Management of locally advanced prostate cancer : 1. Staging, natural history, and results of radical surgery

Prostate cancer presents clinically as T3 disease in about 20-25% of cases. With repeated screening of large parts of the male population, this proportion may drop in the future. Correct staging of T3 prostate cancer is difficult to achieve. Rectal examination and ultrasonography produce similar results. Overstaging in the presence of pT2 disease and understaging (pT4 or pN+ disease) are common and present a dilemma for proper treatment decisions. The optimal management of T3 prostate cancer is not known at this time. Radical prostatectomy for locally advanced disease can be carried out with acceptable morbidity and mortality and is especially beneficial in patients who have been downstaged to pT2 (17-30%) and in those with moderately or well-differentiated disease. In this group of men, historical comparison suggests that radiotherapy alone is inferior to surgery. These comparisons, however, are heavily biased by differences in the distribution of prognostic factors for which a correction is impossible. Surgery alone is clearly not useful in patients presenting with poorly differentiated disease or with prostate-specific antigen (PSA) values exceeding 10-20 microg/ml. Adjuvant treatment is desirable. Considering the high prevalence of lymph node metastases in this group of patients (25-50%), lymphadenectomy is mandatory prior to surgery, radiotherapy, or any type of combination treatment.