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EDITORIAL COMMENT

This article contains extremely valuable information for the prac- ticing urologist confronted with a n unfavorable pathology report after radical prostatectomy. Setting aside patients with nodal involv- ment it is interesting to note tha t the incidence of biochemical failure defined by a PSA greater than 0.2 ng./ml. is identical whatever the

level of extracapsular extension-roughly 30%, the only difference being the delay at which biochemical relapse occurs: 9 months when the seminal vesicles are invaded versus 30 months in the other cases, indicating tha t the primary determinant of biochemical relapse may indeed be capsular penetration.

When biochemical failure occurs roughly 20%' of untreated pa- tients will experience local or distant progression a t 5 years whereas 77% of the patients offered local or systemic chemotherapy will experience a complete response during the same timeframe; this suggests that treatment a t biochemical relapse is indeed beneficial,

It is possible to define a group of patients who in spite of the presence of extracapsular extension are a t low risk of biochemical failure. These patients are characterized by a PSA less than 10 ng./ml. prior to surgery, a specimen Gleason score Of less than 6 and a unique positive margin. The risk of biochemical failure in these patients is identical to what it is observed in patients with pT1-T2 disease, leading to suspect tha t the patients with pTl-T2 disease who experience biochemical relapse probably have undetected lim- ited capsular penetration. On the contrary, patients with a PSA greater than 10 ng./ml., specimen Gleason score greater than 7 and several positive margins are a t high risk of biochemical relapse which will however occur in only 50% of the cases.

The question remains open whether all of these patients should be submitted to immediate adjuvant treatment at the risk of over treat- ing 1 patient of 2 or whether adjuvant treatment should be imple- mented only at biochemical relapse. The superiority of immediate versus delayed (at biochemical relapse) therapeutic intervention has yet to be proved.

L. BoccowGibod Department of Urology H6pital Bichat Paris. France