Radical cystectomy as first-line treatment for clinical stage T4NxM0 prostate cancer

Clinical stage T4 prostate cancer is characterized by prostate tumors that have grown through the prostate capsule and into or even through the bladder wall. There is no agreed or “standard” form of first-line treatment for this form of localized prostate cancer.

According to a presentation by Spahn et al., given at the annual meeting of the European Association of Urology in Paris earlier this week and reported on the Medscape Web site,

After a mean follow-up of 59.9 months, … 35% of patients who underwent a cystectomy were tumor free and 20% were metastasis free 10 years after surgery. There was no difference between cancer-specific survival and overall survival.

These outcomes are based on a retrospective analysis of data from 62 patients with clinical stage T4NxM0 disease treated at eight European tertiary referral centers and at the Mayo Clinic in Rochester, Minnesota.

The question of how best to treat men with clinical stage T4NxM0 prostate cancer is problematic, and many factors need to be taken into account in making this treatment decision, most particularly the age and health of the patient and the degree to which the clinical status of the patient can be determined with great accuracy.

A radical cystectomy is a highly aggressive form of treatment that involves the complete removal of the bladder and the prostate and is often referred to as a radical cystoprostatectomy.

The patients being treated by Dr. Spahn and his colleagues had a median age of 64.1 years and all had Gleason scores of 8 to 10. Their Charlson comorbidity scores, however, were no higher than 2.

Other data reported by Spahn et al. for this cohort of patients are as follows:

  • Half the men had positive surgical margins post-surgery.
  • Half the men had pelvic lymph node involvement.
  • Many men received adjuvant radiotherapy, hormonal therapy, and chemotherapy post-surgery
  • The two independent predictors of prostate cancer-specific survival were positive surgical margins and adjuvant hormone therapy.

To quote Dr. Spahn again,

These tumors are huge, … [but] … local tumor control is excellent and all the complications we see from local tumor growth and recurrence in conservatively treated men can be avoided.

One of the moderators for the session at which Spahn et al. presented these data was careful to point out that:

  • The decision to use radical cystectomy for men with T4NxM0 diseases needs to be one that is “best for the patient.”
  • All such patients should be given a  careful cystoscopic examination prior to any decision to execute a radical cystectomy.
  • Tissue samples should be taken from the bladder so that the surgeon is 100 percent certain of the presence of clinical stage T4 disease.

The potential of radical cystectomy is considerable in a definable set of men with evident clinical stage 4 disease, with limited risk for positive lymph nodes, and who can be clearly shown to have low risk for micrometastasis at the time of treatment. However, patients need to be very clear what the consequences are of such an operation and its potential risks and benefits, and they should be fully involved in the decision process if such a procedure is to be considered.

Current recommendations for the management of clinical stage T4 prostate cancer issued by the National Comprehensive Cancer Consortium (NCCN) here in the USA and the EAU in Europe include:

  • External beam radiotherapy combined with androgen deprivation therapy (ADT) for at least 2 to 3 years
  • Brachytherapy combined with ADT
  • Radical prostatectomy with or without ADT in carefully selected men
  • ADT alone for very high-risk patients.

It can be stated, however, that there are limited data to support any of these “recommended” therapeutic options.

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