Neoadjuvant androgen deprivation therapy before radical prostatectomy: who is unlikely to benefit?

• Published in: British Journal of Urology Vol. 79; no. 2; pp. 221 - 225
• Main Authors: Rabbani, F., Sullivan, L.D., Goldenberg, S.L., Stothers, L.
• Format: Journal Article
• Language: English
• Published: Oxford Blackwell Science Ltd 01-02-1997; Blackwell
• Subjects: Aged; Androgen Antagonists - therapeutic use; Antineoplastic agents; Biological and medical sciences; Combined treatments (chemotherapy of immunotherapy associated with an other treatment); Humans; Lymph Node Excision; Lymphatic Metastasis; Male; Medical sciences; Middle Aged; Multivariate Analysis; neoadjuvant; pathology; Pharmacology. Drug treatments; Preoperative Care; Prostate-Specific Antigen - blood; Prostatectomy - methods; prostate‐specific antigen; Prostatic neoplasms; Prostatic Neoplasms - surgery; Prostatic Neoplasms - therapy; radical prostatectomy; Human; Adenocarcinoma; Urinary system disease; Prostate disease; Androgen; Male; Malignant tumor; Survival; Neoadjuvant treatment; Chemotherapy; Treatment; Surgery; Adult; Prostatectomy; Male genital diseases; Prostate
• ISSN: 0007-1331; 1464-410X
• DOI: 10.1046/j.1464-410X.1997.26714.x

Objective To determine which patients undergoing radical prostatectomy for localized cancer are unlikely to benefit from neoadjuvant androgen withdrawal therapy.
Patients and methods Over a 5‐year period, 173 patients underwent radical retropubic prostatectomy; 87 patients received no pre‐operative androgen withdrawal therapy, for whom the clinical stages were T1b (17 patients), T1c (3), T2a (31) and T2b/c (36). Pre‐operative prostate biopsies contained well‐differentiated cancer in 43 and moderately differentiated cancer in 44 patients. Serum prostate‐specific antigen (PSA) ranged from 0.4 ng/mL to 110.1 ng/mL (median 5.0). The presence of extracapsular disease, positive surgical margins and seminal vesicle involvement were correlated with pre‐operative PSA, PSA density (PSAD), the natural logarithm of PSA [ln(PSA)], biopsy grade, clinical stage, and sparing of neurovascular bundles.
Results Patients with a PSA ≤4.0 ng/mL had a rate of extracapsular disease and positive margins of 8.3% and none had seminal vesicle invasion; corresponding rates for patients with a PSA >4.0 ng/mL were 57%, 51% and 12%, respectively. Multivariate analysis revealed ln(PSA) to be the best predictor of extracapsular disease (P0.001), margin positivity (P0.001) and seminal vesicle invasion (P=0.0019).
Conclusions These results suggest that in patients who have clinically localized, well or moderately differentiated prostate cancer, a PSA ≤4.0 ng/mL is predictive for organ‐confined disease. This group is unlikely to benefit from neoadjuvant androgen deprivation. Ln(PSA) may be able to improve the accuracy of mathematical multivariate models predicting the presence of extracapsular disease or margin positivity, but this will require verification in larger population‐based studies.