Postoperative Prostate-specific Antigen Research Articles

Prostate Specific Antigen Values after Radical Retropubic Prostatectomy for Adenocarcinoma of the Prostate: Impact of Adjuvant Treatment (Hormonal and Radiation)

Prostate specific antigen (PSA) levels were obtained before and after radical retropubic prostatectomy in 192 patients: 78 (41%) had pathological stage B2 cancer or less, 83 (43%) had stage C or C+ and 31 (16%) had stage D1 disease. Of those with stages B2 or less, C, C+ and D1 disease 82, 86, 65 and 90%, respectively, had postoperative PSA values of 0.2ng./ml. or less (when first evaluated 30 or more days postoperatively). At 1 year postoperatively 94% of the stages C and C+ cancer patients treated with adjuvant radiation had PSA levels of 0.2ng./ml. or less, which was significantly different from those not treated adjuvantly (p = 0.02). This effect of adjuvant radiation on PSA was temporary in the small number of patients with longer followup. Adjuvant orchiectomy for stage D1 lesions resulted in female PSA levels in virtually all cases. This decrease may be misleading and may reflect a direct hormonal effect rather than a decrease in tumor volume. Positive surgical margins did not significantly affect postoperative PSA levels, possibly because of the frequent use of adjuvant treatment.

Role of Nerve-Sparing Radical Prostatectomy for Clinical Stage B2 Prostate Cancer

To examine the role of nerve-sparing radical prostatectomy in patients with clinical stage B2 prostate cancer we reviewed the first 77 such patients in our series since we adopted the nervesparing technique. A total of 47 patients (61%) underwent bilateral and 26 (34%) underwent unilateral nerve-sparing prostatectomy, while in 4 (5%) both neurovascular bundles were resected. Among the patients followed for 12 months 27 of 41 (66%) treated with bilateral and 7 of 19 (37%) treated with unilateral nerve-sparing prostatectomy had potency preserved.With the strict clinicopathological criteria of organ-confined tumor, that is intracapsular tumor with negative surgical margins and undetectable postoperative prostate specific antigen levels, complete tumor excision was achieved in 17 patients (36%) treated with bilateral and 7 of 26 (27%) treated with unilateral nerve-sparing prostatectomy. All patients in whom both neurovascular bundles were resected had pathological stage C or D1 disease. Of the 24 patients who had complete tumor excision by the strict criteria only 15 (19.5% of the 77 preoperatively potent patients) had potency preserved.Of these patients 19 had microscopically positive margins without seminal vesicle invasion (pathological stage Cl) with undetectable postoperative prostate specific antigen levels. In addition, 4 patients had seminal vesicle involvement with negative surgical margins and undetectable postoperative prostate specific antigen levels. If these patients also are considered as having complete tumor excision, there was an over-all complete tumor excision rate of 61% (47 of 77), of whom 25 (32% of the 77 patients) had preservation of potency. Ten patients with clinical stage B2 tumor whose potency was preserved had histological and serological evidence of incomplete tumor excision. Of 53 patients with pathological stage Cl disease 9 (17%) had margins positive only in the regions of the neurovascular bundles.Preoperative prostate specific antigen and acid phosphatase levels, and findings on transrectal ultrasonography failed to predict accurately which patients had extracapsular tumor extension. Patients with poorly differentiated tumors and/or bulky disease on rectal examination had a higher incidence of extracapsular extension and positive margins.We conclude that in the majority of potent patients with clinical stage B2 prostate cancer not all of the goals of nerve-sparing radical prostatectomy are realized. Because of the high incidence of extracapsular tumor extension and positive surgical margins in patients with clinical stage B2 disease, and because some positive surgical margins may be owing to attempts to preserve potency we question whether nerve-sparing prostatectomy should be attempted in patients with bulky clinical stage B2 prostate cancer.

Nerve-Sparing Radical Prostatectomy: Evaluation of Results after 250 Patients

To examine the efficacy of nerve-sparing radical retropubic prostatectomy in preserving sexual potency and urinary continence, and in providing complete tumor excision we analyzed the records of the first 250 consecutive patients with clinical stage A or B prostate cancer treated since this operation was adopted at our institution. Over-all, sexual potency was preserved in 71 of 112 patients (63%) who underwent bilateral nerve-sparing prostatectomy and 13 of 33 (39%) who underwent a unilateral nerve-sparing procedure with a minimum of 6 months of followup. Preservation of potency correlated with patient age (p equals 0.0035, chi-square) and was significantly (p less than 0.001, chi-square) higher in patients with pathologically organ-confined tumors (72%) than in those with pathologically extracapsular tumors (51%). Of 192 patients followed for at least 6 months 188 (98%) achieved urinary continence postoperatively. Over-all, apparent complete tumor excision as defined by organ-confined tumor with negative surgical margins and undetectable postoperative prostate specific antigen levels was achieved in 14 preoperatively potent patients (42%) who underwent a unilateral and 67 (59%) who underwent a bilateral nerve-sparing procedure. Completeness of tumor excision correlated with tumor stage. In approximately 45% of the patients incomplete tumor excision was owing to seminal vesicle and/or lymph node involvement or positive bladder neck margins that could not be attributed to the nerve-sparing modification. However, improper application of the nerve-sparing technique may have contributed in the others. We were unable to detect microscopic penetration of the capsule or distinguish between gross extracapsular tumor extension and periprostatic fibrosis at operation.We conclude that with proper application of nerve-sparing radical retropubic prostatectomy, potency can be preserved in the majority of patients without compromising the adequacy of tumor excision. The completeness of tumor excision appears to be determined primarily by the extent of the tumor. Therefore, patient selection is important. Patients with focal, well differentiated tumors are ideal candidates for a nerve-sparing procedure, while those with high volume, poorly differentiated tumors may be at a higher risk for positive surgical margins. The benefits of wide excision of the neurovascular bundles remain to be demonstrated formally.

Prostate Specific Antigen in the Diagnosis and Treatment of Adenocarcinoma of the Prostate. II. Radical Prostatectomy Treated Patients

Serum prostate specific antigen was determined (Yang polyclonal radioimmunoassay) in 102 men before hospitalization for radical prostatectomy. Prostate specimens were subjected to detailed histological and morphometric analysis. Levels of prostate specific antigen were significantly different between patients with and without a Gleason score of 7 or greater (p less than 0.001), capsular penetration greater than 1cm. in linear extent (p less than 0.001), seminal vesicle invasion (p less than 0.001) and pelvic lymph node metastasis (p less than 0.005). Prostate specific antigen was strongly correlated with volume of prostate cancer (r equals 0.70). Bivariate and multivariate analyses indicate that cancer volume is the primary determinant of serum prostate specific antigen levels. Prostate specific antigen was elevated 3.5ng. per ml. for every cc of cancer, a level at least 10 times that observed for benign prostatic hyperplasia.Prostate specific antigen is useful as a preoperative marker because no patient with lymph node metastasis had serum levels of less than 10ng. per ml. (4 times the upper limit of normal range). Of the patients with greater than 50ng. per ml. two-thirds had microscopic lymph node metastasis and 90 per cent had seminal vesicle invasion.Serum prostatic acid phosphatase levels showed a significantly weaker correlation with cancer volume (r equals 0.51) and every other pathological parameter. Of the patients 73 per cent had serum prostatic acid phosphatase levels in the normal range (0 to 2.1ng. per ml.), including 7 per cent who had pelvic lymph node metastasis.Postoperative prostate specific antigen values were available in 97 of 102 patients, with a mean and maximum followup of 12 and 38 months. No patient with pelvic lymph node metastasis achieved an undetectable prostate specific antigen level without adjunctive therapy (hormonal or radiation). No difference in preoperative or postoperative prostate specific antigen levels, cancer volume, seminal vesicle invasion or incidence of pelvic lymph node metastasis was seen between patients with no capsular penetration and those with minimal capsular penetration (1cm. or less total linear extent of full thickness penetration), providing the first quantitative evidence that small amounts of capsular penetration may not be of biological or prognostic significance.