Management of stage D1 adenocarcinoma of the prostate: The Johns Hopkins experience 1974 to 1987

There is no consensus on the proper management of men with stage D1 adenocarcinoma of the prostate. Although cure is unlikely, many men survive for long intervals apparently free of metastatic disease. Thus, effective palliation of the local lesion with low morbidity is desirable. From 1974 to 1987, 120 consecutive men with stage D1 prostate cancer were treated with 3 primary modes of therapy (mean followup 48 months): 1) expectant therapy (35), 2) external beam radiotherapy (21) and 3) radical prostatectomy (64). These patients were statistically homogeneous as determined by Gleason grade but not by extent of metastatic disease. The over-all 5 and 10-year projected actuarial survival rates for the radical prostatectomy patients were 97 and 62%, respectively, and the apparent clinical survival free of disease at 5 years and 80 months, respectively, was 83 and 68%. The direct disease-specific 10-year survival free of disease was 46%. However, only 3 of 27 patients followed for 3 years or longer had undetectable levels of prostate specific antigen. Using a Cox univariate proportional hazards model several factors appeared to have significantg prognostic value including volume of lymph node metastases (macroscopic greater than 2 mm.), percentage of positive lymph nodes sampled and frozen section diagnosis. Gleason grade, clinical stage and the number of positive nodes did not have significant prognostic value. Local recurrence requiring an operation was noted in 8 of 35 patients (23%) treated expectantly, 5 of 21 (24%) treated with radiotherapy and 2 of 64 (3%) treated with radical prostatectomy. Significant gastrointestinal or genitourinary complications occurred in 33% of the men treated with radiotherapy and 1.5% of those undergoing radical prostatectomy. Since the introduction of nerve-sparing radical prostatectomy in 1982, potency resumed in 55% of the 33 patients who were potent preoperatively and have been followed 1 year or longer. These data suggest that in properly selected patients radical prostatectomy, although not curative, can provide excellent palliation of the local lesion with acceptable morbidity and that symptomatic local recurrence of prostatic cancer achieved with radiation therapy is identical to the results in men who were managed expectantly.