Prostatic carcinoma with positive lymph nodes - the case for primary hormone therapy

At the present time, lymph node metastases may be nomographically predicted or histologically proven. As a rule, this indicates a systemic disease. Un imodal local therapy (radical prostarectomy/irradiation) does not alter the outcome. Occasionally, this appeared to be the case, if lymph nodes were d iagnosed in a very early stage (diagnostic lead-time). This phenomenon disa ppears, when the follow-up time is long. A comparable situation is encounte red, if one relies on the bimodal local therapy, i.e, radical prostatectomy plus adjuvant irradiation. Similarly, there is a diagnostic lead-time effe ctive. However, patients with minimal lymph node metastases (also known as pN(1.1)) may probably not need immediate endocrine therapy. The combination of tele- and brachy-therapy in the presence of positive nodes appears to b e not useful. Unimodal systemic therapy following radical prostatectomy has never been tested in a phase III-trial. If one weighs the arguments pro im mediate versus delayed hormone therapy, the following trends can be found: The time-to-progression is prolonged, however, that does not translate in a longer cause-specific survival. In the results of a phase III-trial of irr adiation plus primary versus delayed androgen deprivation in stage N-1/pN(1 ) prostate cancer the above trends were noticed. Neoadjuvant hormone therap y in N-1 prostate cancer has not been rested in a phase III-trial, however, it is very unlikely that patients benefit more than from a similar treatme nt in the presence of locally advanced, but node-negative prostate cancer. An interesting concept in these potentially long surviving patients is the intermittent hormone therapy, among the benefits is the reduced number of s ide-effects.