Radical prostatectomy for high-risk prostate cancer

Treatment for high-risk prostate cancer (PCa) (cT3 PCa, Gleason score 8-10 or PSA>20ng/mL) remains controversial. Radiotherapy with androgen deprivation therapy (ADT) is widely used for high-risk prostate cancer. However, there is a considerable overlap of outcomes among risk groups, suggesting that the so-called high-risk prostate cancer group consists of a heterogeneous population in terms of tumor biology. Actually, the over-staging of cT3a PCa is relatively frequent and occurs in 13-27% of cases. Thus, radical prostatectomy (RP) alone is a reasonable treatment option for selected patients with high-risk prostate cancer. RP can provide an excellent biochemical and clinical progression-free survival for these patients if they have a pathologically organ-confined disease, or their tumors are extirpated completely with a negative surgical margin. A thorough preoperative evaluation, including imaging study and the use of a nomogram, is mandatory for selecting candidates appropriate for RP. Our recent study indicates that a positive biopsy core percentage is a strong independent predictor of organ-confined disease in these high-risk patients. In cases of adverse tumor characteristics, such as positive surgical margin, extraprostatic extension and seminal vesicle invasion, the patient must be informed of the likelihood of a multimodal approach. The use of adjuvant radiotherapy may be reasonable after recuperation from surgery. Immediate ADT may be indicated for those with positive pelvic lymph node.