Despite the stage migration associated with prostate-specific antigen (PSA) testing and the growing number of low-stage

and organ-confined tumors, at least 10% of men with newly diagnosed prostate cancer have locally advanced disease (T3 NX/+ M0). Although this proportion has declined somewhat, it remains significant and has been relatively constant during the past decade treatment of disease with local or regional spread by any single modality is associated with significant risk of recurrent disease Whereas biochemical-free survival is a frequent endpoint of current prostate cancer studies, it merely represents a purported intermediate surrogate outcome variable; further trials and studies are necessary to confirm the utility of biochemical recurrence as a marker for reduced prostate cancer specific survival after treatment. The most widely used tools to predict disease recurrence after local therapy are the nomograms developed by Kattan and colleagues (Kattan, 1998, 2000 [55] [56]). percentage of total polyunsaturated fatty acid in the prostate was inversely correlated with higher pathologic stage (P = .035), primarily due to the risk of seminal vesicle invasion

the presence of clinically advanced disease (i.e., T3-4) decreased from 11.8% to 3.5%, with a decline from 32.3% to 21.9% in the high-risk group during the observation period. In general, radical prostatectomy with pelvic lymphadenectomy is reserved for those high-risk men with smaller tumors that can be completely removed. The alternative treatment strategy for these men with locally advanced disease and higher risk of biochemical failure is AD therapy combined with radiation therapy. Many men with clinical stage T3 disease have regional spread and may not benefit from prostatectomy; however, select patients (e.g., lower volume disease) may benefit as local control may be achieved in most, and complete cancer excision is possible in some men. Without the use of secondary treatment, 5-year biochemical relapse is higher than 60% ( van den Ouden et al, 1998 ). In other series with variable use of adjuvant therapy, 5- and 10-year biochemical progression was observed in 42% to 49% and 59% to 62%, respectively. The impact of adjuvant therapy may be minimal with respect to clinical progression (i.e., biopsy-proven local recurrence or objective distant metastasis) after radical prostatectomy. Rates of clinical progression at 5, 10, and 15 years are 12% to 45%, 39% to 49%, and 50% to 71%, respectively. Patients with evidence of seminal vesicle invasion or lymph node metastasis are highly likely to develop clinical progression (86% and 95%, respectively) after radical prostatectomy complete surgical removal of all prostatic tissue, regardless of clinical or pathologic stage, should be accomplished when prostatectomy is undertaken. Seminal vesicle involvement not only increases the risk of biochemical recurrence but also significantly increases the risk of local recurrence after radical prostatectomy

whereas clinical downstaging may occur frequently, pathologic downstaging is significantly less common after NAD, ranging between 8% and 31%. Most studies do not show decreased seminal vesicle invasion ( Table 102-6 ). Similarly, rates of lymph node metastases are not altered, with the incidence varying between 3.3% and 16% in both the prostatectomy-alone and neoadjuvant groups. Adjuvant radiation therapy (RT) has not clearly been demonstrated to be of benefit after radical prostatectomy; older studies demonstrate no impact on development of distant metastasis or cancerspecific survival, and more recent data show improved biochemical control In general, men with seminal vesicle invasion are at significant risk for distant metastasis and may not benefit from local or regional RT; however, some men with pT3c may have only local recurrence alone On the basis of limited data, it appears that men with seminal vesicle invasion who achieve a low PSA level (<0.3 ng/mL) after prostatectomy may be a more favorable group in whom adjuvant RT may be considered. Conversely, those men with more advanced disease never reaching an undetectable PSA level generally constitute a poor prognostic group likely harboring unrecognized lymph node or distant disease In the treatment of men with locally advanced or high-risk prostate tumors, monotherapy with RT or permanent interstitial brachytherapy is likely to be inadequate Improved local control and biochemical disease-free and metastases-free survival were noted in the adjuvant AD group at 8 years of follow-up, and this advantage was most prominent with Gleason sum 8 to 10. Overall survival was not statistically different at 5 years (75% versus 72%) and 8 years (49% versus 42%). In those with high-grade tumors, adjuvant AD improved cancer-specific (90% versus 78%) and overall (80% versus 69%) survival at 5 years. It does not appear that the method of AD affects the outcome of combined treatment with RT Thus, a limited period of AD (2 to 4 months) appears to be appropriate for those men with intermediate-risk cancers; more prolonged AD may be beneficial for those with high-risk disease characteristics, including high-stage cancers or very high pretreatment serum PSA values as emerging data support doses greater than 72 Gy as being more effective Systemic therapy in the form of AD may not prevent local progression or reduce need for palliative intervention. most clinicians accept that a PSA level of 0.4 ng/mL or higher that is rising represents treatment failure on the basis of follow-up studies showing that PSA values above this level do not plateau ( Amling et al, 2000 ). Therefore, by consensus ( Scher et al, 2004 ), a patient is considered to have progressed after a radical prostatectomy if the PSA level is 0.4 ng/mL or higher 8 weeks or more after the procedure and rises on a subsequent measurement. The 8-week time frame after surgery is ample to allow the PSA to clear, given a half-life of 2 to 3 days ( Oesterling, 1991 ). The date of failure is the date of the first detectable PSA.

The deepest muscular plane of the palm is the adductor compartment containing the adductor pollicis