Neo-adjuvant hormonal therapy of prostate cancer.

At present, only locally confined carcinoma of the prostate can be cured if all of the tumor tissue can be removed by surgery [36]. Early detection strategies using serum prostate-specific antigen (PSA), digital rectal examination (DRE) and transrectal ultrasound (TRUS) have been increasingly used. However, exact clinical determination of the local tumor extension is only possible to a limited extent [4, 13, 28, 34]. Up to 60% of clinical locally confined tumors are understaged after histopathological examination of the radical prostatectomy specimen. Furthermore a high incidence of positive margins of up to 60% has been reported [7, 21]. Although a clear surgical margin does not exclude local or distant disease recurrence, it is regarded as a good prognostic factor [3, 25]. Androgen withdrawal prior to radical prostatectomy is an attractive theoretical option to decrease the risk of disease recurrence, since tumor regression can be induced by any procedure that reduces the intracellular concentration of dihydrotesterone by more than 80%. The benefit of preoperative medical androgen deprivation is controversial [6-8, 13, 15-17, 20, 23, 35, 37]. A priori a benefit would not be expected in any case if androgen withdrawal had no effect on the tumor. We therefore investigated the effects of a neo-adjuvant androgen-ablative therapy (NAT) in a large population of 375 patients who underwent radical retropubic prostatectomy (RRP) after NAT. We report in particular the effects of NAT on prostate volume measured by TRUS, PSA, clinical stage and tumor morphology including positive surgical margins. Furthermore the recently reported first results of prospective randomized trials comparing RRP alone versus NAT plus RRP are discussed to analyze the possible impact of NAT.