Role of radical prostatectomy in patients with prostate cancer of high Gleason score

BACKGROUND. The routine use of serum prostate-specific antigen (PSA) testin g combined with digital rectal examination has lowered tumor volume and cli nical-pathological stage of men undergoing radical prostatectomy. Therefore , we may identify more men with poorly differentiated tumors of early clini cal stage. In order to identify those who may benefit from radical prostate ctomy, we evaluated known prognostic variables in patients with prostate ca ncer of high Gleason score (8-10). METHODS. Of 652 patients who underwent a radical prostatectomy as monothera py for clinically localized prostate cancer between March 1991-December 199 5, 84 patients with prostatectomy specimen Gleason score 8-10 tumors were i dentified. Clinical-pathological data were obtained from our prostate cance r database. Gleason score, PSA level, margin status, pathologic stage, and tumor volume were analyzed as general prognostic variables for disease-free survival (DFS). Follow-up ranged from 13-84 months (median, 36.2). Biochem ical recurrence was defined as a postoperative PSA elevation greater than 0 .4 ng/ml. RESULTS. The DFS for patients with Gleason score 8-10 and pathologically or gan-confined disease was 62.5%. DFS was 56.2% for patients with PSA less th an or equal to 10 ng/ml, compared to 19.2% for patients with serum PSA >10 ng/ml (P = 0.009). Patients with nonspecimen-confined disease (positive mar gins) had a DFS rate of 26.6% vs. 55% for patients with specimen-confined d isease (negative margins) (P = 0.009). On multivariable analysis, only preo perative PSA less than or equal to 10 ng/ml (P = 0.02) and surgical margin status (P = 0.04) were significant predictors of DFS. CONCLUSIONS. Surgical margin status and preoperative serum PSA level are in dependent predictors of DFS for patients with high Gleason score prostate c ancer treated by radical prostatectomy as monotherapy. Patients with poorly differentiated prostate cancer treated surgically at an early stage can ha ve a favorable prognosis, especially if negative surgical margins are obtai ned. A preoperative serum PSA level less than or equal to 10 ng/ml carries the greatest likelihood of achieving prolonged DFS in this group of patient s. (C) 1999 Wiley-Liss, Inc.