EXPERIENCE WITH NEOADJUVANT DIETHYLSTILBESTROL AND RADICAL PROSTATECTOMY IN PATIENTS WITH LOCALLY ADVANCED PROSTATE-CANCER

Objective To report our experience with neoadjuvant endocrine therapy and radical retropubic prostatectomy (RRP) in patients with locally ad vanced prostate cancer. Patients and methods Fifty-five patients with prostatic adenocarcinoma (18 clinical stage B2/3, 27 clinical stage C, and 10 clinical stage DO) were treated with diethylstilboestrol (DES) 3 mg/d (median time 12 weeks, range 5-36) followed by pelvic lymph no de dissection and planned RRP. Clinical response was monitored bi-week ly with serum prostate-specific antigen (PSA), serum acid phosphatase and digital rectal examination. Results The median pre-treatment serum PSA was 20.4 ng/ml (range 1.2-620). The median post-treatment, pre-op erative serum PSA was 0.4 ng/ml. Twenty-seven (49%), 41 (75%) and 54 ( 98%) patients had serum PSA levels that were undetectable, <1.0 ng/ml and <4.0 ng/ml respectively. In 15 patients, transrectal ultrasound me asurement of prostatic volume changes was performed, and all demonstra ted prostate volume reduction (median reduction 35%, range 18-45). All 55 patients underwent pelvic lymphadenectomy, with 47 (85%) undergoin g RRP. Of the eight patients not undergoing RRP, three had negative ly mph nodes but prostate resection was not deemed feasible and five had nodal metastases as determined by frozen section analysis. Final patho logical stage revealed the following distribution: organ confined tumo urs, 18 (33%): capsular perforation with negative surgical margins, se minal vesicles and lymph nodes, seven (13%); seminal vesicle and/or ma rgin involvement with negative lymph nodes, 18 (33%); lymph node metas tases, 12 (22%). Neither pre-therapy serum PSA nor serum PSA response was predictive of final pathological stage. With a median follow-up in ternal of 26 months (range 12-49), 21 patients (38%) bane undetectable serum PSA without adjuvant therapy. Conclusions Our results indicate that despite clinical evidence suggestive of downstaging, the majority of patients with locally advanced prostatic carcinoma managed with ne oadjuvant DES and RRP continue to bane pathological evidence of extrap rostatic carcinoma.