Effect of total androgen ablation on pathologic stage and resection limit status of prostate cancer - Initial results of the Italian PROSIT study

The likelihood of finding organ-confined untreated prostate cancer (PCa) by pathological examination at the time of radical prostatectomy (RP) is only 50% in patients with clinically organ-confined disease. In addition, tumou r is present at the resection margin in approximately 30% of clinical T2 (c linical stage B) cases. The issue of clinical "understaging" and of resecti on limit positivity have led to the development of novel management practic es, including "neoadjuvant" hormonal therapy (NHT). The optimal duration of NHT is unknown. We undertook the present analysis to evaluate the effect o f NHT on pathologic stage of PCa and resection limit status in patients wit h prostate cancer and treated with total androgen ablation either for three or six months before RP. Between January 1996 and February 1998, 259 men with prostate cancer underw ent radical retropubic prostatectomy and bilateral pelvic node dissection i n the 26 centres participating in the Italian randomised prospective PROSIT study. Whole mount sectioning of the complete RP specimens was adopted in each centre for accurately evaluating the pathologic stage and resection li mit status. By February 1998, haematoxylin and eosin stained sections from 155 RP specimens had been received and evaluated by the reviewing pathologi st (RM). 64 cases had not been treated with total androgen ablation (e.g. N HT) before RP was performed, whereas 58 and 33 had been treated for three a nd six I-months, respectively. 114 patients were clinical stage B whereas 4 1 were clinical stage C. After three months of total androgen ablation, pathological stage B was mor e prevalent among patients with clinical B tumours, compared with untreated patients (57% in treated patients vs. 36% in untreated). The percentage of cancers with negative margins was statistically significantly greater in p atients treated with neoadjuvant therapy than those treated with immediate surgery alone (69% vs. 42%, respectively). After six months of NHT therapy the proportion of patients with pathological stage B (67% vs. 36%, respecti vely) and negative margins was greater than after 3 months (92% vs. 42%, re spectively). For clinical C tumours, the prevalence of pathological stage B and negative margins in the patients treated for either 3 or 6 months was not as high as in the clinical B tumours, when compared with the untreated group (pathological stage B: 31% and 33% vs. 6% in the clinical C cases, re spectively. Negative margins: 56% and 67% vs. 31%, respectively). The initial results of this study suggest that total androgen ablation befo re RP is beneficial in men with clinical stage B because of the significant pathological downstaging and decrease in the number of positive margins in the RP specimens. These two effects are more pronounced after six months o f NHT than after three months of therapy. The same degree of beneficial eff ects are not observed in clinical C tumours.