Prostate cancer will be diagnosed in 2012 in an estimated 241,740 men; 28,170 men will die, and the lifetime risk being diagnosed is 16.48% (1 in 6) in the USA [
The tumor type presented in this paper has extended through the prostate capsule into the seminal vesicles (T3b N0 M0) and is therefore categorized as a very high-risk locally advanced prostate cancer (T3b N0 M0, T4 N0 M0, or any T N1 M0). Radical prostatectomy (RP) can be a reasonable first step treating very high-risk locally advanced prostate cancer in selected patients [
In 1995, a 61-year-old male presented lower urinary tract symptoms secondary to benign prostate hyperplasia to an outpatient urologist. Diagnostic data were in agreement with a benign prostatic obstruction based on benign prostatic enlargement. First, the urologist prescribed extracts of the saw palmetto plant (
In 1997, at age 63, following a suspicious digital rectal exam of the prostate gland, the concentration of prostate-specific antigen in blood was measured for the first time. The level was 9.1 ug/L. A transrectal ultrasound examination identified a conspicuous region. A consecutive guided biopsy of the tissue of this region revealed an adenocarcinoma of the prostate gland with a Gleason score of 4.
A secondary level of care hospital in Germany offered a radical prostatectomy (RP) because of young age and insignificant comorbidities. The size of the removed prostate gland was approximately 150 mL (5.3 cm diameter). Histopathological evaluation revealed an adenocarcinoma that had broadly penetrated the margins of the prostate gland. The tumor mass had bilaterally invaded into the surrounding soft tissue, the seminal gland, and the seminal tract. Furthermore, the urethra was also involved with tumor infiltration. Urinary bladder was not involved. The pathologist identified a wide positive surgical margin in the resection material. Preoperatively, computed tomography did not identify affected pelvic lymph nodes and total body skeletal scintigraphy did not identify distant bone metastases. The pathological staging of T3b N0 M0 (T3c N0 M0 of the TNM modification at that time) was compatible with a high-risk locally advanced prostate cancer. The Gleason score was not determined.
An early androgen deprivation therapy (ADT) was offered using the gonadotropin-releasing hormone (GnRH) analogon leuprorelin. Due to severe adverse events, ADT was discontinued after eight months and followed by radiation therapy (RT) by a nearby tertiary level of care hospital with a total dose of 66 Gy within the next two months after discontinuation of ADT. The patient is alive with no evidence of disease after a followup of 15 years. A PSA level below 0.1 ng/mL for 15 years is compatible with complete remission and absent prostate cancer in 2012.
The patient expressed several complaints. RP was regarded by the physicians as the best choice. Treatment alternatives were not discussed and a shared-decision making was not was not offered. The patient complained mainly about loss of sexual function and enuresis. He asked whether these adverse effects could have been prevented and why he was not informed about the extensive impact of adverse effects. The patient had substantial difficulties to endure the pronounced adverse effect of androgen deprivation therapy. Temporary adverse effects of the patient included a urinary bladder neck stricture treated by electrocauterization, mood depression, emotional distortion, hair loss, and painful defecation. Treatment-related long-term adverse effects of the patient included erectile dysfunction, urinary and rectal incontinence, and gynecomastia. Health-related quality of life is reduced substantially. It is not known whether the sacrifice of sexual integrity was necessary to save the life.
The senior clinician of the hospital misled the patient about the unexpected pathological stage after operation. Hospital representatives informed the patient that everything is alright and that the prostate gland with its cancer tissue inside has been removed. Neither the invasion across the capsule into other organs nor the positive surgical margin and its implication of residual prostate cancer tissue in the body were addressed. The head of the urology department stated that he did not want to worsen the patient's depressed mood. Weeks after discharge, the patient learned about the outcome from a copy of the medical report, which was sent to the general practicioner.
We searched PubMed on February 05, 2012 using these search terms “Prostatic Neoplasms” (MeSH) AND “Prostatectomy” (MeSH) AND “locally advanced” (tiab) and retrieved 330 results. We retrieved two systematic reviews and 18 trials in The Cochrane Library using the same search terms. We used the Clinical Queries of PubMed using these search terms locally advanced prostate cancer radical prostatectomy and retrieved 219 results applying the
Locally advanced prostate cancer is characterized by extracapsular extension including microscopic bladder neck involvement (pT3a) or invading the seminal vesicles (pT3b) or invading other adjacent organs (T4). Positive lymph nodes may be present but distant metastases should be ruled out.
Detection of prostate cancer and differentiation from benign prostate hyperplasia (BPH) depend on histopathological assessment enabled by prostate biopsy [
It is not possible to certainly differentiate a fast from a slow growing tumor. DRE often underestimates the presence of tumor, transrectal ultrasound (TRUS) is not useful for detection of tumor, and PSA is produced by benign and malignant prostatic tissue. The higher the PSA gets the higher the risk for any type of prostate cancer is. For example, the risk of prostate cancer for patients with “normal” PSA levels is estimated at 6.6% for levels 0 to 0.5 ng/mL and climbs up to 26.9% for levels 3.1 to 4 ng/mL [
About 20% of T3 tumors were found to be overstaged, that is, the pathological stage pT2 was found in a patient with a supposed clinical stage cT3 [
In the recent update of the European Association of Urology (EAU) Guidelines of Prostate Cancer RP is recommended as an optional treatment for selected patients with local advanced prostate cancer stage T3a and a multimodal approach including RP and adjuvant RT might be indicated [
Biochemical recurrence will affect a considerable number of patients. It is reported by Xylinas et al., 2010, in 15% to 53% after primary curative therapy [
Overall survival was reported about 77% after RP: 90.2% at 7-year stages T3 to T4 [
After RP, a positive surgical margin was reported in 18.5% to 70.4% of patients with clinical stages ranging from pT2a to pT4 [
After RP, seminal vesicle involvement was reported in 8.5% to 32.1% of patients with clinical stages ranging from pT2a to pT4 [
Xylinas et al., 2010, reported 4% urinary incontinence and 46% erectile dysfunction after RP [
The patient described in the case report was understaged in cT2 with a low risk in agreement with a PSA level below 10 ng/mL. RP was offered because patient had a life expectancy of more than 10 years. This first-line approach is consistent with the current recommendation to offer RP as a standard treatment for the appropriate stages. The pathologic examination established a pT3 stage with a very high risk due to positive surgical margin and seminal vesicle involvement. Adjuvant ADT and RT are consistent with the current recommendation to offer a multimodal therapy. A PSA of less than 0.1 ng/mL within 15 years means a long lasting recurrence-free survival. An alternative treatment might have also led to a tumor control with better preservation of health-related quality of life. Further studies are needed to evaluate long-term health-related quality of life after RP and adjuvant RT versus primary RT without RP, so that the best possible treatment is chosen for our patients. According to current guidelines, patients with high risk disease should be well selected before the indication for primary RP [
The authors declare that they have no competing interests.