Cytoreductive Radical Prostatectomy in Men with Prostate Cancer and Skeletal Metastases

Background: Androgen deprivation therapy (ADT) represents the standard treatment for hormone-naïve prostate cancer with systemic metastases (mPCA). The role of radical prostatectomy (RP) in this setting is unclear. Objective: To evaluate the oncological and functional outcomes of men with mPCA who underwent cytoreductive RP (CRP). Design, setting, and participants: Retrospective, multi-institutional study of 113 patients with biopsy-proven mPCA who fulfilled the following selection criteria: (1) completely resectable PCA; (2) osseous metastases; (3) absence of gross retroperitoneal lymph node metastases; (4) absence of bulky pelvic lymph node metastases >3 cm; (5) no or minimal visceral metastases; (6) Eastern Cooperative Oncology Group performance status of 0–1; and (7) written informed consent. Intervention: CRP with extended pelvic lymphadenectomy. Eighty patients (70.8%) received neoadjuvant ADT and 91 (86.5%) adjuvant ADT and/or radiation therapy. Outcome measurements and statistical analysis: Cancer-specific survival, overall survival (OS), biochemical relapse-free survival (BRFS), and clinical relapse-free survival (CRFS) were evaluated using descriptive statistical analyses, the Kaplan-Meier method, and univariate and multivariate analyses. Treatment-associated complications were analysed according to the Clavien-Dindo classification. Results and limitations: The mean patient age was 61 yr (range 42–69). The mean follow-up was 53.6 mo (range 13–96, median 45.7). The 3-yr and 5-yr OS was 99 (87.6%) and 90 (79.6%), respectively, and the mean CRFS was 72.3 mo. Preoperative prostate-specific antigen (PSA) < 1.0 ng/ml and PSA below the median of 8.0 ng/ml were significantly associated with BRFS (p < 0.0004). Pathohistology revealed viable PCA in all cases: 16 (14.2%) had pT4a, 21 (18.6%) had pT2a–c, and 76 (67.3%) had pT3a/b PCA. Positive lymph nodes were identified in 61.6% and positive surgical margins in 36.8% of the patients. Eleven men (9.7%) experienced Clavien Dindo grade IIIa–b complications. Low-volume disease, neoadjuvant ADT, and preoperative PSA were significantly associated with a lower risk of surgery-related complications (p < 0.05). No, mild (1–2 pads/d), and severe incontinence (>2 pads/d) was observed in 68.1%, 17.7%, and 14.1%, respectively. Limitations of the study are the retrospective nature and potential patient selection bias. Conclusions: CRP results in 5-yr OS of 80%, a low rate of significant complications, and good functional outcome in well-selected patients. CRP might be an individualised treatment option in the multimodal management of mPCA. Patient summary: We assessed oncological and functional outcomes associated with cytoreductive radical prostatectomy (CRP) in select men with prostate cancer and osseous metastases. We found that CRP might be associated with long overall and relapse-free survival in well-selected patients. CRP could become an additional treatment option in the multimodal therapy of metastatic prostate cancer; it should be performed in a clinical protocol setting and does not represent a standard therapeutic option. Cytoreductive radical prostatectomy (CRP) results in a 5-yr survival rate of 80%, a low rate of significant complications, and good functional outcome in well selected patients. CRP might be an individualized treatment option in the multimodal management of metastatic prostate cancer.