Lymph node positive prostate carcinoma. A case for primary hormone therapy

Abstract

At the present time, lymph node metastases may be nomographically predicted or histologically proven. As a rule, this indicates a systemic disease. Unimodal local therapy (radical prostatectomy/irradiation) does not alter the outcome. Occasionally, this appeared to be the case, if lymph nodes were diagnosed in a very early stage (diagnostic lead-time). This phenomenon disappears, when the follow-up time is long. A comparable situation is encountered, if one relies on the bimodal local therapy, i.e. radical prostatectomy plus adjuvant irradiation. Similarly, there is a diagnostic lead-time effective. However, patients with minimal lymph node metastases (also known as pN1.1) may probably not need immediate endocrine therapy. The combination of tele- and brachy-therapy in the presence of positive nodes appears to be not useful. Unimodal systemic therapy following radical prostatectomy has never been tested in a phase III-trial. If one weighs the arguments pro immediate versus delayed hormone therapy, the following trends can be found: The time-to-progression is prolonged, however, that does not translate in a longer cause-specific survival. In the results of a phase III-trial of irradiation plus primary versus delayed androgen deprivation in stage N1/pN1 prostate cancer the above trends were noticed. Neoadjuvant hormone therapy in N1 prostate cancer has not been tested in a phase III-trial, however, it is very unlikely that patients benefit more than from a similar treatment in the presence of locally advanced, but node-negative prostate cancer. An interesting concept in these potentially long surviving patients is the intermittent hormone therapy, among the benefits is the reduced number of side-effects.