Adjuvant and salvage radiotherapy after prostatectomy: AUA/ASTRO Guideline

Late genitourinary toxicity in salvage radiotherapy for prostate cancer after radical prostatectomy: impact of daily fraction doses

OBJECTIVE

To evaluate the impact of daily fraction doses on late genitourinary (GU) toxicity after salvage radiotherapy (SRT) for prostate cancer.

METHODS

This multi-institutional retrospective study included 212 patients who underwent SRT between 2008 and 2018. All patients received image-guided intensity-modulated SRT at a median dose of 67.2 Gy in 1.8-2.3 Gy/fraction. The cumulative rates of late grade ≥2 GU and gastrointestinal (GI) toxicities were compared using Gray test, stratified by the ≤2.0 Gy/fraction (n = 137) and ≥2.1 Gy/fraction groups (n = 75), followed by multivariate analyses. The total dose was represented as an equivalent dose in 2-Gy fractions (EQD2) with α/β = 3 Gy.

RESULTS

After a median follow-up of 63 months, the cumulative rates of 5-year late grade ≥2 GU and GI toxicities were 14% and 2.5%, respectively. The cumulative rates of 5-year late grade ≥2 GU toxicity in the ≥2.1 Gy/fraction and ≤2.0 Gy/fraction groups were 22% and 10%, respectively (P = .020). In the multivariate analysis, ≥2.1 Gy/fraction was still associated with an increased risk of late grade ≥2 GU toxicity (hazard ratio, 2.37; 95% confidence interval, 1.12-4.99; P = .023), while the total dose was not significant.

CONCLUSION

The present results showed that ≥2.1 Gy/fraction resulted in a higher incidence of late grade ≥2 GU toxicity in SRT.

ADVANCES IN KNOWLEDGE

The impact of fraction doses on late GU toxicity after SRT remains unknown. The results suggest that higher fraction doses may increase the risk of late GU toxicity in SRT.

Noninferiority of Hypofractionated vs Conventional Postprostatectomy Radiotherapy for Genitourinary and Gastrointestinal Symptoms: The NRG-GU003 Phase 3 Randomized Clinical Trial

Importance

No prior trial has compared hypofractionated postprostatectomy radiotherapy (HYPORT) to conventionally fractionated postprostatectomy (COPORT) in patients primarily treated with prostatectomy.

Objective

To determine if HYPORT is noninferior to COPORT for patient-reported genitourinary (GU) and gastrointestinal (GI) symptoms at 2 years.

Design, Setting, and Participants

In this phase 3 randomized clinical trial, patients with a detectable prostate-specific antigen (PSA; ≥0.1 ng/mL) postprostatectomy with pT2/3pNX/0 disease or an undetectable PSA (<0.1 ng/mL) with either pT3 disease or pT2 disease with a positive surgical margin were recruited from 93 academic, community-based, and tertiary medical sites in the US and Canada. Between June 2017 and July 2018, a total of 296 patients were randomized. Data were analyzed in December 2020, with additional analyses occurring after as needed.

Intervention

Patients were randomized to receive 62.5 Gy in 25 fractions (HYPORT) or 66.6 Gy in 37 fractions (COPORT).

Main Outcomes and Measures

The coprimary end points were the 2-year change in score from baseline for the bowel and urinary domains of the Expanded Prostate Cancer Composite Index questionnaire. Secondary objectives were to compare between arms freedom from biochemical failure, time to progression, local failure, regional failure, salvage therapy, distant metastasis, prostate cancer-specific survival, overall survival, and adverse events.

Results

Of the 296 patients randomized (median [range] age, 65 [44-81] years; 100% male), 144 received HYPORT and 152 received COPORT. At the end of RT, the mean GU change scores among those in the HYPORT and COPORT arms were neither clinically significant nor different in statistical significance and remained so at 6 and 12 months. The mean (SD) GI change scores for HYPORT and COPORT were both clinically significant and different in statistical significance at the end of RT (-15.52 [18.43] and -7.06 [12.78], respectively; P < .001). However, the clinically and statistically significant differences in HYPORT and COPORT mean GI change scores were resolved at 6 and 12 months. The 24-month differences in mean GU and GI change scores for HYPORT were noninferior to COPORT using noninferiority margins of -5 and -6, respectively, rejecting the null hypothesis of inferiority (mean [SD] GU score: HYPORT, -5.01 [15.10] and COPORT, -4.07 [14.67]; P = .005; mean [SD] GI score: HYPORT, -4.17 [10.97] and COPORT, -1.41 [8.32]; P = .02). With a median follow-up for censored patients of 2.1 years, there was no difference between HYPORT vs COPORT for biochemical failure, defined as a PSA of 0.4 ng/mL or higher and rising (2-year rate, 12% vs 8%; P = .28).

Conclusions and Relevance

In this randomized clinical trial, HYPORT was associated with greater patient-reported GI toxic effects compared with COPORT at the completion of RT, but both groups recovered to baseline levels within 6 months. At 2 years, HYPORT was noninferior to COPORT in terms of patient-reported GU or GI toxic effects. HYPORT is a new acceptable practice standard for patients receiving postprostatectomy radiotherapy.

Trial Registration

ClinicalTrials.gov Identifier: NCT03274687.

Optimizing anti-androgen treatment use among men with pathologic lymph-node positive prostate cancer treated with radical prostatectomy: the importance of postoperative PSA kinetics

BACKGROUND

Optimal postsurgical management of prostate cancer (PCa) patients with nodal metastasis at the time of radical prostatectomy remains unclear. We sought to examine the role of postoperative PSA kinetics and pathologic tumor characteristics in guiding additional hormonal therapy use in pN1 men.

METHODS

In total, 297 pN1 PCa patients treated with radical prostatectomy and ePLND between 2002 and 2018 were identified within our prospectively maintained institutional cancer data-registry. Following surgery, these patients were managed with either immediate androgen deprivation therapy (iADT) or observation with deferred ADT (dADT). The former was defined as ADT given within ≤6 months of surgery and the latter as >6 months. The primary outcome was metastasis. Regression-tree analysis was used to stratify patients into novel risk-groups based on post-prostatectomy tumor characteristics and PSA kinetics and the corresponding metastasis risk. Multivariable Cox regression analyses tested the impact of iADT versus observation ± dADT on metastasis, cancer-specific mortality, and overall mortality within each risk-group separately.

RESULTS

The median follow-up was 6.1 years (IQR 3.2-9.0). Regression-tree analysis stratified patients into 3 novel risk-groups (Harrell's C-index 0.79) based on PSA-nadir and time to biochemical failure: group 1 (low-risk) included patients with time to biochemical recurrence >6 months (n = 115), while groups 2 and 3 included patients with biochemical failure within ≤6 months with a postoperative PSA-nadir <1.05 ng/mL (group 2 [intermediate-risk], n = 125) or ≥1.05 ng/mL (group 3 [high-risk], n = 57), respectively. No other patient or tumor characteristics were significant for risk stratification. Within each risk-group, the 10-year metastasis-free survival rates with iADT versus observation ± dADT use were: group 1, 100% versus 95.4% (Log-rank p = 0.738), group 2, 80.6% versus 53.5% (Log-rank p = 0.016), and group 3, 41.5% versus 0% (Log-rank p = 0.015), respectively. Adjusted Cox regression analyses confirmed the benefit of iADT utilization in reducing metastasis in group 2 (p = 0.029) and group 3 (p = 0.008) patients, with no benefit for group 1 patients (p = 0.918). Similar results were noted for cancer-specific and overall mortality.

CONCLUSIONS

Following radical prostatectomy, early postoperative PSA kinetics may provide valuable information for guiding the timing of ADT initiation-this may reduce over- and undertreatment of pN1 PCa men.

Impact of radiation doses on clinical relapse of biochemically recurrent prostate cancer after prostatectomy

The relationship between radiation doses and clinical relapse in patients receiving salvage radiotherapy (SRT) for biochemical recurrence (BCR) after radical prostatectomy (RP) remains unclear. We identified 292 eligible patients treated with SRT between 2005 and 2018 at 15 institutions. Clinical relapse-free survival (cRFS) between the ≥ 66 Gy (n = 226) and < 66 Gy groups (n = 66) were compared using the Log-rank test, followed by univariate and multivariate analyses and a subgroup analysis. After a median follow-up of 73 months, 6-year biochemical relapse-free survival, cRFS, cancer-specific survival, and overall survival rates were 58, 92, 98, and 94%, respectively. Six-year cRFS rates in the ≥ 66 Gy and < 66 Gy groups were 94 and 87%, respectively (p = 0.022). The multivariate analysis revealed that Gleason score ≥ 8, seminal vesicle involvement, PSA at BCR after RP ≥ 0.5 ng/ml, and a dose < 66 Gy correlated with clinical relapse (p = 0.015, 0.012, 0.024, and 0.0018, respectively). The subgroup analysis showed the consistent benefit of a dose ≥ 66 Gy in patients across most subgroups. Doses ≥ 66 Gy were found to significantly, albeit borderline, increase the risk of late grade ≥ 2 GU toxicity compared to doses < 66 Gy (14% vs. 3.2%, p = 0.055). This large multi-institutional retrospective study demonstrated that a higher SRT dose (≥ 66 Gy) resulted in superior cRFS.

Association of radiotherapy for prostate cancer and second primary colorectal cancer: a US population-based analysis

BACKGROUND

Radiotherapy (RT) is a common treatment for prostate cancer, yet the risk of second primary colorectal cancer (SPCRC) in patients with prostate cancer undergoing RT has not been adequately studied.

METHODS

This study employed a population-based cohort design using the US Surveillance, Epidemiology, and End Results (SEER) database to identify individuals diagnosed between January 1975 and December 2015. The cumulative incidence of SPCRC was estimated using Fine-Gray competing risk regression. Poisson regression analysis was used to estimate the risk associated with RT. Survival outcomes of patients with SPCRC were evaluated using the Kaplan-Meier method.

RESULTS

A total of 287,607 patients diagnosed with prostate cancer were identified. The cumulative incidences were higher in patients who did not receive RT (2.00%) compared to those who underwent RT (2.47%) after 25 years. After adjustment for multiple variables, RT was associated with an increased risk of developing combined SPCRC (adjusted HR 1.590). Additionally, the overall survival was significantly lower in patients who developed colorectal cancer after receiving RT as compared to those who did not receive RT.

CONCLUSION

These findings underscore the need for diligent long-term monitoring and effective management strategies to detect SPCRC in patients treated with RT for prostate cancer.

15-year biochemical failure, metastasis, salvage therapy, and cancer-specific and overall survival rates in men treated with robotic radical prostatectomy for PSA-screen detected prostate cancer

BACKGROUND

An informed decision regarding a treatment option requires data on its long-term efficacy and side-effect profile. While the side-effects of robotic radical prostatectomy have been well-quantified, the data on its long-term efficacy are lacking. We here provide 15-year oncological outcomes of clinically-localized prostate cancer (CLPCa) patients treated with robot-assisted laparoscopic prostatectomy (RALP).

METHODS

We treated 1,807 men with CLPCa with RALP between 2001 and 2005 and prospectively collected follow-up data through 2020. We examined the rates of biochemical failure (BCF), metastatic progression, secondary therapy use, PCa-specific mortality (PCSM), and overall survival (OS) using Kaplan-Meier and competing-risk cumulative incidence methods as appropriate.

RESULTS

The median follow-up was 14.1 years. Six hundred eight and 312 men had D'Amico intermediate- and high-risk disease, respectively. Overall, the 15-year rates of BCF, metastasis, secondary therapy use, PCSM, and OS were 28.1%, 4.0%, 16.3%, 2.5%, and 82.1%, respectively. The rates of oncologic failure increased with increasing D'Amico (preoperative) and Diaz (postoperative) risk scores - BCF, metastasis, and PCSM rates in D'Amico low-, intermediate-, and high-risk groups at 15-years were 15.2%, 38.3%, and 44.1% [BCF], 1.1%, 4.1%, and 13.0% [metastasis], and 0.5%, 3.4%, and 6.6% [PCSM], respectively, and in Diaz risk groups 1, 2, 3, 4, and 5 were 5.5%, 20.6%, 41.8%, 66.9%, and 89.2% [BCF], 0%, 0.5%, 3.2%, 20.5%, and 60.0% [metastasis], and 0%, 0.8%, 0.6%, 13.5%, and 37.5% [PCSM], respectively. The OS rates in D'Amico low-to-high and Diaz 1-to-5 risk groups at 15-years were 85.9%, 78.6%, and 75.2%, and 89.4%, 83.2%, 80.6%, 67.2%, and 23.4%, respectively.

CONCLUSIONS

Men diagnosed with clinically-localized prostate cancer in the contemporaneous PSA-screening era and treated with RALP achieve durable long-term oncological control. The data reported here (in a risk-stratified manner) represent the longest follow-up after robotic radical prostatectomy, and as such, should be of value when counseling patients regarding expected oncologic outcomes from RALP.

Clinical outcomes for men with positive surgical margins after radical prostatectomy-results from the South Australian Prostate Cancer Clinical Outcomes Collaborative community-based registry

Objective

Positive surgical margins (PSMs) after radical prostatectomy (RP) indicate failure of surgery to completely clear cancer. PSMs confer an increased risk of biochemical recurrence (BCR), but how more robust outcomes are affected is unclear. This study investigated factors associated with PSMs following RP and determined their impact on clinical outcomes (BCR, second treatment [radiotherapy and/or androgen deprivation therapy], and prostate cancer-specific mortality [PCSM]).

Methods

The study cohort included men diagnosed with prostate cancer (pT2-3b/N0/M0) between January 1998 and June 2016 who underwent RP from the South Australian Prostate Cancer Clinical Outcomes Collaborative database. Factors associated with risk of PSMs were identified using Poisson regression. The impact of PSMs on clinical outcomes (BCR, second treatment, and PCSM) was assessed using competing risk regression.

Results

Of the 2827 eligible participants, 28% had PSMs-10% apical, 6% bladder neck, 17% posterolateral, and 5% at multiple locations. Median follow-up was 9.6 years with 81 deaths from prostate cancer recorded. Likelihood of PSM increased with higher pathological grade and pathological tumor stage, and greater tumour volume, but decreased with increasing surgeon volume (odds ratio [OR]: 0.93; 95% confidence interval [CI]: 0.88-0.98, per 100 previous prostatectomies). PSMs were associated with increased risk of BCR (adjusted sub-distribution hazard ratio [sHR] 2.5; 95% CI 2.1-3.1) and second treatment (sHR 2.9; 95% CI 2.4-3.5). Risk of BCR was increased similarly for each PSM location, but was higher for multiple margin sites. We found no association between PSMs and PCSM.

Conclusion

Our findings support previous research suggesting that PSMs are not independently associated with PCSM despite strong association with BCR. Reducing PSM rates remains an important objective, given the higher likelihood of secondary treatment with associated comorbidities.

PSMA guided approach for bIoCHEmical relapse after prostatectomy- (PSICHE) trial (NCT05022914). Detection rate and treatment decision after 68Ga-PSMA PET/CT within a prospective study

BACKGROUND

Ultrasensitive imaging has been demonstrated to influence biochemical relapse treatment. PSICHE is a multicentric prospective study, aimed at exploring detection rate with 68Ga-PSMA-11 positron emission tomography/computed tomography (PET/CT) and outcomes with a predefined treatment algorithm tailored to the imaging.

METHODS

Patients affected by biochemical recurrence after surgery (prostate specific antigen [PSA] > 0.2 < 1 ng/mL) underwent staging with 68Ga-PSMA PET/CT. Management followed this treatment algorithm accordingly with PSMA results: prostate bed salvage radiotherapy (SRT) if negative or positive within prostate bed, stereotactic body radiotherapy (SBRT) if pelvic nodal recurrences or oligometastatic disease, androgen deprivation therapy (ADT) if nonoligometastatic disease. Chi-square test was used to evaluate the relationship between baseline features and rate of positive PSMA PET/CT.

RESULTS

One hundred patients were enrolled. PSMA results were negative/positive in the prostate bed in 72 patients, pelvic nodal or extrapelvic metastatic disease were detected in 23 and 5 patients. Twenty-one patients underwent observation because of prior postoperative radiotherapy (RT)/treatment refusal. Fifty patients were treated with prostate bed SRT, 23 patients underwent SBRT to pelvic nodal disease, five patients were treated with SBRT to oligometastatic disease. One patient underwent ADT. NCCN high-risk features, stage > pT3 and ISUP score >3 reported a significantly higher rate of positive PSMA PET/CT after restaging (p = 0.01, p = 0.02, and p = 0.002). By quartiles of PSA, rate of positive PSMA PET/CT was 26.9% (>0.2; <0.29 ng/mL), 24% (>0.3; <0.37 ng/mL), 26.9% (>0.38; <0.51 ng/mL), and 34.7% (>0. 52; <0.98 ng/mL).

CONCLUSIONS

PSICHE trial constitute a useful platform to collect data within a clinical framework where modern imaging and metastasis-directed therapy are integrated.

Orientation of capture antibodies on gold nanoparticles to improve the sensitivity of ELISA-based medical devices

The sensitivity of ELISA-based devices strongly depends on the right orientation of antibodies on the sensor surface. The aim of this work was to increase the analytical performance of a commercial ELISA-based medical device (VIDAS®), thanks to the specific orientation of antibodies on gold nanostructured disposables. For this purpose, fPSA VIDAS® assay was used as model and the disposable providing the antigen binding surface (SPR®) was functionalized with gold nanostructures coated with monovalent half-fragment antibodies (reduced IgG, rIgG). The functionalization of polystyrene SPRs® with gold nanostructures was achieved through a one-step incubation of gold dispersions in a mixture of non-toxic solvents. Five different concentrations of gold nanoparticles (NPs) were tested with a maximum fluorescence enhancement for NPs density around 3-8 *10³ NPs/μm² (752 ± 11 RFV vs 316 ± 5 RFV of bare SPRs®). The comparison of the dose-response curve obtained with commercial and gold coated-SPRs® revealed a significant improvement (p < 0.0001) of the analytical sensitivity of the VIDAS® system using nanostructured disposables. This improved version of SPRs® allows to distinguish small variations of fPSA concentrations opening the way to the application of this biomarker to other kinds of cancer as recently described in the literature.

Early biochemical outcomes following PSMA guided approach for bIoCHEmical relapse after prostatectomy-PSICHE trial (NCT05022914): preliminary results

PSICHE (NCT05022914) is a prospective trial to test a [68Ga]Ga- PSMA-11 PET/CT imaging tailored strategy. All evaluable patients had biochemical relapse after surgery and underwent centralized [68Ga]Ga-PSMA-11 PET/CT imaging. The treatment was performed according pre-defined criteria. Observation and re-staging at further PSA progression were proposed to patients with negative PSMA and previous postoperative RT. Prostate bed SRT was proposed to all patients with a negative staging or positive imaging within prostate bed. Stereotactic body radiotherapy (SBRT) to all sites of disease was used for all patients with pelvic nodal recurrence (nodal disease < 2 cm under aortic bifurcation) or oligometastatic disease. At 3 months after treatment, 54.7% of patients had a complete biochemical response Only 2 patients experienced G2 Genitourinary toxicity. No G2 Gastrointestinal toxicity was recorded. A PSMA targeted treatment strategy led to encouraging results and was well tolerated.

Direct Comparison of Two Different Definitions with Biochemical Recurrence after Low-Dose-Rate Brachytherapy for Prostate Cancer

We aimed to determine whether biochemical recurrence-free survival (BRFS) of patients with prostate cancer (PCa) who received low-dose-rate brachytherapy (LDR-BT) differed according to the definition of biochemical recurrence (BCR) after radical prostatectomy (RP) and the definition given by the Japanese Prostate Cancer Outcome Study of Permanent Iodine-125 Seed Implantation (J-POPS). We reviewed the clinical records of 476 consecutive patients with PCa who received LDR-BT at the Gifu University Hospital. The primary endpoint of this study was the difference in BRFS between the two aforementioned definitions. When the follow-up period ended, 74 (15.5%) and 20 (4.2%) patients had BCR according to the RP and J-POPS definitions, respectively. The 5-year BRFS rates were 85.0% and 96.9% for the RP and J-POPS definitions, respectively (p < 0.005). According to the RP definition, the 5-year BRFS rates were 80.6% in the group aged <63 years and 86.6% in those aged ≥63 years (p = 0.050). According to the J-POPS definition, the 5-year BRFS rates were 94.1% and 97.8% in the groups aged <63 years and ≥63 years, respectively (p = 0.005). The definition of recurrence in LDR-BT may need to be reconsidered.

Outcomes of salvage high dose-rate brachytherapy with or without pelvic external beam radiotherapy in patients with palpable local recurrence of prostate cancer after radical prostatectomy

PURPOSE

This study aims to evaluate the outcomes and toxicities in patients with palpable local recurrence of prostate cancer after radical prostatectomy (RP), who were treated with salvage high dose-rate brachytherapy (HDR-BT) with or without pelvic external beam radiotherapy (EBRT).

METHODS

This retrospective review included patients with palpable local recurrence of prostate cancer after RP who underwent salvage HDR-BT at a single institution between 2002 and 2020. HDR-BT regimens included 950 cGy x 2 (N = 4) or 1500 cGy x 1 (N = 2) combined with EBRT; or monotherapy with 950 cGy x 4 (N = 1) or 800 cGy x 2 (N = 1). Toxicity was graded according to CTCAE Version 5.0.

RESULTS

A total of 8 patients were included. Median follow-up was 49 months (range: 9-223 months). Median age at time of salvage brachytherapy was 68 years (range: 59-85 years). Seven out of 8 patients were alive at last follow-up. There have been no locoregional recurrences. Three patients developed distant metastatic disease. One patient developed acute grade 3 urinary obstruction requiring catheterization, which lasted for 1 day postbrachytherapy. One patient developed late grade 3 urinary incontinence 18 months after brachytherapy. There were no other grade 2+ toxicities.

CONCLUSIONS

This study demonstrates the safety and efficacy of salvage HDR-BT in the setting of palpable local recurrence of prostate cancer after RP, with durable locoregional control and acceptable rates of toxicity. HDR-BT should be further explored as an option for dose-escalated salvage radiotherapy after prior radical prostatectomy.

Modeling secondary cancer risk ratios for proton versus carbon ion beam therapy: A comparative study based on the local effect model

BACKGROUND

Ion beam therapy allows for substantial sparing of normal tissues. Besides deterministic normal-tissue complications, stochastic long-term effects like secondary cancer (SC) induction are of importance when comparing different treatment modalities.

PURPOSE

To develop a modeling approach for comparison of SC risk in proton and carbon ion therapy.

METHODS AND MATERIALS

The local effect model (LEM) is used to predict the relative biological effectiveness (RBE) of SC induction after particle therapy. A key feature of the new approach is the double use of the LEM, reflecting the competition between the two processes of mutation induction (leading to cancer development) and cell inactivation (leading to suppression of cancer development). Based on previous investigations, treatment plans were in this work analyzed for an idealized geometry in order to assess the underlying systematic dependencies of cancer induction. In a further step, relative SC risks were predicted for proton and carbon ion treatment plans prepared for 10 prostate cancer patients.

RESULTS

We investigated the impact of factors such as treatment plan geometry, fractionation scheme, and tissue radiosensitivity to photon irradiation on the ion beam SC risk. Our model studies do not result in a clear preference for either protons or carbon ions, but rather indicate a complex interplay of different aspects. Reduced lateral scattering leads to a lower SC risk for carbon ions compared to protons at the lateral field margins in the entrance channel, while an increased risk was found closely behind the tumor due to projectile fragmentation. The fractionation scheme had little impact on the expected risk ratio. With respect to sensitivity parameters, those characterizing RBE for cell killing of potentially cancerous cells as well as of the primary tumor had the most significant impact. The observed general systematic dependencies are in agreement with results from previous model studies. The prostate patient study reveals reduced SC risks predictions for skin and bones for carbon ions as compared to protons, but higher mean risks for bladder and rectum.

CONCLUSION

The methods established in this work provide a basis for further investigating treatment optimizing strategies for ion beam therapy with regard to SC risk comparisons.

Postoperative moderately hypofractionated radiotherapy in prostate cancer: a mono-institutional propensity-score-matching analysis between adjuvant and early-salvage radiotherapy

AIM

To evaluate the impact of moderately hypofractionated postoperative radiotherapy (RT) in prostate cancer (PCa).

MATERIALS AND METHODS

The data of 304 surgically resected PCa patients were analyzed. One hundred and five patients underwent adjuvant RT (aRT), 77 early-savage RT (esRT), and 123 salvage RT (sRT). Biochemical relapse-free survival (BRFS), progression-free survival (PFS) and toxicity were analyzed. A propensity score matching (PSM) was performed to account for potential confounders between aRT and esRT groups.

RESULTS

The median follow-up was 33 months. Three-year BRFS and PFS were 82 and 85.2%, respectively, in the overall population. At the multivariate analysis, Gleason score and hormone therapy were factors independently correlated with BRFS and PFS. After PSM, there was no difference in BRFS and PFS between aRT and esRT patients. Severe toxicity was represented by grade 3 urinary incontinence (3.5%) and urgency (1%), and aRT correlated with increased any-grade acute toxicity. Severe grade 3 gastrointestinal late toxicity occurred in 1.3% of cases.

CONCLUSION

Postoperative moderately hypofractionated RT achieved acceptable disease control rate and demonstrated no increased or unexpected toxicity. Future prospective studies should evaluate the role of postoperative RT in patients with unfavorable disease characteristics.

Nomogram for predicting the overall survival of patients with early-onset prostate cancer: A population-based retrospective study

Background

The incidence of early‐onset prostate cancer (PCa) has increased significantly over the past few decades. It is necessary to develop a prognostic nomogram for the prediction of overall survival (OS) in early‐onset PCa patients.

Methods

A total of 23,730 early‐onset PCa patients (younger than 55 years old) between 2010 and 2015 in the Surveillance, Epidemiology, and End Results (SEER) database were enrolled for the current study, and randomly separated into the training cohort and the validation cohort. 361 eligible early‐onset PCa patients from The Cancer Genome Atlas‐Prostate Adenocarcinoma (TCGA‐PRAD) cohort were obtained as the external validation cohort. Independent predictors were selected by univariate and multivariate Cox regression analysis, and a prognostic nomogram was constructed for 1‐, 3‐, and 5‐year OS. The accurate and discriminative abilities of the nomogram were evaluated by the concordance index (C‐index), receiver operating characteristic curve (ROC), calibration plot, net reclassification index (NRI), and integrated discrimination improvement (IDI).

Results

Multivariate Cox analysis showed that race, marital status, TNM stage, prostate‐specific antigen, Gleason score, and surgery were significantly associated with poor prognosis of PCa. A nomogram consisting of these variables was established, which had higher C‐indexes than the TNM system (training cohort: 0.831 vs. 0.746, validation cohort: 0.817 vs. 0.752). Better AUCs of the nomogram than the TNM system at 1, 3, and 5 years were found in both the training cohort and the validation cohort. The 3‐year and 5‐year AUCs of the nomogram in the TCGA‐PRAD cohort were 0.723 and 0.679, respectively. The calibration diagram, NRI, and IDI also showed promising prognostic value in OS.

Conclusions

We developed an effective prognostic nomogram for OS prediction in early‐onset PCa patients, which will further assist both the precise clinical treatment and the assessment of long‐term outcomes.

A case of CRPC with multiple bladder invasions treated with EBRT followed by HDR-BT boost

We report a case of post-operative local recurrence of castration-resistant prostate cancer with multiple bulky bladder invasions treated using external beam radiotherapy (EBRT) followed by a high-dose-rate brachytherapy (HDR-BT) boost. The EBRT dose was 46 Gy delivered in 23 fractions with intensity-modulated radiotherapy to the entire pelvis. The HDR-BT dose was 15 Gy delivered in 1 fraction using ultrasound, CT, and MRI-guided brachytherapy with 18 interstitial needles. We achieved excellent local control of cancer in the prostate bed and multiple bulky bladder invasions. EBRT plus HDR-BT boost can allow higher doses to be delivered than EBRT alone for locally recurrent bulky prostate cancer following prostatectomy.

Stereotactic or conventional radiotherapy for macroscopic prostate bed recurrence: a propensity score analysis

Purpose

To assess outcomes between salvage radiation therapy (SRT) with curative intent and stereotactic radiotherapy for macroscopic prostate recurrence (SSRT) after radical prostatectomy (RP). In order to compare these two different options, we compared their outcomes with a propensity score-based matched analysis.

Methods

Data from 185 patients in seven Italian centres treated for macroscopic prostate bed recurrence after RP were retrospectively collected. To make a comparison between the two treatment groups, propensity matching was applied to create comparable cohorts.

Results

After matching, 90 patients in the SRT and SSRT groups were selected (45 in each arm). Kaplan–Meier analysis did not show any significant differences in terms of BRFS and PFS between matched populations (p = 0.08 and p = 0.8, respectively). Multivariate models show that treatment was not associated with BRFS, neither in the whole or matched cohort, with HR of 2.15 (95%CI 0.63–7.25, p = 0.21) and 2.65 (95%CI 0.59–11.97, p = 0.21), respectively. In the matched cohort, lower rate of toxicity was confirmed for patients undergoing SSRT, with acute GI and GU adverse events reported in 4.4 versus 44.4% (p < 0.001) and 28.9 versus 46.7% (p = 0.08) of patients, and late GI and GU adverse events reported in 0 versus 13.3% (p = 0.04) and 6.7 versus 22.2% (p = 0.03) of patients, respectively.

Conclusion

Considering the favourable therapeutic ratio of this approach and the lower number of fractions needed, SSRT should be considered as an attractive alternative to conventional SRT in this setting.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11547-022-01465-w.

Description of Surgical Technique and Oncologic and Functional Outcomes of the Precision Prostatectomy Procedure (IDEAL Stage 1-2b Study)

BACKGROUND

The existing treatment options for men with intermediate- or high-volume low-risk prostate cancer (PCa) are associated with a substantial risk of over- or undertreatment. The development of risk-adjusted therapies is an unmet need for these patients.

OBJECTIVE

To describe our novel technique of precision prostatectomy, a form of surgical focal therapy that allows radical excision of the index PCa lesion along with >90% prostatic tissue extirpation while preserving the prostatic capsule and seminal vesicle/vas deferens complex on the side contralateral to the dominant cancer lesion, and to report on medium-term functional and oncologic outcomes in the first 88 consecutive men who underwent this procedure between December 2016 and January 2020.

DESIGN, SETTING, AND PARTICIPANTS

Men with (1) prostate-specific antigen (PSA) ≤20 ng/ml, (2) clinical T stage ≤cT2, (3) a dominant unilateral lesion with Gleason ≤ 4 + 3 disease with any number or percentage of cores involved ipsilaterally on prostate biopsy, (4) no primary Gleason ≥4 lesion contralaterally, and (5) a preoperative Sexual Health Inventory of Men (SHIM) score of ≥17 (out of 25) with/without phosphodiesterase type-5 inhibitor use who consented to undergo precision prostatectomy were included in this single-arm, single-center, IDEAL stage 2b prospective development study.

INTERVENTION

Robotic precision prostatectomy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The safety and urinary, sexual, and oncologic outcomes of the precision prostatectomy technique were studied. Descriptive statistics and Kaplan-Meier analyses were used to assess 12-mo urinary continence (0-1 pad), 12-mo sexual potency (SHIM score ≥17), 36-mo freedom from clinically significant PCa (grade group ≥2), secondary treatments, metastatic disease, and mortality.

RESULTS AND LIMITATIONS

At study entry, the median age, PSA, and SHIM score were 60.0 yr (interquartile range [IQR] 54.2-65.9), 5.7 ng/ml (IQR 4.2-7.1), and 22 points (IQR 19-24), respectively. The median follow-up was 25 mo (IQR 14-38). At 12 mo, all patients were continent (0-1 pads), with 90.9% of patients using 0 pads. The median time to urinary continence was 1 mo (IQR 1-4). At 12 mo, 85% of all-comers and 90.2% of the preoperatively potent men were potent. The median time to sexual potency was 4 mo (IQR 4-12). From an oncologic standpoint, at 36 mo an estimated 93.4% of the patients were free from clinically significant residual PCa and 91.7% had not undergone any additional treatment. All patients were alive and free of metastatic disease at 36 mo.

CONCLUSIONS

Precision prostatectomy is technically safe and reproducible and offers excellent postoperative functional results. At 36-mo follow-up, the oncologic outcomes and secondary treatment rates appear to be superior to existing ablative focal therapy results. Pending long-term data, a risk-stratified surgical approach to PCa may avoid whole-gland therapy and preserve functional quality of life in men with localized PCa.

PATIENT SUMMARY

Precision prostatectomy is a new form of focal therapy for intermediate-risk prostate cancer in which a 5-10-mm rim of prostate capsule is left on the opposite side of the gland to where the dominant cancer is located. The technique appears to be safe and efficacious and adds to the growing armamentarium of risk-adapted therapies for treatment of localized prostate cancer that avoid the adverse effects on urinary and erectile function of whole-gland treatments.

Potential Targets Other Than PSMA for Prostate Cancer Theranostics: A Systematic Review

Background: Prostate-specific membrane antigen (PSMA) is not sufficiently overexpressed in a small proportion of prostate cancer (PCa) patients, who require other strategies for imaging and/or treatment. We reviewed potential targets other than PSMA for PCa theranostics in nuclear medicine that have already been tested in humans. Methods: We performed a systematic web search in the PubMed and Cochrane databases, with no time restrictions by pooling terms (“prostate cancer”, “prostatic neoplasms”) and (“radioligand”, “radiotracer”). Included articles were clinical studies. The results were synthetized by the target type. Results: We included 38 studies on six different targets: gastrin-releasing peptide receptors (GRPRs) (n = 23), androgen receptor (n = 11), somatostatin receptors (n = 6), urokinase plasminogen activator surface receptor (n = 4), fibroblast activation protein (n = 2 studies) and integrin receptors (n = 1). GRPRs, the most studied target, has a lower expression in high-grade PCa, CRPC and bone metastases. Its use might be of higher interest in treating earlier stages of PCa or low-grade PCa. Radiolabeled fibroblast activation protein inhibitors were the most recent and promising molecules, but specific studies reporting their interest in PCa are needed. Conclusion: Theranostics in nuclear medicine will continue to develop in the future, especially for PCa patients. Targets other than PSMA exist and deserve to be promoted.

Application of Primary/Secondary Circulating Tumor Cells for the Prediction of Biochemical Recurrence in Nonmetastatic Prostate Cancer Patients following Radical Prostatectomy or Radiotherapy: A Meta-Analysis

Background

Circulating tumor cells (CTCs) have been regarded as an independent prognostic marker for metastatic castration-resistant prostate cancer (mCRPC). Its prognostic value, however, in nonmetastatic prostate cancer (NMPC) is still unclear.

Purpose

To elucidate whether CTCs can predict the biochemical recurrence (BCR) in NMPC patients following radical prostatectomy (RP) or radiotherapy (RT).

Methods

PubMed, Cochrane Database, and Embase and the references in relevant studies were systematically searched. Studies that investigated the correlation of CTCs and BCR in NMPC patients after RP or RT were identified and reviewed. Overall odds ratio (OR) of BCR in such patients with/without CTCs was pooled. We also calculated and pooled overall prevalence of BCR in such CTC-positive patients.

Results

In total, 12 studies comprising 1917 participants were eligible for the meta-analysis and showed that the presence of secondary circulating tumor cells (SCTCs) is associated with a higher BCR rate of 59% (95% CI: 22%-88%) in patients with NMPC after RP or RT (OR = 6.12; 95% CI: 2.22-16.85; P < 0.001). However, regardless of the presence of primary circulating tumor cells (PCTCs), it has not been shown to be associated with higher BCR.

Conclusions

Our research demonstrated that SCTC-positive patients are associated with higher BCR compared to SCTC-negative patients in NMPC. Therefore, it is recommended that NMPC patients undergo CTC surveillance intensively after RP or RT.

Impact of positive surgical margin on biochemical recurrence in localized prostate cancer

BACKGROUND

We analyzed the relationship between biochemical recurrence (BCR) and the status of positive surgical margin (PSM) in patients with pT3a prostate cancer (PCa).

MATERIALS AND METHODS

Patients (n = 150) who underwent radical prostatectomy for pT3a PCa without nodal/distant metastasis were retrospectively reviewed between 2010 and 2013. The data regarding the status of PSM including the number, length, and margin Gleason score were collected. The predictors of BCR were analyzed using Cox regression hazard models. BCR-free survival was compared between the patients with negative surgical margin (NSM) and with PSM using Kaplan-Meier curves and log-rank tests.

RESULTS

PSM was noted in 74 patients (49.3%). Seventy-six patients (50.7%) had NSM and 38 patients (25.3%) had single PSM. Twenty patients (13.3%) had two PSMs and 16 patients (10.7%) had ≥3 PSMs. In total patients, the multivariate analysis demonstrated that a pathological Gleason score of ≥8 was significantly associated with BCR [hazard ratio (HR), 2.173; 95% confidence interval (CI), 1.244-3.797; P = 0.038]. In patients with PSM, the number of PSM more than two was significantly associated with BCR (HR, 2.723; 95% CI, 1.256-5.902; P = 0.011). PSM length of ≥3 mm was also a significant predictive factor (HR, 1.024; 95% CI, 0.994-1.055, P = 0.042). Patients with the highest margin Gleason score of ≥4 had poorer BCR-free survival than those with that of 3/no surgical margin.

CONCLUSIONS

Number (more than one), length (≥3 mm), and higher margin Gleason score (≥4) of PSM were significantly associated with an increased likelihood of BCR in patients with pT3a PCa.

Subtotal surgical therapy for localized prostate cancer: a single-center precision prostatectomy experience in 25 patients, and SEER-registry data analysis

Background

We recently described a novel form of focal therapy for prostate cancer (CaP)—the precision prostatectomy. Here we report on the first 25 consecutive patients. Further, utilizing Surveillance Epidemiology and End Results (SEER)-registry data, we assess long-term oncological efficacies of various focal therapy techniques.

Methods

Men who met the criteria: (I) PSA ≤15 ng/mL, (II) stage ≤cT2, (III) dominant unilateral lesion with Gleason ≤4+3 with any number or percentage (%) of cores involved ipsilaterally on biopsy, (IV) no primary Gleason ≥4 contralaterally, and (V) preoperative erectile function score (IIEF-5/SHIM) of ≥17 with/without PDE-5i were included in this prospective, single-arm, IDEAL stage 2b study (December 2016 to July 2017). Safety of the technique, and intermediate-term urinary, sexual and oncological outcomes were studied. Descriptive statistics and Kaplan-Meier (KM) analysis were used to assess 12-month urinary continence (0–1 pad), 12-month sexual potency (SHIM ≥17), and 36-month freedom from clinically-significant CaP (grade group ≥2), radical treatment, metastatic disease and mortality. SEER-registry was queried to evaluate CaP-specific survival in patients undergoing hyperthermia, cryotherapy, or segmental prostatectomy.

Results

At study entry, the median (IQR) age, PSA and SHIM score were 56.5 (53.1–62.3) years, 4.2 (3.8–5.9) ng/mL and 23 [20–25], respectively. Only 1 patient met the Epstein criteria for active surveillance. All patients were followed for a minimum of 2 years. At 12 months, from a functional standpoint, all patients were continent. Twenty-three (92%) patients were potent at 12 months. From an oncological standpoint, at 36 months, the KM analysis (95% CI) demonstrated a 96.2% (92.9–98.7) rate of freedom from clinically-significant CaP and a 92.7% (88.9–97.2) rate of freedom from radical treatment. All patients were alive and free of metastatic disease at the latest follow-up. Analysis of the SEER-registry data demonstrated 10-year CaP-specific survival rates of 91.6% to 97.7% among the 3 studied modalities, P=0.298.

Conclusions

Precision prostatectomy is feasible, technically safe, and offers excellent postoperative functional results. At 36 months of follow-up, the oncological outcomes and secondary procedure rates appear to be at-par with the ablative forms of focal therapy.

Postoperative radiotherapy after upfront radical prostatectomy: debated issues at a turning point-a survey exploring management trends on behalf of AIRO (Italian Association of Radiotherapy and Clinical Oncology)

OBJECTIVES

Postoperative prostate cancer patients are a heterogeneous population, and many prognostic factors (e.g., local staging, PSA kinetics, margin status, histopathological features) may influence their clinical management. In this complex scenario, univocal recommendations are often lacking. For these reasons, the present survey was developed by the Italian Association of Radiotherapy and Clinical Oncology (AIRO) to collect the opinion of Italian radiation oncologists and delineate a representation of current clinical practice in our country.

METHODS

A questionnaire was administered online to AIRO (Italian Association of Radiotherapy and Clinical Oncology) members registered in 2020 with a clinical interest in uro-oncological disease.

RESULTS

Sixty-one per cent of AIRO members answered the proposed survey. Explored topics included career and expertise, indications to adjuvant RT, additional imaging in biochemical recurrence setting, use of salvage radiotherapy (SRT), management of clinically evident locoregional recurrence and future considerations.

CONCLUSIONS

Overall, good level of agreement was found between participants for most of the topics. Most debated issues regarded, as expected, implementation of new imaging methods in this setting. Notably, trend in favour of early SRT vs. immediate adjuvant RT was underlined, and preference for global evaluation rather than isolated risk factors for RT indications was noticed.

Predictors of Patient-Reported Incontinence at Adjuvant/Salvage Radiotherapy after Prostatectomy: Impact of Time between Surgery and Radiotherapy

BACKGROUND

Baseline urinary incontinence (UI) strongly modulates UI recovery after adjuvant/salvage radiotherapy (ART/SRT), inducing clinicians to postpone it "as much as possible", maximizing UI recovery but possibly reducing efficacy. This series aims to analyze the trend of UI recovery and its predictors at radiotherapy start.

METHODS

A population of 408 patients treated with ART/SRT enrolled in a cohort study (ClinicalTrials.gov #NCT02803086) aimed at developing predictive models of radiation-induced toxicities. Self-reported UI and personality traits, evaluated by means of the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-SF) and Eysenck Personality Questionnaire - Revised (EPQ-R) questionnaires, were assessed at ART/SRT start. Several endpoints based on baseline ICIQ-SF were investigated: frequency and amount of urine loss (ICIQ3 and ICIQ4, respectively), "objective" UI (ICIQ3 + 4), "subjective" UI (ICIQ5), and "TOTAL" UI (ICIQ3 +4 + 5). The relationship between each endpoint and time from prostatectomy to radiotherapy (TTRT) was investigated. The association between clinical and personality variables and each endpoint was tested by uni- and multivariable logistic regression.

RESULTS

TTRT was the strongest predictor for all endpoints (p-values ≤ 0.001); all scores improved between 4 and 8 months after prostatectomy, without any additional long-term recovery. Neuroticism independently predicted subjective UI, TOTAL UI, and daily frequency.

CONCLUSIONS

Early UI recovery mostly depends on TTRT with no further improvement after 8 months from prostatectomy. Higher levels of neuroticism may overestimate UI.

The prognostic value, sensitivity, and specificity of multiparametric magnetic resonance imaging before salvage radiotherapy for prostate cancer

AIM

To determine the operational characteristics of pelvic magnetic resonance imaging (MRI) prior to salvage radiation therapy (SRT) for biochemically recurrent prostate cancer following radical prostatectomy.

METHODS AND MATERIALS

We reviewed the medical records of 386 patients who underwent MRI prior to SRT. We assessed associations of pre-SRT MRI findings with biochemical recurrence (BCR), distant metastasis (DM), prostate cancer-specific mortality (PCSM), and salvage androgen deprivation therapy (ADT) use following SRT. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of MRI for detecting local recurrence were also calculated.

RESULTS

Pre-SRT MRI was positive for local recurrence in 216 patients (56%), indeterminate in 46 (12%), and negative in 124 (32%). On univariate analysis, BCR following SRT was significantly less likely for patients with positive (HR: 0.58, 95% CI: 0.42-0.8) or indeterminate (HR: 0.6: 0.36-1) MRI findings, compared to patients with negative imaging (p = 0.003). These associations remained significant on multivariate analysis (p < 0.05) and across pre-SRT PSA groups. For the entire cohort, the sensitivity of MRI for local recurrence was 61.0% (53.5-68.1%), specificity 60.0% (44.3-73.0%), PPV 86.1% (78.9-91.5%) and NPV 27.6% (19.0-37.5%). Sensitivity of MRI was better in men with higher pre-SRT PSA (80.0% for PSA > 1.0), and specificity was improved with lower pre-SRT PSA (73.9% for PSA 0.1-0.5).

CONCLUSIONS

Positive or indeterminate MRI findings prior to SRT were associated with improved biochemical control following SRT, across PSA levels. The sensitivity and specificity of MRI for local recurrence were 61% and 58.7%, respectively.

Prognostic significance of histomorphologic features of lymph node metastases in prostate cancer patients treated with radical prostatectomy: A single center study

OBJECTIVE

We assessed the prognostic value of histomorphologic features of lymph node (LN) metastases in patients with prostate cancer treated with radical prostatectomy MATERIALS AND METHODS: We evaluated the effect of the features of LN metastasis on the risk of biochemical recurrence (BCR) in 280 LN-positive patients who underwent radical prostatectomy between 2006 to 2018. LN specific parameters recorded included number of metastatic LNs, size of the largest metastatic focus, Gleason Grade (GG) of the metastatic focus, and extranodal extension (ENE).

RESULTS

A solitary positive LN was found in 166/280 (59%), 95/280 (34%) patients had 2-4 positive LNs, and 19/280 (7%) had 5 or more positive LNs. The size of the largest metastatic focus > 2 mm (macrometastasis) in 154/261 (59%). GG of the metastatic focus was as follows: GG 1-2: 29/224 (13%); GG 3: 27/224 (12%); and GG 4-5: 168/224 (75%). ENE was identified in 99/244 (41%). We found the number of LNs positive (2-4 vs. 1 Hazard ratio (HR) = 1.60; 95% CI: 1.02 to 2.5; P = 0.04) and GG of the metastatic focus (GG 4&5 vs. 1-3 HR = 1.90; 95% CI: 1.14-3.2; P= 0.014) to be independent predictors of the risk of BCR after surgery on multivariate analysis.

CONCLUSIONS

Our study showed the number of LNs positive and GG of the LN metastatic focus to be significant independent predictors of BCR after radical prostatectomy. We recommend reporting histomorphologic parameters of LN metastasis as they may help in defining BCR risk categorization.

Impact of Lymphovascular Invasion on Overall Survival in Patients With Prostate Cancer Following Radical Prostatectomy: Stage-per-Stage Analysis

BACKGROUND

The detrimental impact of lymphovascular invasion (LVI) in prostate cancer (PCa) on biochemical recurrence has been described; the impact of LVI on overall survival (OS) remains unclear. This investigation sought to evaluate the impact of LVI on OS in patients with PCa.

METHODS

We examined men with nonmetastatic PCa treated with radical prostatectomy between 2010 and 2015. Only men with documented LVI status were included (n = 232,704). Patients were stratified according to final pathologic T stage (pT2, pT3a, and pT3b).

RESULTS

Of the 232,704 patients who met inclusion criteria, 17,758 (8%) were found to have LVI on final pathology. Overall, 174,838 (75%), 40,281 (17%), and 17,585 (8%) patients had pT2, pT3a, and pT3b disease, respectively. Median follow-up was 42.7 months (27.1-58.7). At 5 years, the OS in LVI versus non-LVI patients was 94% versus 95% in pT2 (P = .0004), 92% versus 95% in pT3a (P < .0001), and 86% versus 92% in pT3b (P < .0001). On multivariable analysis, LVI status was not an independent predictor of OS in pT2 disease (hazard ratio, 1.12; 95% confidence interval [CI], 0.93-1.36; P = .2). In pT3a and pT3b disease, presence of LVI had 1.2-fold (95% CI, 1.03-1.44; P = .02) and 1.4-fold (95% CI, 1.20-1.59; P < .001) higher overall mortality than their counterparts without LVI.

CONCLUSIONS

Our report demonstrates the detrimental impact of LVI on OS in locally advanced PCa (pT3a and higher). This information may prove valuable when risk stratifying based on final pathology.

Salvage Radiotherapy for Macroscopic Local Recurrence Following Radical Prostatectomy

Introduction

Salvage radiotherapy is the only curative treatment for biochemical progression after radical prostatectomy. Macroscopic recurrence may be found in the prostatic bed. The purpose of our study is to evaluate the effectiveness of salvage radiotherapy of the prostate bed with a boost to the area of the macroscopic recurrence.

Material and Methods

From January 2005 to January 2020, 89 patients with macroscopic recurrence in the prostatectomy bed were treated with salvage radiotherapy +/- hormone therapy. The average PSA level prior to radiotherapy was 1.1 ng/mL (SD: 1.6). At the time of biochemical progression, 96% of the patients had a MRI that revealed the macroscopic recurrence, and 58% had an additional choline PET scan. 67.4% of the patients got a boost to the macroscopic nodule, while 32.5% of the patients only underwent radiotherapy of the prostate bed without a boost. The median total dose of radiotherapy was 70 Gy (Min.: 60 - Max.: 74). The most commonly-used regimen was radiotherapy of the prostatectomy bed with a concomitant boost. 48% of the patients were concomitantly treated with hormone therapy.

Results

After a median follow-up of 53.7 months, 77 patients were alive and 12 had died, of which 4 following metastatic progression. The 5-year and 8-year survival rates (CI95%) are, respectively, 90.2% (78.9-95.6%) and 69.8% (46.4-84.4%). The 5-year biochemical progression-free survival rate (CI95%) is 50.8% (36.7-63.3). Metastatic recurrence occurred in 11.2% of the patients. We did not find any statistically significant impact from the various known prognostic factors for biochemical progression-free survival. No toxicity with a grade of > or = to 3 was found.

Conclusions

Our series is one of the largest published to date. Salvage radiotherapy has its place in the management of patients with biochemical progression with local recurrence in the prostate bed, with an acceptable toxicity profile. The interest of the boost is to be evaluated in prospective trials.

Patterns of disease detection using [18F]DCFPyL PET/CT imaging in patients with detectable PSA post prostatectomy being considered for salvage radiotherapy: a prospective trial

PURPOSE

Prostate-specific membrane antigen (PSMA) PET/CT is increasingly used in patients with biochemical recurrence post prostatectomy to detect local recurrence and metastatic disease at low PSA levels. The aim of this study was to assess patterns of disease detection, predictive factors and safety using [¹⁸F]DCFPyL PET/CT versus diagnostic CT in patients being considered for salvage radiotherapy with biochemical recurrence post prostatectomy.

METHODS

We conducted a prospective trial recruiting 100 patients with detectable PSA post prostatectomy (PSA 0.2-2.0 ng/mL) and referred for salvage radiotherapy from August 2018 to July 2020. All patients underwent a PSMA PET/CT using the [¹⁸F]DCFPyL tracer and a diagnostic CT. The detection rates of [¹⁸F]DCFPyL PET/CT vs diagnostic CT were compared and patterns of disease are reported. Clinical patient and tumour characteristics were analysed for predictive utility. Thirty-day post-scan safety is reported.

RESULTS

Of 100 patients recruited, 98 were suitable for analysis with a median PSA of 0.32 ng/mL. [¹⁸F]DCFPyL PET/CT was positive 46.4% and equivocal 5.2%, compared to 15.5% positivity for diagnostic CT. Local recurrence was detected on [¹⁸F]DCFPyL PET/CT in 28.5%, nodal disease in 27.5% and bony metastases in 6.1% of patients. Both ISUP grade group (p < 0.001) and pre-scan PSA (p = 0.029) were significant predictors of [¹⁸F]DCFPyL PET/CT positivity, and logistic regression generated probabilities combining the two showed improved prediction rates. No significant safety events were reported post [¹⁸F]DCFPyL administration.

CONCLUSIONS

[¹⁸F]DCFPyL PET/CT increases detection of disease in patients with biochemical recurrence post prostatectomy compared to diagnostic CT. Patients being considered for salvage radiotherapy with a PSA >0.2 ng/mL should be considered for [¹⁸F]DCFPyL PET/CT scan.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry Number: ACTRN12618001530213 ( http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375932&isReview=true ).

Hypofractionated Postprostatectomy Radiation Therapy for Prostate Cancer to Reduce Toxicity and Improve Patient Convenience: A Phase 1/2 Trial

PURPOSE

The phase 1 portion of this multicenter, phase 1/2 study of hypofractionated (HypoFx) prostate bed radiation therapy (RT) as salvage or adjuvant therapy aimed to identify the shortest dose-fractionation schedule with acceptable toxicity. The phase 2 portion aimed to assess the health-related quality of life (QoL) of using this HypoFx regimen.

METHODS AND MATERIALS

Eligibility included standard adjuvant or salvage prostate bed RT indications. Patients were assigned to receive 1 of 3 daily RT schedules: 56.6 Gy in 20 Fx, 50.4 Gy in 15 Fx, or 42.6 Gy in 10 Fx. Regional nodal irradiation and androgen deprivation therapy were not allowed. Participants were followed for 2 years after treatment with outcome measures based on prostate-specific antigen levels, toxicity assessments (Common Terminology Criteria for Adverse Events, v4.0), QoL measures (the Expanded Prostate Cancer Index Composite [EPIC] and EuroQol EQ-5D instruments), and out-of-pocket costs.

RESULTS

There were 32 evaluable participants, and median follow-up was 3.53 years. The shortest dose-fractionation schedule with acceptable toxicity was determined to be 42.6 Gy in 10 Fx, with most patients (23) treated with this schedule. Grade 3 genitourinary (GU) and gastrointestinal (GI) toxicities occurred in 3 patients and 1 patient, respectively. There was 1 grade 4 sepsis event. Higher dose to the hottest 25% of the rectum was associated with increased risk of grade 2+ GI toxicity; no dosimetric factors were found to predict for GU toxicity. There was a significant decrease in the mean bowel, but not bladder, QoL score at 1 year compared with baseline. Prostate-specific antigen failure occurred in 34.3% of participants, using a definition of nadir plus 2 ng/mL. Metastases were more likely to occur in regional lymph nodes (5 of 7) than in bones (2 of 7). The mean out-of-pocket cost for patients during treatment was $223.90.

CONCLUSIONS

We identified 42.6 Gy in 10 fractions as the shortest dose-fractionation schedule with acceptable toxicity in this phase 1/2 study. There was a higher than expected rate of grade 2 to 3 GU and GI toxicity and a decreased EPIC bowel QoL domain with this regimen. Future studies are needed to explore alternative adjuvant/salvage HypoFx RT schedules after radical prostatectomy.

Restaging the Biochemical Recurrence of Prostate Cancer with [68Ga]Ga-PSMA-11 PET/CT: Diagnostic Performance and Impact on Patient Disease Management

Simple Summary

We aimed to evaluate the diagnostic performance, impact on patient disease management, and therapy efficacy prediction of [⁶⁸Ga]Ga-PSMA-11 PET/CT on 294 patients with biochemical recurrence of prostate cancer. We established a composite standard of truth for the imaging based on all clinical data available collected during the follow-up period with a median duration of follow-up of 17 months. Using this methodology, we found that the overall per-patient sensitivity and specificity were both 70%, the patient disease management was changed in 68% of patients, and that [⁶⁸Ga]Ga-PSMA-11 PET/CT impacted this change in 86% of patients. The treatment carried out on the patient was considered effective in 78% of patients; in 89% of patients when guided by [⁶⁸Ga]Ga-PSMA-11 PET/CT versus 61% of patients when not guided by [⁶⁸Ga]Ga-PSMA-11 PET/CT.

Abstract

Background: Detection rates of [⁶⁸Ga]Ga-PSMA-11 PET/CT on the restaging of prostate cancer (PCa) patients presenting with biochemical recurrence (BCR) have been well documented, but its performance and impact on patient management have not been evaluated as extensively. Methods: Retrospective analysis of PCa patients presenting with BCR and referred for [⁶⁸Ga]Ga-PSMA-11 PET/CT. Pathological foci were classified according to six anatomical sites and evaluated with a three-point scale according to the uptake intensity. The impact of [⁶⁸Ga]Ga-PSMA-11 PET/CT was defined as any change in management that was triggered by [⁶⁸Ga]Ga-PSMA-11 PET/CT. The existence of a PCa lesion was established according to a composite standard of truth based on all clinical data available collected during the follow-up period. Results: We included 294 patients. The detection rate was 69%. Per-patient sensitivity and specificity were both 70%. Patient disease management was changed in 68% of patients, and [⁶⁸Ga]Ga-PSMA-11 PET/CT impacted this change in 86% of patients. The treatment carried out on patient was considered effective in 89% of patients when guided by [⁶⁸Ga]Ga-PSMA-11 PET/CT versus 61% of patients when not guided by [⁶⁸Ga]Ga-PSMA-11 PET/CT (p < 0.001). Conclusions: [⁶⁸Ga]Ga-PSMA-11 PET/CT demonstrated high performance in locating PCa recurrence sites and impacted therapeutic management in nearly two out of three patients.

Adjuvant versus early salvage radiotherapy for prostate cancer patients: Time to move on

In the management of prostate cancer , few treatments have caused as much controversy as adjuvant radiotherapy (ART) after radical prostatectomy in high-risk patients In the present article, we assess the exclusion and inclusion criteria of the 6 randomised trials and 5-year biochemical relapse-free survival and overall survival rates in order to identify the patient subgroups most likely to benefit from ART. We also evaluate treatment-related toxicity and the indications for androgen deprivation therapy . The main aim of this analysis was to determine whether the available evidence, which previously appeared to support ART, now favours early salvage radiotherapy. If so, perhaps we can finally resolve the controversy surrounding the optimal timing of postoperative radiotherapy.

Urodynamic evaluation of patients with localized prostate cancer before and 4 months after robotic radical prostatectomy

Radical prostatectomy can alter the anatomy of the urinary bladder. We aimed to evaluate bladder function before and 4 months after radical prostatectomy using the urodynamic test and overactive bladder (OAB) symptom score. Among 70 prospectively enrolled patients, 61 patients completed the study. In the urodynamic test, bladder capacity and compliance did not change, the frequency of involuntary detrusor contraction decreased, the maximum flow rate and bladder outlet obstruction index improved, and the maximum urethral closure pressure (MUCP) deteriorated. Further evaluation of urodynamic parameters according to changes in symptoms was made. Although change in bladder compliance was correlated with changes in OAB symptoms, not the relative change of bladder compliance but the relative change in the MUCP was reliable factor when OAB symptoms were deteriorated. In general, prostatectomy did not deteriorate the condition of the detrusor; rather, change in the MUCP could be responsible for postprostatectomy OAB.

Peritumoral Delivery of Docetaxel-TIPS Microparticles for Prostate Cancer Adjuvant Therapy

Recurrence of prostate cancer after radical prostatectomy is a consequence of incomplete tumor resection. Systemic chemotherapy after surgery is associated with significant toxicity. Improved delivery methods for toxic drugs capable of targeting positive resection margins can reduce tumor recurrence and avoid their known toxicity. This study evaluates the effectiveness and toxicity of docetaxel (DTX) release from highly porous biodegradable microparticles intended for delivery into the tissue cavity created during radical prostatectomy to target residual tumor cells. The microparticles, composed of poly(dl-lactide-co-glycolide) (PLGA), are processed using thermally induced phase separation (TIPS) and loaded with DTX via antisolvent precipitation. Sustained drug release and effective toxicity in vitro are observed against PC3 human prostate cells. Peritumoral injection in a PC3 xenograft tumor model results in tumor growth inhibition equivalent to that achieved with intravenous delivery of DTX. Unlike intravenous delivery of DTX, implantation of DTX-TIPS microparticles is not accompanied by toxicity or elevated systemic levels of DTX in organ tissues or plasma. DTX-TIPS microparticles provide localized and sustained release of nontoxic therapeutic amounts of DTX. This may offer novel therapeutic strategies for improving management of patients with clinically localized high-risk disease requiring radical prostatectomy and other solid cancers at high risk of positive resection margins.

Impact of Decipher on use of post‐operative radiotherapy: Individual patient analysis of two prospective registries

Objective

To assess the association between Genomic Classifier (GC)‐risk group and post‐radical prostatectomy treatment in clinical practice.

Methods

Two prospective observational cohorts of men with prostate cancer (PCa) who underwent RP in two referral centers and had GC testing post‐prostatectomy between 2013 and 2018 were included. The primary endpoint of the study was to assess the association between GC‐risk group and time to secondary therapy. Univariable (UVA) and multivariable (MVA) Cox proportional hazards models were constructed to assess the association between GC‐risk group and time to receipt of secondary therapy after RP, where secondary therapy is defined as receiving either RT or ADT after RP.

Results

A total of 398 patients are included in the analysis. Patients with high‐GC risk were more likely to receive any secondary therapy (OR: 6.84) compared to patients with low/intermediate‐GC risk. The proportion of high‐GC risk patients receiving RT at 2 years post‐RP was 31.5%, compared to only 6.3% among the low/intermediate‐GC risk patients.

Conclusion

This study demonstrates that physicians in routine practice used GC to identify high risk patients who might benefit the most from secondary treatment. As such, GC score was independent predictor of receipt of secondary treatment.

External beam radiotherapy for prostate cancer: What are the current research trends and hotspots?

Background

The external beam radiotherapy (EBRT) applied for prostate cancer (PCa) has been one of the most important and hottest research fields over recent decades. This study aimed to explore the research hotspots of EBRT in PCa and help the researchers have a clear and intuitive reference basis for later researches.

Methods

The literature scientometric analysis related to “EBRT applied for PCa” was conducted via the Web of Science Core Collection from 2010 to 2019. The Microsoft Office Excel 2019 and CiteSpace V. 5.7.R1 software were introduced for visualizing and analyzing the data.

Results

A total of 7860 relevant papers were extracted and downloaded. A total of 7828 papers were extracted and analyzed after data cleansing by CiteSpace. The tendency of published papers was comprehensively increasing from 2010 to 2019. Among all 73 countries/regions, USA published the most papers, accounting for 39%, which was the most active contributor with most publications. Australia (Centrality: 0.18), England (Centrality: 0.12) were cooperating most cohesively with other countries. Univ Toronto was the most productive institute (229), while Harvard Univ (Centrality: 0.67) had extensive collaborations with other institutes. The International journal of Radiation Oncology Biology Physics had the largest number of publications and the highest number of co‐citations. Briganti A had the largest volume of publications. D'Amico AV had the highest number of co‐citations. Four latest and largest clusters were identified as oligometastases, salvage therapy (SRT), prostate‐specific membrane antigen (PSMA), and hypofractionation. Thirteen references became strongest burst citations lasting until 2019. The studies of “oligometastases,” “SRT,” “PSMA,” “hypofractionation,” “postoperative radiotherapy,” and “dose and fraction regimen changes” were prevailing in the recent years.

Conclusion

The “oligometastases,” “SRT,” “PSMA,” “hypofractionation,” “postoperative radiotherapy,” and “dose and fraction regimen changes” may be the state‐of‐art research frontiers, and related studies will advance in this field over time.

External validation of genomic classifier-based risk-stratification tool to identify candidates for adjuvant radiation therapy in patients with prostate cancer

OBJECTIVE

To externally validate a Genomic Classifier (GC) based risk-stratification nomogram identifying candidates who would benefit from adjuvant radiation (aRT) therapy after radical prostatectomy (RP).

METHODS

We identified 350 patients who underwent RP, between 2013 and 2018, and had adverse pathological features (positive margin, and/or pT3a or higher) on final pathology. Genomic profile was available for all these men. The clinical recurrence-free survival was estimated using the Kaplan-Meier method. The external validity of the nomogram was tested using the concordance index (c-index), calibration plot, and decision curve analysis.

RESULTS

The median follow-up of the cohort was 26.5 months. Overall, 14% of the patients received aRT. During the follow-up period, 3.4% of the patients developed metastasis. Overall 3-year metastasis-free survival was 95% (95% CI 0.92-0.98). The c-index of the nomogram was 0.84. The calibration of the model was favorable. Decision-curve analysis showed a positive net benefit for probabilities ranging between 0.01 and 0.09, with the highest difference at threshold probability around 0.05. At that threshold, the net benefit is 0.06 for the model and 0 for treating all the patients.

CONCLUSION

Our report is the first to confirm the validity of this genomic-based risk-stratification tool in identifying men who might benefit from aRT after RP. As such, it can be a useful instrument to be incorporated in shared decision making on whether administration of aRT will lead to a clinically meaningful benefit. Such a model can also be useful for patients' classification in future clinical trials.

Assessment of Postprostatectomy Radiotherapy as Adjuvant or Salvage Therapy in Patients With Prostate Cancer: A Systematic Review

Importance

After radical prostatectomy, adverse pathologic features and postoperative prostate-specific antigen (PSA) levels can herald disease recurrence or progression. Postoperative radiotherapy (RT) remains beneficial in this setting.

Objective

To examine the evidence supporting the use of postoperative RT as well as recent advances that help determine timing, scope, and use in combination with androgen deprivation therapy (ADT) with or without lymphatic irradiation.

Evidence Review

A search was conducted of MEDLINE (Ovid), Embase (Elsevier), and the Cochrane Library (Wiley) databases, in addition to clinical trial registries. The reference list of included studies was reviewed for relevant articles. The search was limited to studies published between January 1, 2014, and December 31, 2019.

Findings

After 548 citations were screened, 27 articles were selected for inclusion. In addition to conventional imaging, positron-emission tomographic (PET)-based radiotracers can aid in disease localization. While PET imaging may influence management with RT, studies are underway examining this issue, and several limitations must be considered, such as limited detectability at lower PSA levels and regional sensitivity. Available genomic classifiers can risk stratify patients or assess potential added benefit of RT. Prospective validation is underway with cooperative group trials. Adjuvant RT, on the basis of adverse pathologic features (such as extraprostatic extension or positive margins) is beneficial in terms of disease control, but it is unclear whether this therapy translates into more meaningful clinical benefit (eg, improved overall survival and a reduction in metastasis), which has been demonstrated by only 1 older, prospective randomized study. Preliminary data suggest that for a relatively favorable-risk population (low Gleason score but with positive margins), PSA monitoring may be a reasonable alternative in some men. Use of androgen deprivation therapy and lymphatic irradiation should be considered in higher-risk cohorts (those with high PSA, high Gleason score, seminal vesicle invasion or node positivity) in conjunction with postoperative RT.

Conclusions and Relevance

The findings of this review suggest that postprostatectomy RT should be considered for men with prostate cancer in the setting of adverse pathologic features; in carefully selected patients with favorable characteristics, close PSA monitoring is an option. Androgen deprivation therapy and pelvic lymphatic irradiation should be considered for higher risk cohorts (eg, higher PSA values, higher Gleason score). PET imaging and molecular studies remain unproven as decision tools.

Lead-time bias does not falsify the efficacy of early salvage radiotherapy for recurrent prostate cancer

BACKGROUND

In prostate cancer (PCa) recurring after radical prostatectomy (RP), salvage radiotherapy (SRT) is recommended to be given at PSA <0.5 ng/ml. It has been speculated, that the advantage from early SRT is mainly caused by lead-time bias: Calculating from time of SRT, earlier treatment would per-se result in longer time to event/censoring compared with later treatment, but not extend the interval from RP to post-SRT failure.

METHODS

In 603 consecutive PCa patients receiving SRT between 1997 and 2017, we compared outcomes, calculating from time of irradiation vs. time of surgery.

RESULTS

In multivariable analysis, tumor stage pT3-4, pathological Gleason score GS ≤6 vs. GS 7 vs. GS ≥8, post-RP PSA persistence (nadir ≥0.1 ng/ml), and the pre-SRT PSA (continuous or with cutoff 0.4 ng/ml) were significant risk-factors for biochemical progression (BCR) and progression-free survival (PFS) post-SRT and post-RP. A pre-SRT PSA <0.4 ng/ml was a significant discriminator for Kaplan-Meier rates of BCR and PFS. The Cox model for overall survival (OS) included age at RP (continuous), pT2 vs. pT3-4, and pre-SRT PSA (continuous) as significant predictors. However, no significant cutoff for the pre-SRT PSA could be identified to differentiate Kaplan-Meier estimates of OS, possibly because there were too few events, as 88% of the patients were still alive at last follow-up.

CONCLUSIONS

The pre-SRT PSA has a significant impact on BCR, PFS and potentially on OS, calculating either from RP or from SRT to event/censoring, respectively. This contradicts the hypothesis of lead-time bias falsifying the advantage from early SRT.

Role of fiducial markers in the assessment of prostate bed motion in post-prostatectomy patients treated with volumetric modulated arc therapy

Aim:

Accurate localisation of target position is crucial when using techniques with sharp dose fall off such as volumetric modulated arc therapy (VMAT). Gold seed fiducial markers have been used for target localisation in image-guided radiation therapy for various tumors including intact prostate cancers. However, their role for target localisation in post-prostatectomy radiotherapy is unclear. This study was undertaken to determine the feasibility and effectiveness of gold seed fiducial markers in patients undergoing prostate bed VMAT.

Materials and methods:

The institutional radiation oncology database was used to analyse the treatment data of 18 post-prostatectomy patients with implanted gold seed fiducial markers. The shifts of the fiducial markers were reviewed, tabulated and statistically analysed.

Results:

Three hundred and eighty-six orthogonal pair images for 18 patients were reviewed. Specifically, the average gold seed fiducial shifts were 0·34 cm in the superior–inferior (S/I) axis (0·31 SD), 0·31 cm (0·29 SD) in the anterior–posterior (A/P) axis and 0·28 cm (0·25 SD) in the lateral axis (R/L). As a result, the 95% probability of fiducial marker displacement was 0·96 cm in the S/I, 0·89 cm in the A/P and 0·78 cm in the R/L axes. The most frequent shifts occurred in the inferior, left and posterior directions. The percentage of shifts more than 0·5 cm were 19·74, 21·56 and 12·47% for the S/I, A/P and R/L axes, respectively.

Conclusion:

In the absence of fiducial markers, non-uniform planning target volume (PTV) margins of 1 cm for S/I, 9 mm for A/P and 8 mm for the lateral direction are necessary for target localisation in post-prostatectomy radiotherapy. By improving prostate bed localisation, gold seed fiducial markers can decrease PTV margins, reduce normal tissue radiation exposure and allow for dose-escalated and/or hypofractionated radiotherapy to be considered in appropriate clinical scenarios.

Fusion of high B-value diffusion-weighted and T2-weighted MR images increases sensitivity for identification of extraprostatic disease in prostate cancer

PURPOSE

To evaluate whether fusion of high b-value diffusion-weighted imaging (DWI) and T2-weighted imaging (T2WI) increases radiologists' ability to detect pathologic features responsible for upstaging in prostate cancer patients prior to radical prostatectomy (RP).

BASIC PROCEDURES

This was a retrospective study including 103 patients who underwent RP and a prostate MRI performed at 3T. High b-value DWI and T2WI were fused and interpreted by three radiologists with different degrees of experience. Prior to and after fusion, readers answered questionnaires about cancer presence, extraprostatic extension (EPE), seminal vesicle (SV) invasion, lymph node (LN) involvement, and reader confidence. Pathology reports served as the reference standard.

MAIN FINDINGS

High b-value DWI-T2WI fusion increased sensitivity for detection of EPE from 65.6% to 77.4% (p < 0.05), SV invasion from 40.5% to 48.8% (p < 0.05), and LN metastasis by 23.8% to 44.4% (p < 0.05). Readers' confidence significantly improved with the use of fusion imaging. Across all readers, confidence of cancer detection increased by 12.5% (p < 0.05), EPE by 14.7% (p < 0.05), SV invasion by 8.1% (p < 0.05), and LN metastasis by 2.5% (p < 0.05) using Wilcoxon signed rank test.

PRINCIPAL CONCLUSIONS

Fusion overlay of high b-value DWI and T2WI increases sensitivity for detection of extraprostatic disease resulting in upstaging at the time of RP.

A comparison of side-effects and quality-of-life in patients operated on for prostate cancer with and without salvage radiation therapy

PURPOSE

The extent of late side-effects in prostate cancer patients, after radical prostatectomy (RP = reference group) and salvage radiation therapy (SRT) in a self-reporting perspective (PROM) is still under-reported. We aimed to investigate the rate and severity of side-effects and quality-of-life (QoL) according to PROM.

METHODS AND MATERIALS

A PROM survey was administered to a cohort of SRT patients matched to a reference group with median follow-up 10 years after surgery. In total, 740 patients were analyzed. To investigate the association between SRT versus reference group regarding side-effects and QoL, a Poisson regression analysis was conducted and presented as relative risk estimates (RR) together with 95% confidence intervals regarding questions related to urinary, rectal, sexual symptoms and QoL.

RESULTS

RRs ranged from of 1.7-6.5 on rectal symptoms and 1.2-1.4 for urinary symptoms. In general health, QoL and sexual function all RRs were below 1.1. With increasing age, higher RRs were seen for urinary leakage and lowered sexual function whereas longer time following irradiation showed higher RRs for rectal symptoms and rectal leakage. Limitations of this study include the cross-sectional design and lack of baseline assessment.

CONCLUSIONS

Adding SRT to RP does not seem to result in other than acceptable side-effects in the majority of men receiving SRT when taking a long follow-up time (median 10 years after surgery) into account. However, a subset of men develop severe side-effects where rectal bleeding dominates.

Long-term outcomes of incidental prostate cancer at radical cystectomy

OBJECTIVE

We evaluated the natural history and long-term outcomes of incidentally detected prostate cancer (PCa) at radical cystectomy (RC) for bladder cancer (BCa).

PATIENTS AND METHODS

We identified 1,640 male patients who underwent RC between 1992 and 2012. Patients were stratified as clinically insignificant and clinically significant PCa, based on Grade Group (GG) 1 and ≥2, respectively. Survival was assessed using the Kaplan-Meier method.

RESULTS

There were 329 (20%) patients with incidentally detected PCa at RC: 245 (15%) GG1, 52 (3.2%) GG2, 20 (1.2%) GG3, 6 (0.4%) GG4, and 6 (0.4%) GG5. Median follow-up among survivors was 9.6 years (interquartile range 7.5-13.3), during which time 253 patients died, of whom 127 died of BCa and 1 died of PCa. Nine patients experienced biochemical recurrence (BCR), 4 underwent salvage PCa therapies, and 2 developed PCa metastases. Patients with clinically significant PCa were significantly more likely to experience BCR (6% vs. 1.6%; P = 0.04) and had shorter median time to BCR (1.8 vs. 10.4 years; P = 0.01) than those with clinically insignificant PCa. No patients with BCR had greater than pT2N0 BCa or positive BCa margins. Ten-year PCa-specific survival, BCa-specific survival, other cause-specific survival, and overall survival were 99%, 57%, 63%, and 35%, respectively.

CONCLUSIONS

In a large RC series, we note a 20% rate of incidental PCa, the majority of which are clinically insignificant. On long-term follow-up, we determined that BCR and PCa mortality are extremely rare events among these patients. Pending validation, future guidelines may consider omission of PCa surveillance for some patients with incidental PCa at RC.