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Home:
PCU1|2002:
Mark Soloway, MD
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Mark
Soloway, MD |
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Professor and Chairman, Department of
Urology
University of Miami School of Medicine
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Edited comments by Dr Soloway
CHALLENGING CASE 1: 41-year-old man with a Gleason
6, T1 tumor
Clinical History
This healthy young man decided to check his PSA during a routine
medical check-up while he was evaluating his cholesterol. His PSA
was 15 ng/mL. DRE was negative, but biopsy revealed 3/6 positive
core biopsies. The patient elected treatment with radical prostatectomy.
Key Management Question
Should bilateral nerve-sparing surgery be performed?
Follow-up
Bilateral nerve-sparing prostatectomy was performed. Subsequently,
the patient has maintained full potency and continence. Six years
later, PSA is undetectable, and there is no clinical evidence of
disease.
Case Discussion
Most physicians, including radiation oncologists, would recommend
prostatectomy for a man of this age. Whether to perform nerve-sparing
surgery is the key issue. Since cancer eradication is the most important
objective, one thought would be to not compromise that goal. On
the other hand, if the fascia on the prostate can be left intact
and the nerves preserved, there is a very small chance of compromising
that goal. Since erections are very important to quality of life
and failure is most likely to be systemic as opposed to local, I
performed a bilateral nerve-sparing prostatectomy.
Many urologists do not perform nerve-sparing prostatectomy for
fear of compromising cancer control. In a rare patient, nerve-sparing
surgery may compromise local tumor control or cure. However, if
you have one or both of the neurovascular bundles totally removed,
erectile function is diminished. I perform nerve-sparing prostatectomies
in 70% to 80% of men with good prognostic factors (cT1c, Gleason
Score <= 7 or non-palpable disease). Age, preoperative potency,
time after prostatectomy, the number of nerves involved and the
use of sildenafil (Viagra®) will determine a man’s postoperative
potency. Our study of my own series — published in the Journal
of Clinical Oncology — retrospectively compared men with or
without nerve-sparing procedures. The curves for PSA recurrences
are superimposable in men with or without nerve-sparing procedures.
There may be a small group of men who experience a local recurrence
because of a nerve-sparing prostatectomy. However, I tend to agree
with Dr Patrick Walsh and other research leaders that the probability
is less than 10%.
CHALLENGING CASE 2: 66-year-old man with 4/9 positive
nodes at prostatectomy
Clinical History
The patient had a history of ulcerative colitis that was asymptomatic.
He complained of a decrease in ejaculate volume, nocturia and hesitancy.
DRE revealed an asymmetric, moderately enlarged prostate (~35 grams),
with the right side being firmer than the left. Biopsy revealed
8/8 positive cores, and his Gleason score was 7. CT and bone scans
were negative. Radical prostatectomy revealed 4/9 positive lymph
nodes on the right, bilateral seminal vesicle involvement, positive
surgical margins and pathologic Gleason score of 9. Postoperatively,
the PSA was undetectable.
Key Management Question
Should adjuvant endocrine therapy be implemented?
Follow-up
LHRH-agonist therapy was initiated, and the patient's PSA has
remained undetectable. He is fully continent but experiences some
hot flashes as well as severely diminished libido and erectile function.
Case Discussion
This gentleman is not likely to be cured with local therapy alone.
In the operating room, we encountered enlarged lymph nodes containing
adenocarcinoma of the prostate. Intraoperatively, the question was,
“Should a prostatectomy be performed?” Some urologists
would stop the procedure and give hormone therapy alone or radiation
therapy in combination with hormone therapy. In men with diploid
tumors, the Mayo Clinic advocates prostatectomy. Even though we
did not know this patient’s ploidy, I proceeded with a radical
prostatectomy in the hope of performing the operation with minimal
morbidity. Perhaps, removing the prostate may minimize local problems
at the time of relapse. At the time of progression, 10% to 15% of
men with intact prostates will develop local problems such as bleeding
or ureteral obstruction.
In light of the data from the Eastern Cooperative Group (ECOG)
trial by Dr Messing, I initiated androgen deprivation with an LHRH-agonist
and an antiandrogen. Since this man is not a good candidate for
intermittent therapy, I have also recommended a bilateral orchiectomy.
CHALLENGING CASE 3: 57-year-old man with Gleason
9 tumor on TURP
Clinical History
This otherwise healthy patient had a 2-3 year history of prostatitis,
consisting of perineal discomfort and voiding problems. Tr a n s
rectal biopsy x 3 was negative. His PSA increased from 0.6 to 1.3
ng/mL in one year. TURP was performed, and Gleason 9 prostate cancer
was diagnosed. Subsequent DRE revealed palpable disease. CT and
bone scans were negative.
Key Clinical Question
Should neoadjuvant chemotherapy and/or endocrine therapy be utilized?
Follow-up
The patient was enrolled on a clinical trial consisting of neoadjuvant
estramustine phosphate, etoposide (VP-16), paclitaxel and an LHRH-agonist
for 5 months followed by a radical prostatectomy. At surgery, the
margins were negative, but bilateral seminal vesicle invasion was
observed. The Gleason score was 9 and nodes were negative.
The patient continues to receive an LHRH-agonist. His PSA is undetectable,
and he is fully continent.
Case Discussion
Since this man was young, healthy and had a low PSA, we suggested
an investigational approach that included chemotherapy and hormone
therapy for several months prior to his definitive local treatment.
If this man had not enrolled on a clinical trial, the choices would
have included androgen deprivation followed by prostatectomy or
prostatectomy alone.
CHALLENGING CASE 4: 75-year-old man in excellent health
with a Gleason 6, cT2 tumor
Clinical History
A PSA that increased from 4.9 to 6.7 ng/mL in 3 years led to a
biopsy that revealed a single focus of prostate cancer. DRE was
asymmetrical (cT2, 65 grams), and Gleason score was 6.
Key Clinical Question
Should the patient be managed with local and/or systemic therapy?
Follow-up
The initial plan was for androgen deprivation to be later followed
with external beam radiation therapy and interstitial brachytherapy.
However, after 9 months of androgen deprivation with an LHRH-agonist,
the patient decided to continue on hormone therapy and not proceed
with the radiation. After another 3 months on the LHRH-agonist,
his PSA was 0.1 ng/mL. At that time, about 3 years ago, the LHRH-agonist
was discontinued, and he remains asymptomatic with a PSA of 4.5
ng/mL.
Case Discussion
There were several good choices for this type of patient —
interstitial brachytherapy, external beam radiation with or without
interstitial brachytherapy, intermittent androgen deprivation and
observation alone. Very few urologists would have removed his prostate.
He is now 79 years old and asymptomatic, and we can say that he
has had a reasonable treatment.
Selected References
Brown JAet al. Fluorescence in situ hybridization aneuploidy
as a predictor of clinical disease recurrence and prostate-specific
antigen level 3 years after radical prostatectomy. Mayo Clin
Proc 1999;74(12):1214-20. Abstract
Han M et al. Isolated local recurrence is rare after radical
prostatectomy in men with Gleason 7 prostate cancer and positive
surgical margins: Therapeutic implications. J Urol 2001;
165(3):864-6. Abstract
Messing EM et al. Immediate hormonal therapy compared with
observation after radical prostatectomy and pelvic lymphadenectomy
in men with node-positive prostate cancer. N Engl J Med
1999;341:1781-8. Abstract
Sofer M et al. Risk of positive margins and biochemical recurrence
in relation to nerve-sparing radical prostatectomy. J Clin
Oncol 2002;20(7):1853-8. Abstract
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