Introduction. Treatment of locally advanced prostate cancer is under discussion. Differences between clinical and pathological staging and risk factors such as positive surgical margins and seminal vesicle involvement challenge the individual treatment decisions. Case Presentation. Clinical tumor stage before treatment was assessed to be T2. After radical prostatectomy, pathological examination revealed the stage pT3b N0 M0 including positive surgical margin and seminal vesicle involvement. Early adjuvant androgen deprivation therapy and late adjuvant radiation therapy were added in response to the pathological risk factors. No evidence of disease was observed for 15 years after the treatment. The unexpected pathological findings were not explained by the physicians in charge. Discussion. A narrative review of the recent literature showed that multiple treatment modalities including adjuvant radiotherapy following radical prostatectomy are consistent with current recommendations. The multimodal approach has possibly cured a high-risk patient and may also work successfully in other patients. An alternative treatment option with better preservation of health-related quality of life might have also achieved a similar good overall survival. 1. Introduction Prostate cancer will be diagnosed in 2012 in an estimated 241,740 men; 28,170 men will die, and the lifetime risk being diagnosed is 16.48% (1 in 6) in the USA [1]. Locally advanced prostate cancer can be defined by the categories T3a, T3b, T4, or by the category N1 associated with any T of the Tumor-Node-Metastasis (TNM) staging system [2] if combined with an absence of distant metastasis (M0). Patients are regarded at high risk if the prostate cancer is locally advanced or the Gleason score is 8 to 10 or a serum prostate-specific antigen is greater than 20？ng/mL [3]. The tumor type presented in this paper has extended through the prostate capsule into the seminal vesicles (T3b N0 M0) and is therefore categorized as a very high-risk locally advanced prostate cancer (T3b N0 M0, T4 N0 M0, or any T N1 M0). Radical prostatectomy (RP) can be a reasonable first step treating very high-risk locally advanced prostate cancer in selected patients [3]. Microscopic metastases may be present but not yet detectable and there is a considerable risk of incomplete tumor removal. Lymph node disease (N1) is associated with a high risk for systemic tumor progression and treatment failure. Therefore, multiple treatment modalities such as extended pelvic lymph node dissection, adjuvant radiotherapy (RT), and adjuvant androgen
References
[1]
R. Siegel, D. Naishadham, and A. Jemal, “Cancer statistics,” A Cancer Journal for Clinicians, vol. 62, no. 1, pp. 10–29, 2012.
[2]
World Health Organization, “Chapter 3. tumours of the prostate,” in World Health Organization Classification of Tumours. Pathology and Genetics of Tumours of the Urinary System and Male Genital Organs, International Agency for Research on Cancer (IARC), Lyon, France; World Health Organization, Geneva, Switzerland, 2012.
[3]
A. Heidenreich, M. Bolla, S. Joniau, et al., Guidelines on Prostate Cancer, European Association of Urology (EAU), Arnhem, The Netherlands, 2012.
[4]
A. Heidenreich, J. Bellmunt, M. Bolla et al., “EAU guidelines on prostate cancer. Part 1: screening, diagnosis, and treatment of clinically localised disease,” European Urology, vol. 59, no. 1, pp. 61–71, 2011.
[5]
W. H. Cooner, B. R. Mosley, C. L. Rutherford Jr. et al., “Prostate cancer detection in a clinical urological practice by ultrasonography, digital rectal examination and prostate specific antigen,” Journal of Urology, vol. 143, no. 6, pp. 1146–1154, 1990.
[6]
L. Egevad, T. Granfors, L. Karlberg, A. Bergh, and P. Stattin, “Prognostic value of the Gleason score in prostate cancer,” British Journal of Urology International, vol. 89, no. 6, pp. 538–542, 2002.
[7]
I. M. Thompson, D. K. Pauler, P. J. Goodman et al., “revalence of prostate cancer among men with a prostate-specific antigen level < or = 4.0？ng per milliliter,” The New England Journal of Medicine, vol. 350, no. 22, pp. 2239–2246, 2004.
[8]
NCCN, NCCN Guidelines for Patients: Prostate Cancer, Version 1, National Comprehensive Cancer Network (NCCN), Washington, DC, USA, 2011.
[9]
D. Ulmert, A. M. Cronin, T. Bj？rk et al., “Prostate-specific antigen at or before age 50 as a predictor of advanced prostate cancer diagnosed up to 25 years later: a case-control study,” BMC Medicine, vol. 6, article 6, 2008.
[10]
A. J. Vickers, C. J. Savage, F. J. Bianco et al., “Surgery confounds biology: the predictive value of stage-, grade- and prostate-specific antigen for recurrence after radical prostatectomy as a function of surgeon experience,” International Journal of Cancer, vol. 128, no. 7, pp. 1697–1702, 2011.
[11]
E. Xylinas, A. Daché, and M. Rouprêt, “Is radical prostatectomy a viable therapeutic option in clinically locally advanced (cT3) prostate cancer?” British Journal of Urology International, vol. 106, no. 11, pp. 1596–1600, 2010.
[12]
V. Berge, T. Thompson, and D. Blackman, “Use of additional treatment for prostate cancer after radical prostatectomy, radiation therapy, androgen deprivation, or watchful waiting,” Scandinavian Journal of Urology and Nephrology, vol. 41, no. 3, pp. 198–203, 2007.
[13]
M. D. Shelley, S. Kumar, B. Coles, T. Wilt, J. Staffurth, and M. D. Mason, “Adjuvant hormone therapy for localised and locally advanced prostate carcinoma: a systematic review and meta-analysis of randomised trials,” Cancer Treatment Reviews, vol. 35, no. 7, pp. 540–546, 2009.
[14]
S. Kumar, M. Shelley, C. Harrison, B. Coles, T. J. Wilt, and M. D. Mason, “Neo-adjuvant and adjuvant hormone therapy for localised and locally advanced prostate cancer,” Cochrane Database of Systematic Reviews, no. 4, Article ID CD006019, 2006.
[15]
A. J. Stephenson, M. Bolla, A. Briganti, et al., “Postoperative radiation therapy for pathologically advanced prostate cancer after radical prostatectomy,” European Urology, vol. 61, no. 3, pp. 443–451, 2012.
[16]
T. Wiegel, D. Bottke, U. Steiner, et al., “Phase III postoperative adjuvant radiotherapy after radical prostatectomy compared with radical prostatectomy alone in pT3 prostate cancer with postoperative undetectable prostate-specific antigen: ARO 96-02/AUO AP 09/95,” Journal of Clinical Oncology, vol. 27, no. 18, pp. 2924–2930, 2009.
[17]
S. S. Chang and M. S. Cookson, “Impact of positive surgical margins after radical prostatectomy,” Urology, vol. 68, no. 2, pp. 249–252, 2006.
[18]
T. Steuber, A. Erbersdobler, M. Graefen, A. Haese, H. Huland, and P. I. Karakiewicz, “Comparative assessment of the 1992 and 2002 pathologic T3 substages for the prediction of biochemical recurrence after radical prostatectomy,” Cancer, vol. 106, no. 4, pp. 775–782, 2006.
[19]
P. Gontero, G. Marchioro, R. Pisani et al., “Is radical prostatectomy feasible in all cases of locally advanced non-bone metastatic prostate cancer? Results of a single-institution study,” European Urology, vol. 51, no. 4, pp. 922–930, 2007.
[20]
C. Y. Hsu, S. Joniau, R. Oyen, T. Roskams, and H. van Poppel, “Outcome of surgery for clinical unilateral T3a prostate cancer: a single-institution experience,” European Urology, vol. 51, no. 1, pp. 121–129, 2007.
[21]
H. Miyake, I. Sakai, K. I. Harada, I. Hara, and H. Eto, “Long-term results of adjuvant hormonal therapy plus radiotherapy following radical prostatectomy for patients with pT3N0 or pT3N1 prostate cancer,” International Journal of Urology, vol. 11, no. 6, pp. 397–401, 2004.
[22]
R. K. Berglund, J. S. Jones, J. C. Ulchaker et al., “Radical prostatectomy as primary treatment modality for locally advanced prostate cancer: a prospective analysis,” Urology, vol. 67, no. 6, pp. 1253–1256, 2006.
[23]
C. Y. Hsu, M. F. Wildhagen, H. van Poppel, and C. H. Bangma, “Prognostic factors for and outcome of locally advanced prostate cancer after radical prostatectomy,” British Journal of Urology International, vol. 105, no. 11, pp. 1536–1540, 2010.
[24]
L. Mearini, A. Zucchi, E. Costantini, V. Bini, E. Nunzi, and M. Porena, “Outcomes of radical prostatectomy in clinically locally advanced N0M0 prostate cancer,” Urologia Internationalis, vol. 85, no. 2, pp. 166–172, 2010.
[25]
G. Ploussard, M. A. Agamy, O. Alenda et al., “Impact of positive surgical margins on prostate-specific antigen failure after radical prostatectomy in adjuvant treatment-naive patients,” British Journal of Urology International, vol. 107, no. 11, pp. 1748–1754, 2011.
[26]
S. Schelin, M. Madsen, E. Palmqvist, E. M？kel？, C. Klintenberg, and G. Aus, “Long-term follow-up after triple treatment of prostate cancer stage pT3,” Scandinavian Journal of Urology and Nephrology, vol. 43, no. 3, pp. 186–191, 2009.
[27]
A. M. Kamat, K. Babaian, M. R. Cheung et al., “Identification of factors predicting response to adjuvant radiation therapy in patients with positive margins after radical prostatectomy,” Journal of Urology, vol. 170, no. 5, pp. 1860–1863, 2003.
[28]
I. C. Cho, W. A. Kwon, J. E. Kim et al., “Prostate volume has prognostic value only in pathologic T2 radical prostatectomy specimens,” Journal of Korean Medical Science, vol. 26, no. 6, pp. 807–813, 2011.
