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Prostate Cancer Surgical Practice Guidelines

Prostate Cancer Surgical Practice Guidelines

Scope and Format of Guidelines

The Society of Surgical Oncology surgical practice guidelines focus
on the signs and symptoms of primary cancer, timely evaluation of the symptomatic
patient, appropriate preoperative evaluation for extent of disease, and
role of the surgeon in diagnosis and treatment. Separate sections on adjuvant
therapy, follow-up programs, or management of recurrent cancer have been
intentionally omitted. Where appropriate, perioperative adjuvant combined-modality
therapy is discussed under surgical management. Each guideline is presented
in minimal outline form as a delineation of therapeutic options.

Since the development of treatment protocols was not the specific aim
of the Society, the extensive development cycle necessary to produce evidence-based
practice guidelines did not apply. We used the broad clinical experience
residing in the membership of the Society, under the direction of Alfred
M. Cohen, md, Chief, Colorectal Service, Memorial Sloan-Kettering Cancer
Center, to produce guidelines that were not likely to result in significant

Following each guideline is a brief narrative highlighting and expanding
on selected sections of the guideline document, with a few relevant references.
The current staging system for the site and approximate 5-year survival
data are also included.

The Society does not suggest that these guidelines replace good medical
judgment. That always comes first. We do believe that the family physician,
as well as the health maintenance organization director, will appreciate
the provision of these guidelines as a reference for better patient care.

Society of Surgical Oncology Practice Guidelines:
Prostate Cancer

Symptoms and Signs

    Early-stage disease
  • Related to prostatism
  • Diminished force of stream
  • Frequency and urgency related to benign prostate hyperplasia (BPH)
    or prostate cancer
  • Palpation for nodularity or firmness on digital rectal examination
  • Routine prostate specific antigen (PSA) test more than 4 ng/mL
  • Age-specific reference ranges have been suggested but have not proven
    to be beneficial.
    Advanced-stage disease
  • Symptoms secondary to disseminated disease
  1. Pain
  2. Anemia
  3. Azotemia
  • Above symptoms may cause shortness of breath, easy fatigability, or
    generalized debility.
  • Signs are related to elevations in PSA and secondary alterations in
    serum alkaline phosphatase, especially isoenzymes.
  • Other symptoms may be secondary to progressive obstructive disease
    with elevation in serum creatinine or blood urea nitrogen, and secondary
    metabolic effects associated with azotemia.
  • Further symptoms may
    be related to widespread bone marrow replacement and secondary involvement
    of the bone marrow, particularly platelets and red cell count.
  • Hematuria may be noted but is rare.
  • Evaluation of the Symptomatic Patient

    • Previous health history or the previous studies obtained by the referring
    • PSA: normal range 0-4 ng/mL. Some authors have advocated age-related
      PSA values. PSA velocity more than 0.8 ng/mL per year is cause for concern.
    • CBC and evaluation of renal function
      Physical examination
    • Include palpation of the abdomen and digital rectal examination.
    • Transrectal ultrasound with biopsy is often utilized for patients with
      elevation of PSA alone.
    • The major role of transrectal ultrasound is identification of hypoechoic
      areas and guidance of needle biopsies into different areas of the prostate.
    • Cystoscopy may be indicated for hematuria.
      Appropriate timeliness of surgical referral
    • Depends upon the degree and severity of signs and symptoms, as well
      as laboratory tests compatible with either localized or disseminated disease
    • Reasonable interval for evaluation should be within 4 weeks.

    Preoperative Evaluation for Extent of Disease

      Staging studies for localized disease
    • Digital rectal examination
    • Transrectal ultrasound
    • Gleason sum of the biopsy specimen
    • Number and percentage of cores involved with prostate cancer and level
      of PSA
    • For extracapsular disease involvement, include CT scan, which seems
      to be useful predominantly for involvement of seminal vesicles, or endorectal
      surface coil MRI.
    • MRI seems to be the most accurate imaging study for local staging,
      although data with clinical surgical correlation are still accumulating.
      Evaluation for metastatic disease
    • Include a bone scan of the bony skeleton if PSA more than 8 ng/mL
    • Regional lymph node involvement. CT scan is only modestly useful for the evaluation of the regional lymph
      nodes that lie in the obturator and external iliac chain.

    Role of the Surgeon in Initial Management

      Evaluation of the symptomatic patient
    • The surgeon is often involved in establishing the diagnosis of prostate
      cancer. Patients with a palpable nodule or elevated PSA generally undergo
      transrectal ultrasound, done either by a urologist or radiologist, with
      ultrasound-directed needle biopsies using a spring-loaded biopsy gun.
    • For patients with palpable nodules, digitally directed biopsies may
      be utilized.
    • For patients with hypoechoic areas seen on ultrasound, biopsies can
      be directed through the hypoechoic area.
    • For patients with elevated PSA but no palpable or visual abnormalities,
      six sector biopsies of the prostate are obtained. The surgeon generally
      assumes the role of diagnostician to obtain selected staging studies as
      indicated, based on the patient's symptoms.
      Diagnostic procedures
    • Transrectal ultrasound-guided needle biopsies of the prostate
      Surgical considerations
    • Unilateral or bilateral nerve-sparing radical retropubic prostatectomy
    • Radical perineal prostatectomy
    • Lymphadenectomy via open or laparoscopic approach
      Other therapeutic considerations
    • External-beam radiation therapy
    • Interstitial radiation therapy
    • Hormonal manipulation
    • Observation

    These guidelines are copyrighted by the Society of Surgical Oncology
    (SSO). All rights reserved. These guidelines may not be reproduced in any
    form without the express written permission of SSO. Requests for reprints
    should be sent to: James R. Slawny, Executive Director, Society of Surgical
    Oncology, 85 W Algonquin Road, Arlington Heights, IL 60005.

    An estimated 317,100 new cases of prostate cancer were diagnosed in
    the United States in 1996 with 41,400 concurrent deaths.[1] The most important
    risk factors for prostate cancer, as they are understood today, are a positive
    family history and being of the African-American race.[2] For this and
    other reasons, the American Cancer Society, American Urologic Association,
    American College of Radiology, and College of American Pathology all recommend
    an annual digital rectal examination and a prostate-specific antigen (PSA)
    blood test commencing at age 50.[2] However, for those with either of the
    two risk factors, annual testing is recommended beginning at age 40.[2]

    The American Cancer Society has followed a cohort of men, age 55 years
    and older, since 1988, and based on these and other data, has determined
    that the tumors detected by early detection efforts are clinically significant
    and warrant treatment.[3-6]

    In general, 0 to 4 ng/mL (Hybritech Tandem-R) is considered the normal
    range for PSA.[5] Other applications of PSA evaluation include PSA density,
    PSA velocity, and age-related levels.[5] All of these, with the exception
    of the age-related levels, appear to offer some individual benefit with
    regard to increased sensitivity but at the expense of decreased specificity.[5,6]


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