European Journal of Cancer Supplements vol:5 issue:5 pages:157-169
Despite the successful efforts to diagnose prostate cancer at an increasingly early stage, there are still a significant number of men presenting with locally advanced disease. Locally advanced prostate cancer is defined as cancer that has extended clinically beyond the prostatic capsule with invasion of the pericapsular tissue, apex, bladder neck or seminal vesicles, but without lymph node involvement or distant metastases .
An important part of evaluating prostate cancer is determining the stage, or how far the cancer has spread. The most common staging system is the TNM (tumour, node, metastasis) system . It includes the size of the tumour, the number of involved lymph nodes, and the presence of any other metastases. Locally advanced cancer is referred to as T3-T4 N0 M0 disease. T3 stage refers to palpable disease
sufficient to indicate that the tumour has penetrated through the prostate capsule. T4 stage indicates local invasion of a structure adjacent to the prostate other than the seminal vesicle(s). N0 refers to no lymph node involvement and M0 to no distant metastasis. Local staging (T-staging) is based on the findings of digital rectal examination (DRE) and imaging modalities of which transrectal ultrasound (TRUS) is the most popular . Prostate specific antigen (PSA) level and the extent of cancer in prostate biopsies and the Gleason score may provide additional information . The gold standard for lymph node status (N-staging) is bilateral pelvic lymphadenectomy although computed tomography (CT) or MRI are used to show enlarged nodes. Skeletal metastasis (M-staging) is best assessed by bone scintigraphy . Some methods are used to improve staging accuracy, for example endorectal coil MRI for better assessment of the seminal vesicles , or TRUS-guided biopsies of periprostatic tissue or seminal vesicles , but they are not routinely used. Correct staging of clinical T3 disease is difficult and both overstaged pathological T2 (pT2) tumours and
understaged pT4 or node-positive (pN+) cases are common. Surgical series of clinical T3 cases have shown that 9−27% represent clinically overstaged pT2 disease [7−11]. In accordance with the European Association of Urology (EAU) guidelines on prostate cancer there are different treatment options available; watchful waiting, radiotherapy (RT), radical prostatectomy (RP), hormonal therapy (HT) and various combinations . The objectives of treatment for T3 prostate cancer are to cure the disease, prolong survival or metastasis-free survival and improve quality of life.
There is currently no single standard of care for clinical T3 disease and there is an urgent need to determine which treatment options offer superior results in cT3 patients because if left untreated, a significant proportion of those patients will die of prostate cancer. In this manuscript we highlight the different treatment options and key studies that may provide interim answers while awaiting definitive results from randomised trials. We also aim to clarify the role of surgery as treatment option for locally
advanced prostate cancer.