Neoadjuvant Hormonal Deprivation before Radical Prostatectomy

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Abstract
Hormonal deprivation before radical prostatectomy remains controversial. The main purpose is to achieve downstaging, downgrading, improvement of the surgical results and increased survival. Experience with the last 100 patients who underwent radical prostatectomy, in whom 40 patients received complete preoperative androgen blockade (luteinizing-hormone- releasing hormone agonist and flutamide) prior to radical surgery, has shown a definitive decrease in volume of 40-50%). The significant reduction of volume seemed to facilitate the dissection of the prostate from closely vulnerable structures. Clinical downstaging was observed in one third of the patients, but the final pathological staging did not confirm the clinical impression and shows that it is difficult to solve this issue. There was one PT(0) patient. Histological changes are observed in both the nonneoplastic tissue as well as in the prostatic carcinoma with more marked effects on the latter. Downgrading was not observed, but this is even more difficult to assess since biopsies cannot be considered as representative of the entire heterogeneous tumor. Prostate-specific antigen (PSA) dropped to undetectable levels in 59% of the patients 3 months after hormonal suppression. Among these, 80% had PT(2) and only 13% had PT(3) tumor. PSA, 3 months after neoadjuvant hormonal treatment, might have a useful predictive value in patient selection for radical surgery since 86% with undetectable PSA had tumors confined to the gland (PT(2)/B(2)). On the other hand, patients who still had PSA >4 ng/ml after neoadjuvant therapy had all stage PT(3)-PT(4) disease. The true influence on the local control, time to progression and overall survival needs to be addressed by large prospective randomized studies comparing radical prostatectomy versus radical prostatectomy with neoadjuvant complete androgen deprivation in locally advanced (T(2)-T(3) N(0) M(0)) prostatic carcinoma.

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