Radical prostatectomy represents an effective treatment in patients with specimen‐confined high pathological Gleason score prostate cancer
Authors: Lughezzani Giovanni , Gallina Andrea , Larcher Alessandro , Briganti Alberto , Capitanio Umberto , Suardi Nazareno , Lista Giuliana , Abrate Alberto , Sangalli Mattia Nicola , Buffi Nicolòmaria , Cestari Andrea , Guazzoni Giorgio , Rigatti Patrizio , Montorsi Francesco 
Published: April 2012

What's known on the subject? and What does the study add?

To date, only a few studies have addressed the long‐term oncological outcomes of radical prostatectomy (RP) in patients with pathological Gleason score ≥ 8 prostate cancer. According to these reports, some individuals with pathological Gleason score ≥ 8 may benefit from RP, with cancer‐control outcomes comparable with those of patients with low‐ and intermediate‐risk prostate cancer.

The presence of pathological Gleason score 8–10 represents a poor prognostic factor in the outcome of men with prostate cancer. However, in patients with specimen‐confined disease, RP and bilateral PLND provided long‐term cancer‐control outcomes similar to those of patients with more favourable disease characteristics.

Objectives

To evaluate the outcomes of patients with pathological Gleason score 8–10 prostate cancer subjected to radical prostatectomy (RP).

To determine the prognostic factors associated with cancer‐specific survival (CSS) in this subset of patients.

Patients and Methods

The study included 580 consecutive patients with pathological Gleason sum 8–10 prostate cancer treated with RP and pelvic lymph node dissection (PLND) at a single European institution between July 1988 and April 2010. All patients had detailed pathological and follow‐up data.

Pathological Gleason score was determined by a single expert genitourinary pathologist. Biochemical recurrence (BCR) was defined PSA concentration of ≥0.2 ng/mL and rising.

Kaplan–Meier plots were used to graphically explore BCR‐free survival as well as CSS and overall survival (OS) rates. Moreover, univariable and multivariable Cox regression models were fitted to test the predictors of CSS.

Results

The mean (median, range) age at surgery was 66.1 (66.4, 41–85) years. The mean (median, range) total PSA concentration was 29.6 (11.1, 0.5–1710) ng/mL.

Pathological Gleason score was 8 in 238 (41.0%), 9 in 330 (56.9%) and 10 in 12 (2.1%) patients. Overall, 119 (20.5%), 124 (21.4%), 281 (48.4%) and 56 (9.7%) patients had pT2, pT3a, pT3b and pT4 prostate cancer, respectively. Overall, 275 (47.4%) had LN invasion, while 150 (25.1%) patients had specimen‐confined disease (defined as pT2cR0 pN0 or pT3aR0 pN0 prostate cancer).

The mean (median, range) follow‐up was 53 (47, 1–226) months. At 5 and 10 years after RP, BCR‐free survival was 76.7% and 49.6%, respectively. Similarly, the 5‐ and 10‐year CSS rates were 87.3% and 69.5%, respectively.

Patients with specimen‐confined disease (P < 0.001) and patients with negative LNs (P = 0.012) had significantly better CSS rates than their counterparts with less favourable pathological characteristics. In multivariable Cox regression models, only the presence of specimen‐confined disease achieved independent predictor status (P = 0.001).

Conclusion

Presence of high Gleason score at RP represents a poor prognostic factor in the outcome of patients with prostate cancer.

However, RP provides excellent long‐term cancer control outcomes in the subset of patients with specimen‐confined disease.