disease
    • The 10-year biochemical recurrence-free survival rates were 25.8 percent in the pre-PSA group, 28.6 percent in the early PSA group, and 19.6 in the contemporary group.
    • The 10-year prostate cancer-specific survival rates were 79.9 percent in the pre-PSA group, 79.6 percent in the early PSA group, and 83.8 percent in the contemporary group.
  • Among pT3bN0 cases in the early PSA and contemporary groups combined
    • PSA level, clinical stage ≥ T2b, pathological Gleason sum 7 and 8–10, and positive surgical margins were significant predictors of biochemical recurrence-free survival.
    • Clinical stage ≥ T2c and Gleason 8–10 were predictors of metastasis-free and prostate cancer-specific survival.

The authors conclude that, in the Johns Hopkins series, even though there has been a reduction in the number of patients diagnosed with  pT3b disease from 1982 to the present, as well as a reduction in the frequency of occurrence of positive surgical margins and positive lymph nodes, patients with seminal vesicle invasion still have a relatively high rate of biochemical progression (> 70 percent) within 10 years of their surgery (compared to 75 to 80 percent in the pre-PSA and early PSA eras). For men with pTb disease treated in the contemporary era, the 10-year prostate cancer-specific mortality rate is of the order of 16 percent (compared to about 20 percent in the pre-PSA and early PSA eras).

11 Responses

  1. Does this study say that the PCSM is 16% at the 10-year mark with surgery alone, and that no other treatment has been given except for surgery?

    Thank you for your input!

  2. The paper states that:

    “In the contemporary PSA era, 30 men with pT3bN0 (5.1%) received [adjuvant radiation therapy], including 19 with positive SMs. A total of 141 men (41.1%) received adjuvant or salvage radiation (73 or 21.5%), hormone therapy (96 or 28.2%) and/or chemotherapy (29 or 8.9%). When the 144 patients who received adjuvant or salvage therapy were excluded, multivariate analysis including the same variables as before indicated that pathological Gleason sum 8–10 (HR 4.7, 95% CI 1.6–13.6, p = 0.004) and positive SMs (HR 2.5, 95% CI 1.4–4.3, p = 0.001) were predictors of BFS. In general, patients receive salvage therapy upon evidence of metastatic disease at our institution.”

    Johns Hopkins has long maintained that there is limited benefit to the use of hormonal therapy prior to the occurrence of symptoms of metastatic disease.

  3. We can see from this study that PSA testing results in a significant reduction in the percentage of pT3b disease, an increase in the biochemical failure-recurrence rate, and an increase in prostate cancer survivability. My conclusion is that we need to promote PSA testing.

    Do it early and do it often!

  4. Dear Reuven:

    Actually the whole point being made by this study is that despite the significant reduction in the incidence of pT3b disease (which is > 50% compared to the pre-PSA era), the impact on biochemical progression-free survival and prostate cancer-specific survival in these patients is rather small.

  5. Yea … I’m happy to read that. (Not really, I’m a pT3b patient diagnosed at the age of 44.)

    But I side with the 144 and not Johns Hopkins. We do have study data out there that shows that neoadjuvant hormone therapy improves the performance of radiation therapy, adjuvant radiation therapy, and salvage radiation therapy. I certainly hope it gets me past this study data in good shape.

  6. Tony: As far as I am aware, Johns Hopkins does use hormone therapy in combination with radiation therapy (where there are data from large, randomized, double-blind trials showing a clear survival benefit). They do not use early hormone therapy alone to manage men with a rising PSA.

  7. Hi.

    I am someone who has just just been told that the radical surgery “worked” in that the cancerous prostate was removed and that the margins were clear but that the cancer has spread into the seminal vesicles, plus I am now regarded as a pT3b, with a Gleason score of 7 but a low PSA (less than 5 ng/ml) before surgery.

    I have been told that I will need radiation therapy starting in September for 6 weeks as well as hormone therapy for 1 year.

    My questions are — (1) What are the chances that this will work? (2) What are the rates for 5 and 10 years without a return of the cancer? (3) What are the rates of 10-year plus survival following this treatment for people in my situation. Are there any alternatives?


  8. Dear Chris:

    First, the precise role of combined adjuvant radiation and androgen deprivation therapy in men with T3b disease and an elevated Gleason score is highly dependent on the precise clinical characteristics of the individual patient. In addition, its use is controversial, and the length of time that the patient should be on androgen deprivation (ADT, a.k.a. “hormone” therapy) can vary from 3 months to 2 years.

    Second, I know of no nomogram that can give you accurate predictive data on outcomes after this type of treatment in men like you. It requires large series of men to create such nomograms, and I doubt if such data exist at any one center.

    My suggestion is as follows:

    (1) The first thing that needs to be established is your PSA level post surgery. Ideally this should be established using ultrasensitive PSA testing to see if your PSA has dropped down to a level of less than 0.01 ng/ml.

    (2) Having adjuvant therapy of the type suggested is very certainly an option. It is designed to minimize the probability of recurrence of your disease. However, … if your PSA drops to < 0.01 ng/ml post-surgery it can be carefully monitored using ultasensitive PSA tests, and the same type of therapy could be instituted if/when there was any significant suggestion of a recurrence and a rising PSA.

    The use of adjuvant or so-called "salvage" radiation therapy with or without ADT in men like you is, in the end, a matter of the doctor's opinion and the patient's choice. The first thing you might want to do is use the Kattan post-treatment nomogram to establish your risk for recurrence if you don’t do anything. To use that nomogram, however, you do need to know that your PSA has dropped to at least < 0.1 ng/ml following your surgery.

    If you want to join our social network, we could discuss your options there in a lot more detail.

  9. I had my prostate removed 26 months ago. The pathology report said pT3b. My PSA was 5 before surgery; now it’s at 0.01 and hasn’t changed since surgery. I decided to not have any further treatments … just waiting and watching. I was 59 at time of surgery.

  10. Much like Chris, my RP was “successful,” resulting in clear margins, including at the tumor extension toward the bladder neck, but pathology confirmed positive unilateral seminal vesicle involvement and positive involvement in one of 13 nodes. My cancer has been designated pT3bN1.

    I’ll have my first post-op PSA test in August and will discuss with my doctor the recommended course of treatment then.

    For the time being, I’m wondering if data are available comparing long-term outcomes in patients with only either seminal vesicle involvement (one of both sides) or node involvement (one or more nodes) with patients who have both seminal vesicle and node involvement.

    Thank you.

  11. Dear Robert:

    IF your initial PSA level after surgery drops to 0.1 ng/ml or lower, then you can use the post-surgical nomogram on the Memorial Sloan-Kettering Cancer Center web site to estimate your probabilities of progression-free survival at up to 10 years and your probability of prostate cancer-specific survival at 15 years. This nomogram is based on extensive outcome data from many hundreds of patients.

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