RALP in treatment of high-risk prostate cancer: a systematic review

Researchers from City of Hope in Los Angeles have conducted an expert, systematic review of the published literature on the use of robot-assisted, laparoscopic radical prostatectomy (RALP) in the management of high-risk, localized prostate cancer.

This new review by Yuh et al. identified a total of 12 peer-reviewed, published papers addressing outcomes in the treatment of 1,360 patients publshed up to and including October 2012. In particular, the research team was interested in looking at things like the indications for surgical treatment of high-risk disease, the roles of nerve-sparing and lymph node dissection in such patients, and other outcomes-related issues.

Here are the key findings from the review:

  • 8/12 studies (67 percent) applied the D’Amico criteria in defining high-risk disease (i.e., any one or more of a Gleason score of 8 to 10; a clinical stage of T2c or T3a, or a PSA > 20 ng/ml).
  •  61 percent of patients were identified as having high-risk disease based on a biopsy-based Gleason score of 8 to 10.
  • Length of follow-up post-RALP ranged from 9.7 to 37.7 months.
  • The incidence of nerve sparing varied (as one would expect), but when nerve-sparing was performed it did not seem to compromise oncologic outcomes.
  • Extended lymph node dissection identified positive nodes in up to a third of patients.
  • 3 percent of men undergoing extended lymph node dissection had symptomatic lymphocele (a cystic mass containing lymphatic fluid) after the procedure.
  • The average (mean) overall operative time was 168 min.
  • Estimated blood loss averaged 189 ml.
  • Total length of hospital stay averaged 3.2 days.
  • Time on catheterization post-surgery averaged 7.8 days.
  • Continence rates at 12 months post-surgery (using a no-pad definition for continence) ranged from 51 to 95 percent.
  • Potency recovery ranged from 52 to 60 percent (although potency is not defined in the study’s abstract).
  • The rate for organ-confined prostate cancer was 35 percent.
  • The rate for positive margins was 35 percent.
  • The rate of biochemical recurrence-free survival at 3 years post-surgery ranged from 45 to 86 percent.

Yuh et al. conclude that, although the published data on the use of RALP for high-risk prostate cancer are limited, “it appears safe and effective for select patients” and  “Short-term results are similar to the literature on open radical prostatectomy.”

They also note that there is some degree of variation in the application of nerve-sparing and in the extent to which lymph node dissection is conducted, but it is clear that extended lymph node dissection “improves staging and removes a higher number of metastatic nodes.”

2 Responses

  1. And once the surgery is done comes the pathology report, upon which future treatment decisions are based. Many are aware that it might be wise to seek a second opinion on a biopsy report, especially when it was done at a local hospital and not by a prostate cancer specialist. But a very recent study (“Gleason scoring at a comprehensive cancer center: what’s the difference?) shows that the same logic applies to a post-prostatectomy clinical pathology report.

    For an ongoing clinical trial, Fox Chase Cancer Center (FCCC) reviewed the pathology reports for prospective participants for proper classification. In this process, they changed the Gleason score (GS) from that of the referring institution (RI) as follows:

    “Overall, compared with RI GS (ie, 6 vs 7 vs 8-9), FCCC GS was upgraded in 8% of patients and downgraded in 6% of patients. In the RI GS 6 (3 + 3) group, 79 (8%) patients were upgraded to the intermediate category: 62 patients (6%) upgraded to GS 3 + 4, and 17 (2%) upgraded to GS 4 + 3. A greater impact of the FCCC SPR was observed in the RI GS 7 group where 20% were downgraded to FCCC GS 6 and 2% upgraded to FCCC GS 8 through 9. Regarding changes within the GS 7 group, 12% of men with RI GS 3 + 4 were reassigned FCCC GS 4 + 3 and 14% of men with RI GS 4 + 3 were reassigned FCCC GS 3 + 4. The greatest impact of the FCCC SPR was seen in the RI GS 8 through 9 group, wherein most men (58%) were downgraded to FCCC GS 6 (12%) or 7 (88%). The FCCC GS altered the NCCN risk group assignment in 144 men (9%): 92 (64%) men to lower risk and 52 (36%) to higher risk.”

    The study aimed to find out the effect of a second confirmatory pathology report (SPR) in predicting biochemical failure (BF). It concludes:

    “An SPR at a dedicated comprehensive cancer center by a pathologist specializing in genitourinary malignancies resulted in a change in GS grouping in 13% and GS overall by 26%. The FCCC GS altered the NCCN risk group assignment in 144 men (9%): 92 (64%) men to lower risk and 52 (36%) to higher risk. These changes all have the potential to alter management and prognosis. The GSs assigned based on the SPR provided greater prognostication of BF risk. Patients may benefit from national standards encouraging an SPR at a comprehensive cancer center.”

    Other papers cited by the study also noted similar changes when pathology reports underwent central review.

    Considering the weight of the Gleason score in all treatment decisions after RALP, some may feel one in 11 chance of an erroneous NCCN risk classification and a 14% percent chance of an erroneous Gleason score justifies the added expense of a second opinion by an expert prostate cancer pathologist.

  2. Dear Tom:

    While your analysis is certainly meaningful and appropriate, there is still a small problem. Even two or three experts may not agree about the Gleason classification of specific specimens (when they each review the specimen independently). The assignation of Gleason grades is by no means “an exact science”.

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