Biochemical disease-free survival in patients with a high prostate-specific antigen level (20–100 ng/mL) and clinically localized prostate cancer after radical prostatectomy

In the Urological Oncology section this month, there are seven original articles, dealing with two subjects: prostate cancer and testicular cancer. They come from a variety of countries, in order of appearances, as it were: the USA, Israel, Turkey, UK and Italy. The authors from Indianapolis examine their experience with radical prostatectomy in patients with a serum PSA of 20–100 ng/mL, a group which might be considered by many to be unsuitable for such an operation. This is a controversial subject and there are two editorial comments at the end of the article. The authors found that not surprisingly cancer-free survival is not as good as in patients with a lower PSA level, but they felt that biochemical disease-free survival could be achieved. The authors from Israel found that colour-Doppler ultrasonography is helpful in detecting perineural invasion, and thus in predicting histologically localised prostate cancer. The papers on testicular cancer are also controversial, examining several issues relating to seminomatous and nonseminomatous germ cell tumours. There is a comment at the beginning of this issue of the journal which is devoted to some of these papers. OBJECTIVE To examine our experience with radical prostatectomy (RP) in patients with a serum prostate-specific antigen (PSA) level of > 20 ng/mL (who are sometimes considered poor candidates for RP) to determine the outcome and possible predictors of a favourable outcome. PATIENTS AND METHODS We retrospectively reviewed the medical records of 79 patients who underwent RP with an initial PSA of 20–100 ng/mL. Biochemical disease-free survival (BDFS) was assessed using the Kaplan-Meier method and predictors of treatment outcome examined by uni- and multivariate analysis. Patients excluded from the analysis were 11 (14%) whose surgery was aborted after finding cancerous pelvic nodes and who did not undergo RP; four others with normal nodes during RP who had metastatic tumour on permanent sections; and 14 who had follow-up data for < 2 years. RESULTS The mean (sd) age of the 50 patients in the final study population was 63 (7) years and the mean PSA 37.9 (16.0) ng/mL. The median (range) follow-up was 54 (24–120) months. The BDFS was 60% at 3 years and 48% at 5 years of follow-up. Two patients developed a local recurrence and eight developed metastatic disease. On logistic regression analysis of factors influencing BDFS, only extracapsular extension of disease was predictive of PSA recurrence; no preoperative factor was significant. When time to PSA recurrence was assessed by Cox regression analysis, again only extracapsular extension was predictive, with no preoperative variable a statistically significant predictor. CONCLUSIONS Patients with a high serum PSA level (20–100 ng/mL) may be appropriate candidates for RP. While the cancer-free survival is not as good as in patients with a lower PSA, a significant percentage of patients achieve BDFS. No preoperative variables were predictive of disease-free survival or time to PSA recurrence.