Local Control and Long-Term Disease-Free Survival for Stage D1 (T2-T4N1-N2M0) Prostate Cancer After Radical Prostatectomy in the PSA Era

Objectives: With the advent of prostate-specific antigen (PSA) screening, the number of lymph node metastases found after radical prostatectomy (RP) has been decreasing. Although it has been shown in this population that immediate adjuvant androgen deprivation therapy (ADT) improves survival compared with initiating ADT at clinical recurrence, the effect of starting ADT at biochemical recurrence is unknown. We examined a series of patients with Stage D1 (T2-T4N1-N2M0) prostate cancer discovered after RP, most of whom started ADT at biochemical recurrence. Methods: A total of 2121 patients underwent RP and bilateral pelvic lymph node dissection from January 1990 and December 2000. Of these men, 28 had lymph node metastases (1.3%), 24 of whom had adequate follow-up data for analysis. Results: No perioperative or long-term complications, such as pelvic recurrence, gross hematuria, urinary retention, or hydronephrosis, developed. With a median follow-up of 74 months, the estimated 5-year survival rate was 94%, similar to the average life expectancy of age-matched men in the United States. The 5-year biochemical disease-free survival rate was 15%. A total of 18 patients who did not start immediate ADT had an estimated 100% overall survival rate at 5 years. Conclusions: The results of our study have shown that survival for patients with Stage D1 prostate cancer after RP is excellent and equivalent to that of age-matched controls. Long-term pelvic morbidity due to primary tumor progression was prevented by RP. By waiting until PSA failure to initiate ADT, we found that a small percentage of patients (15% at 5 years) were rendered disease free with surgery alone and could avoid the side effects of ADT, with excellent overall survival maintained for those starting ADT at biochemical progression.