Ergebnisse der radikalen perinealen Prostatektomie

Zusammenfassung

Wir berichten über unsere Erfahrungen mit der radikalen perinealen Prostatektomie (RPP) an einem Kollektiv von 1242 Patienten mit klinisch organbegrenztem Prostatakarzinom (Stadien T1 - T2 N0 M0). In diesem Patientenkollektiv betrug der durchschnittliche Zeitraum bis zum Eintreten eines nicht tumorassoziierten Todes 19,3 Jahre. Bei Patienten mit kapselbegrenztem und kapselüberschreitendem Prostatakarzinom, das jedoch vollständig (mit negativen Absetzungsrändern) entfernt werden konnte, wurde die mittlere tumorassoziierte Überlebenszeit nicht erreicht. Patienten mit positiven Absetzungsrändern hatten hingegen eine mittlere tumorassoziierte Überlebenszeit von 12,7 Jahre. Ein PSA-Anstieg als Zeichen eines Rezidivs ging dem tumorassoziierten Tod des Patienten in Abhängigkeit von Gleason Grad und Summe als Ausdruck der biologischen Tumoraggressivität um durchschnittlich 5 bis 12 Jahre voraus. Gleason Grad und Summe waren entscheidende prognostische Faktoren für die Länge des Zeitraums zwischen RPP und tumorassoziiertem Tod. Zusammenfassend läßt sich sagen, daß die RPP bei Patienten mit organbegrenztem Prostatakarzinom eine effektive Tumorkontrolle leistet und der Mehrzahl der Patienten ein langes tumorfreies Überleben ermöglicht.

Abstract

Purpose: We present our experience with the radical perineal prostatectomy (RPP) in the treatment of clinically confined prostate cancer in a large series of consecutive patients. The importance of the biology of the primary tumor in regards to disease recurrence and progression, as well as the role of prostate specific antigen (PSA) as a surrogate endpoint for defining disease control were investigated.Material and Methods: A total of 1,242 men with clinical stage T1 - T2 N0 M0 disease underwent radical perineal prostatectomy (RPP) in a 24 year period from 1972 to 1996. Prostatectomy specimens were characterized histopathologically by Gleason grade and score, and the extent of disease (organ-confined, specimen-confined or margin positive). Patients were routinely followed at 2 months and then at 6-months intervals for biochemical, physical and radiographic evidence of recurrence.Results: No patient received adjuvant postoperative therapy unless there was documented evidence of recurrence. As endpoints of clinical outcome we analyzed the time to biochemical failure (PSA 0.5 ng/ml or greater) and cancer associated death, which was defined as patient death of any cause with a biologically active malignancy. The median time to noncancer death was 19.3 years. The median time to cancer associated death was not reached by patients with organ and specimen confined disease during the period of follow-up, while patients with margin positive disease had a median cancer associated time to death of 12.7 years. PSA failure preceded cancer associated death by 5 to 12 years depending on the biological aggressiveness predicted by Gleason grade and score. Overall PSA failure rate at 5 years follow-up of patients with organ confined, specimen confined and margin positive disease were 8 %, 35 % and 65 % respectively. Organ confined, high grade disease was associated with a high percentage of disease-free survival.Conclusions: RPP provides a substantial disease control benefit in men with clinically confined prostate cancer. PSA is an excellent surrogate endpoint for defining disease control in these patients. The biology of the cancer as predicted by the Gleason grade and score is an important predictor of the interval between surgical intervention and death from recurrence.

Key words:

perineal prostatectomy - Gleason score - PSA

Literatur

• 1 Cantrell B B, Deklerk D P, Eggleston J C, Boitnott J K, Walsh P C. Pathological Factors that Influence Prognosis in Stage A Prostatic Cancer: The Influence of Extent versus Grade.  J Urol. 1981;  125 516-520
• 2 Gleason D F. Histologic Grading of Prostate Cancer: A Perspective.  Hum Path. 1992;  23 273-279
• 3 Grayhack J T, Assimos D G. Prognostic Significance of Tumor Grade and Stage in the Patient with Carcinoma of the Prostate.  Prostate. 1983;  4 13-31
• 4 Kaplan E L, Meier P. Non-Parametric Estimation from Incomplete Observations.  J Amer Stat Assn. 1958;  53 457-468
• 5 Murphy G P, Whitmore W F. A Report of the Workshops on the Current Status of the Histologic Grading of Prostate Cancer.  Cancer. 1979;  44 1490-1494
• 6 Ohori M, Goad J R, Wheeler T M, Eastham J A, Thompson T C, Scardino P T. Can Radical Prostatectomy Alter the Progression of Poorly Differentiated Prostate Cancer.  J Urol. 1994;  152 1843-1849
• 7 Partin A W, Piantadosi S, Sanda M G, Epstein J I, Marshall F F, Mohler J L, Brendler C B, Walsh P C, Simons J W. Selection of Men at High Risk for Disease Recurrence for Experimental Adjuvant Therapy Following Radical Prostatectomy.  Urology. 1995;  45 831-838
• 8 Paulson D F. Impact of Radical Prostatectomy in the Management of Clinically Localized Disease.  J Urol. 1995;  152 1826-1830
• 9 Pound C R, Partin A W, Epstein J I, Walsh P C. Prostate-Specific Antigen after Anatomic Radical Retropubic Prostatectomy. Patterns of Recurrence and Cancer Control.  Urol Clin N America. 1997;  24 395-406
• 10 Thrasher J B, Paulson D F. Reappraisal of Radical Perineal Prostatectomy.  Europ Urol. 1992;  22 1-8