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Triner D, Daignault-Newton S, Singhal U, Sessine M, Dess RT, Caram MEV, Borza T, Ginsburg KB, Lane BR, Morgan TM. Variation in management of lymph node positive prostate cancer after radical prostatectomy within a statewide quality improvement consortium. Urol Oncol 2024; 42:220.e1-220.e8. [PMID: 38570271 DOI: 10.1016/j.urolonc.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/11/2024] [Accepted: 03/16/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Patients with lymph node positive (pN+) disease found at the time of radical prostatectomy with pelvic lymphadenectomy for clinically localized prostate cancer (CaP) are at high risk of disease persistence and progression. Contemporary management trends of pN+ CaP are not well described. MATERIALS AND METHODS Patients in the Michigan Urologic Surgery Improvement Collaborative (MUSIC) with clinically localized prostate cancer who underwent radical prostatectomy between 2012 and 2023 with cN0/pN+ disease were identified. The primary outcome was to evaluate patient and practice-level factors associated with time to secondary post-RP treatment. Secondary outcomes included practice-level variation in management of pN+ CaP and rates of secondary treatment modality. To assess factors associated with secondary treatment, a Cox proportional hazards model of a 60-day landmark analysis was performed. RESULTS We identified 666 patients with pN+ disease. Overall, 66% underwent secondary treatment within 12 months post-RP. About 19% of patients with detectable post-RP PSA did not receive treatment. Of patients receiving secondary treatment after 60-days post-RP, 34% received androgen deprivation therapy (ADT) alone, 27% received radiation (RT) alone, 36% received combination, and 4% received other systemic therapies. In the multivariable model, pathologic grade group (GG)3 (HR 1.5; 95%CI: 1.05-2.14), GG4-5 (HR 1.65; 95%CI: 1.16-2.34), positive margins (HR 1.46; 95%CI: 1.13-1.88), and detectable postoperative PSA ≥0.1 ng/ml (HR 3.46; 95%CI: 2.61-4.59) were significantly associated with secondary post-RP treatment. There was wide variation in adjusted practice-level 12-month secondary treatment utilization (28%-79%). CONCLUSIONS The majority pN+ patients receive treatment within 12 months post-RP which was associated with high-risk pathological features and post-RP PSA. Variation in management of pN+ disease highlights the uncertainty regarding the optimal management. Understanding which patients will benefit from secondary treatment, and which type, will be critical to minimize variation in care.
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Affiliation(s)
- Daniel Triner
- Department of Urology, Michigan Medicine, Ann Arbor, MI.
| | | | - Udit Singhal
- Department of Urology, Michigan Medicine, Ann Arbor, MI; Department of Urology, Mayo Clinic, Rochester, MN
| | - Michael Sessine
- Department of Urology, Wayne State University School of Medicine, Detroit, MI
| | - Robert T Dess
- Department of Radiation Oncology, Michigan Medicine, Ann Arbor, MI
| | - Megan E V Caram
- Division of Hematology/Oncology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Tudor Borza
- Department of Urology, Michigan Medicine, Ann Arbor, MI
| | - Kevin B Ginsburg
- Department of Urology, Wayne State University School of Medicine, Detroit, MI
| | - Brian R Lane
- Division of Urology, Corewell Health Hospital System, Grand Rapids, MI
| | - Todd M Morgan
- Department of Urology, Michigan Medicine, Ann Arbor, MI
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Barletta F, Tappero S, Morra S, Incesu RB, Cano Garcia C, Piccinelli ML, Scheipner L, Tian Z, Gandaglia G, Stabile A, Mazzone E, Terrone C, Longo N, Tilki D, Chun FKH, de Cobelli O, Ahyai S, Saad F, Shariat SF, Montorsi F, Briganti A, Karakiewicz PI. Identifying low cancer-specific mortality risk lymph node-positive radical prostatectomy patients. J Surg Oncol 2024; 129:1305-1310. [PMID: 38470523 DOI: 10.1002/jso.27612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 01/20/2024] [Accepted: 02/11/2024] [Indexed: 03/14/2024]
Abstract
OBJECTIVES To identify low cancer-specific mortality (CSM) risk lymph node-positive (pN1) radical prostatectomy (RP) patients. METHODS Within Surveillance, Epidemiology and End Results database (2010-2015) pN1 RP patients were identified. Kaplan-Meier plots and multivariable Cox-regression (MCR) models were used. Pathological characteristics were used to identify patients at lowest CSM risk. RESULTS Overall, 2197 pN1 RP patients were identified. Overall, 5-year cancer-specific survival (CSS) rate was 93.3%. In MCR models ISUP GG1-2 (hazard ratio [HR]: 0.12, p < 0.001), GG3 (HR: 0.14, p < 0.001), GG4 (HR: 0.35, p = 0.002), pT2 (HR: 0.27, p = 0.012), pT3a (HR: 0.28, p = 0.003), pT3b (HR: 0.39, p = 0.009), and 1-2 positive lymph nodes (HR: 0.64, p = 0.04) independently predicted lower CSM. Pathological characteristics subgroups with the most protective hazard ratios were used to identify low-risk (ISUP GG1-3 and pT2-3a and 1-2 positive lymph nodes) patients versus others (ISUP GG4-5 or pT3b-4 or ≥3 positive lymph nodes). In Kaplan-Meier analyses, 5-year CSS rates were 99.3% for low-risk (n = 480, 21.8%) versus 91.8% (p < 0.001) for others (n = 1717, 78.2%). CONCLUSIONS Lymph node-positive RP patients exhibit variable CSS rates. Within this heterogeneous group, those at very low risk of CSM may be identified based on pathological characteristics, namely ISUP GG1-3, pT2-3a, and 1-2 positive lymph nodes. Such stratification scheme might be of value for individual patients counseling, as well as in design of clinical trials.
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Affiliation(s)
- Francesco Barletta
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
- Unit of Urology/Division of Oncology, Gianfranco Soldera Prostate Cancer Lab, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Tappero
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
- Department of Urology, IRCCS Policlinico San Martino, Genova, Italy
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy
| | - Simone Morra
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
- Department of Neurosciences, Science of Reproduction and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Reha-Baris Incesu
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Cristina Cano Garcia
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Mattia L Piccinelli
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
- Department of Urology, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Lukas Scheipner
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
- Department of Urology, Medical University of Graz, Graz, Austria
| | - Zhe Tian
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Giorgio Gandaglia
- Unit of Urology/Division of Oncology, Gianfranco Soldera Prostate Cancer Lab, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Armando Stabile
- Unit of Urology/Division of Oncology, Gianfranco Soldera Prostate Cancer Lab, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Elio Mazzone
- Unit of Urology/Division of Oncology, Gianfranco Soldera Prostate Cancer Lab, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Carlo Terrone
- Department of Urology, IRCCS Policlinico San Martino, Genova, Italy
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy
| | - Nicola Longo
- Department of Neurosciences, Science of Reproduction and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
- Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
- Department of Urology, Koc University Hospital, Istanbul, Turkey
| | - Felix K H Chun
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Ottavio de Cobelli
- Department of Urology, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Sascha Ahyai
- Department of Urology, Medical University of Graz, Graz, Austria
| | - Fred Saad
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Urology, Weill Cornell Medical College, New York, New York, USA
- Department of Urology, University of Texas Southwestern, Dallas, Texas, USA
- Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan
| | - Francesco Montorsi
- Unit of Urology/Division of Oncology, Gianfranco Soldera Prostate Cancer Lab, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Briganti
- Unit of Urology/Division of Oncology, Gianfranco Soldera Prostate Cancer Lab, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
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Lehner F, Crippa A, Sigg S, Eberli D, Mortezavi A. Transperineal template saturation and conventional biopsy for stage prediction in prostate cancer. BJU Int 2023; 132:696-704. [PMID: 37704215 DOI: 10.1111/bju.16181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
OBJECTIVE To evaluate the performance of risk calculators (RCs) predicting lymph node invasion (LNI) and extraprostatic extension (EPE) in men undergoing transperineal magnetic resonance imaging/transrectal ultrasound (TRUS)-fusion template saturation biopsy (TTSB) and conventional systematic TRUS-guided biopsy (SB). PATIENTS AND METHODS The RCs were tested in a consecutive cohort of 645 men undergoing radical prostatectomy with extended pelvic LN dissection between 2005 and 2019. TTSB was performed in 230 (35.7%) and SB in 415 (64.3%) men. Risk of LNI and EPE was calculated using the available RCs. Discrimination, calibration, and clinical usefulness stratified by different biopsy techniques were assessed. RESULTS Lymph node invasion was observed in 23 (10%) and EPE in 73 (31.8%) of cases with TTSB and 53 (12.8%) and 158 (38%) with SB, respectively. RCs showed an excellent discrimination and acceptable calibration for prediction of LNI based on TTSB (area under the curve [AUC]/risk estimation: Memorial Sloan Kettering Cancer Center [MSKCC]-RC 0.79/-4%, Briganti (2012)-RC 0.82/-4%, Gandaglia-RC 0.81/+6%). These were comparable in SB (MSKCC-RC 0.78/+2%; Briganti (2012)-RC 0.77/-3%). Decision curve analysis (DCA) revealed a net benefit at threshold probabilities between 3% and 6% when TTSB was used. For prediction of EPE based on TTSB an inferior discrimination and variable calibration were observed (AUC/risk estimation: MSKCC-RC 0.71/+8% and Martini (2018)-RC 0.69/+2%) achieving a net benefit on DCA only at risk thresholds of >17%. Performance of RCs for prediction of LNI and EPE based on SB showed comparable results with a better performance in the DCA for LNI (risk thresholds 1-2%) and poorer performance for EPE (risk threshold >20%). This study is limited by its retrospective single-institution design. CONCLUSIONS The potentially more accurate grading ability of TTSB did not result in improved performance of preoperative RCs. Prediction tools for LNI proved clinical usefulness while RCs for EPE did not.
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Affiliation(s)
- Fabienne Lehner
- Department of Urology, University Hospital Zurich, Zurich, Switzerland
| | - Alessio Crippa
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Silvan Sigg
- Department of Urology, University Hospital Zurich, Zurich, Switzerland
| | - Daniel Eberli
- Department of Urology, University Hospital Zurich, Zurich, Switzerland
| | - Ashkan Mortezavi
- Department of Urology, University Hospital Zurich, Zurich, Switzerland
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Urology, University Hospital Basel, Basel, Switzerland
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Peng ZH, Tian JH, Chen BH, Zhou HB, Bi H, He MX, Li MR, Zheng XY, Wang YW, Chong T, Li ZL. Development of machine learning prognostic models for overall survival of prostate cancer patients with lymph node-positive. Sci Rep 2023; 13:18424. [PMID: 37891423 PMCID: PMC10611782 DOI: 10.1038/s41598-023-45804-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 10/24/2023] [Indexed: 10/29/2023] Open
Abstract
Prostate cancer (PCa) patients with lymph node involvement (LNI) constitute a single-risk group with varied prognoses. Existing studies on this group have focused solely on those who underwent prostatectomy (RP), using statistical models to predict prognosis. This study aimed to develop an easily accessible individual survival prediction tool based on multiple machine learning (ML) algorithms to predict survival probability for PCa patients with LNI. A total of 3280 PCa patients with LNI were identified from the Surveillance, Epidemiology, and End Results (SEER) database, covering the years 2000-2019. The primary endpoint was overall survival (OS). Gradient Boosting Survival Analysis (GBSA), Random Survival Forest (RSF), and Extra Survival Trees (EST) were used to develop prognosis models, which were compared to Cox regression. Discrimination was evaluated using the time-dependent areas under the receiver operating characteristic curve (time-dependent AUC) and the concordance index (c-index). Calibration was assessed using the time-dependent Brier score (time-dependent BS) and the integrated Brier score (IBS). Moreover, the beeswarm summary plot in SHAP (SHapley Additive exPlanations) was used to display the contribution of variables to the results. The 3280 patients were randomly split into a training cohort (n = 2624) and a validation cohort (n = 656). Nine variables including age at diagnosis, race, marital status, clinical T stage, prostate-specific antigen (PSA) level at diagnosis, Gleason Score (GS), number of positive lymph nodes, radical prostatectomy (RP), and radiotherapy (RT) were used to develop models. The mean time-dependent AUC for GBSA, RSF, and EST was 0.782 (95% confidence interval [CI] 0.779-0.783), 0.779 (95% CI 0.776-0.780), and 0.781 (95% CI 0.778-0.782), respectively, which were higher than the Cox regression model of 0.770 (95% CI 0.769-0.773). Additionally, all models demonstrated almost similar calibration, with low IBS. A web-based prediction tool was developed using the best-performing GBSA, which is accessible at https://pengzihexjtu-pca-n1.streamlit.app/ . ML algorithms showed better performance compared with Cox regression and we developed a web-based tool, which may help to guide patient treatment and follow-up.
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Affiliation(s)
- Zi-He Peng
- Department of Urology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
- Health Science Center, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Juan-Hua Tian
- Department of Urology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
- Health Science Center, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Bo-Hong Chen
- Department of Urology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
- Health Science Center, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Hai-Bin Zhou
- Department of Urology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
- Health Science Center, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Hang Bi
- Department of Urology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
- Health Science Center, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Min-Xin He
- Department of Urology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
- Health Science Center, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Ming-Rui Li
- Department of Urology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
- Health Science Center, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Xin-Yu Zheng
- Department of Urology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
- Health Science Center, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Ya-Wen Wang
- Health Science Center, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Tie Chong
- Department of Urology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.
| | - Zhao-Lun Li
- Department of Urology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.
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5
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Perera M, Lebdai S, Tin AL, Sjoberg DD, Benfante N, Beech BB, Alvim RG, Touijer AS, Jenjitranant P, Ehdaie B, Laudone VP, Eastham JA, Scardino PT, Touijer KA. Oncologic outcomes of patients with lymph node invasion at prostatectomy and post-prostatectomy biochemical persistence. Urol Oncol 2023; 41:105.e19-105.e23. [PMID: 36435708 PMCID: PMC10391319 DOI: 10.1016/j.urolonc.2022.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/30/2022] [Accepted: 10/20/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pathologic nodal invasion at prostatectomy is frequently associated with persistently elevated prostate-specific antigen (PSA) and with increased risk of disease recurrence. Management strategies for these patients are poorly defined. We aimed to explore the long-term oncologic outcomes and patterns of disease progression. METHODS We included men treated between 2000 and 2017 who had lymph node invasion at radical prostatectomy and persistently detectable prostate-specific antigen post-prostatectomy. Postoperative imaging and management strategies were collated. Patterns of recurrence and probability of metastasis-free survival, prostate cancer-specific survival, and overall survival (OS) were assessed. RESULTS Among our cohort of 253 patients, 126 developed metastasis. Twenty-five had a positive scan within 6 months of surgery; of these, 15 (60%) had a nodal metastasis, 10 (40%) had a bone metastasis, and 4 (16%) had local recurrence. For metastasis-free survival, 5- and 10-year probabilities were 52% (95% CI 45%, 58%) and 37% (95% CI 28%, 46%), respectively. For prostate cancer-specific survival, 5- and 10-year probabilities were 89% (95% CI 84%, 93%) and 67% (95% CI 57%, 76%), respectively. A total of 221 patients proceeded to hormonal deprivation treatment alone. Ten patients received postoperative radiotherapy. CONCLUSIONS Biochemical persistence in patients with lymph node invasion is associated with high risk of disease progression and reduced prostate cancer-specific survival. Management was hindered by the limitation of imaging modalities utilized during the study period in accurately detecting residual disease. Novel molecular imaging may improve staging and help design a therapeutic strategy adapted to patients' specific needs.
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Affiliation(s)
- Marlon Perera
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Souhil Lebdai
- Urology Service, Department of Surgery, University of Angers, France
| | - Amy L Tin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nicole Benfante
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Benjamin B Beech
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ricardo G Alvim
- Urology Service, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Adam S Touijer
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Pocharapong Jenjitranant
- Urology Service, Department of Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Behfar Ehdaie
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Vincent P Laudone
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - James A Eastham
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Peter T Scardino
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Karim A Touijer
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
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Re: Adjuvant Versus Early Salvage Radiation Therapy After Radical Prostatectomy for pN1 Prostate Cancer and the Risk of Death. Eur Urol 2023; 83:186-187. [PMID: 36528477 DOI: 10.1016/j.eururo.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022]
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7
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Fonteyne V, Van Praet C, Ost P, Van Bruwaene S, Liefhooghe N, Berghen C, De Meerleer G, Vanneste B, Verbaeys C, Verbeke S, Lumen N. Evaluating the Impact of Prostate Only Versus Pelvic Radiotherapy for Pathological Node-positive Prostate Cancer: First Results from the Multicenter Phase 3 PROPER Trial. Eur Urol Focus 2022; 9:317-324. [PMID: 36154809 DOI: 10.1016/j.euf.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 07/29/2022] [Accepted: 09/12/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND The optimal treatment for patients with pathological node-positive (pN1) prostate cancer (PCa) is unclear. OBJECTIVE To evaluate whether whole-pelvis radiotherapy (WPRT) improves clinical relapse-free survival (cRFS) in comparison to prostate-only radiotherapy (PORT) in pN1 PCa. DESIGN, SETTING, AND PARTICIPANTS PROPER was a phase 3 trial randomizing patients to WPRT or PORT. All patients had pN1cM0 PCa with fewer than five lymph nodes involved. INTERVENTION All patients underwent pelvic lymph node dissection followed by radical prostatectomy/primary radiotherapy + 2 yr of androgen deprivation therapy (ADT). Patients were randomized to PORT (arm A) or WPRT (arm B). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was cRFS. The secondary endpoints were overall survival (OS), biochemical relapse-free survival (bRFS), and toxicity. The study was stopped because of poor accrual in June 2021 after the inclusion of 69 patients. We report on OS, bRFS, cRFS, and acute and late toxicity. RESULTS AND LIMITATIONS The median follow-up was 30 mo in arm A (n = 33) and 36 mo in arm B (n = 31). The 3-yr OS rate was 92% ± 5% in arm A and 93% ± 5% in arm B (p = 0.61). None of the patients died of PCa. The 3-yr bRFS was 79% ± 9% in arm A and 92% ± 5% in arm B (p = 0.08). The 3-yr cRFS rate was 88% ± 6% in arm A and 92% ± 5% in arm B (p = 0.31). No pelvic recurrence was observed in arm B. Acute grade 2 gastrointestinal toxicity was higher with WPRT (15% in arm A vs 45% in arm B; p = 0.03). Limitations are the early closure because of poor accrual and the limited follow-up. CONCLUSIONS The results of our trial are hypothesis-generating but add evidence supporting the recommendation to offer WPRT to patients with pN1 PCa. However, WPRT is associated with more acute gastrointestinal toxicity. PATIENT SUMMARY We looked at the impact of radiotherapy to the whole pelvis (WPRT) for patients with prostate cancer that had spread to the lymph nodes. Although the trial was closed early because of poor enrolment, we found that WPRT improves survival free from relapse, and no recurrences were observed in the pelvis. WPRT is associated with more acute side effects on the gastrointestinal system in comparison to radiotherapy to just the prostate.
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Affiliation(s)
- Valérie Fonteyne
- Department of Radiotherapy-Oncology, Ghent University Hospital, Ghent, Belgium.
| | | | - Piet Ost
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | | | - Nick Liefhooghe
- Department of Radiotherapy-Oncology (MAASTRO), AZ Groeninge Kortrijk, Kortrijk, Belgium
| | - Charlien Berghen
- Department of Radiotherapy-Oncology, University Hospitals Leuven, Louvain, Belgium
| | - Gert De Meerleer
- Department of Radiotherapy-Oncology, University Hospitals Leuven, Louvain, Belgium
| | - Ben Vanneste
- Department of Radiotherapy-Oncology, Ghent University Hospital, Ghent, Belgium; Department of Radiation Oncology (MAASTRO) GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Sofie Verbeke
- Department of Pathology, Ghent University Hospital, Ghent, Belgium
| | - Nicolaas Lumen
- Department of Urology, Ghent University Hospital, Ghent, Belgium
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8
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Plata Bello A, Apatov SE, Benfante NE, Rivero Belenchón I, Picola Brau N, Mercader Barrull C, Jenjitranant P, Vickers AJ, Fine SW, Touijer KA. Prevalence of High-Risk Prostate Cancer Metastasis to Cloquet's Ilioinguinal Lymph Node. J Urol 2022; 207:1222-1226. [PMID: 35050701 PMCID: PMC9912356 DOI: 10.1097/ju.0000000000002439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE Cloquet's node, located at the junction between the deep inguinal nodes and the external iliac chain, is easily accessible and commonly excised during pelvic lymph node dissection for prostate cancer. However, we hypothesize that Cloquet's node is not part of lymphatic metastatic spread of prostate cancer. MATERIALS AND METHODS Between September 2016 and June 2019, 105 consecutive patients with high-risk prostate cancer (cT3a or Grade Group 4/5, or prostate specific antigen >20 ng/ml) underwent a laparoscopic radical prostatectomy and pelvic lymph node dissection. First, Cloquet's node was identified, retrieved and submitted separately to pathology as right and left Cloquet's node. Next, a pelvic lymph node dissection was completed including the external iliac, obturator fossa and hypogastric nodal packets. Each lymph node was cut into 3 mm slices which were separately embedded in paraffin, stained with hematoxylin and eosin, and examined microscopically. RESULTS The final analysis included 95 patients. In this high-risk population, the median number of nodes removed was 22 (IQR 18-29); 39/95 patients (41%) had lymph node metastasis. The median number of Cloquet's nodes removed was 2 (IQR 2-3). Cloquet's node was negative in all but 1 patient (1.1%), who had very high-risk features and high metastatic burden in the lymph nodes. CONCLUSIONS In high-risk prostate cancer, metastasis to the ilioinguinal node of Cloquet is rare. Given this low prevalence, Cloquet's node can be safely excluded from the pelvic lymph node dissection template.
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Affiliation(s)
| | - Sarah E Apatov
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Surgical Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Nicole E Benfante
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | | | - Pocharapong Jenjitranant
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Division of Urology, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Andrew J Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Samson W Fine
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Karim A Touijer
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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9
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Current Status and Future Perspective on the Management of Lymph Node-Positive Prostate Cancer after Radical Prostatectomy. Cancers (Basel) 2022; 14:cancers14112696. [PMID: 35681676 PMCID: PMC9179902 DOI: 10.3390/cancers14112696] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 05/25/2022] [Accepted: 05/27/2022] [Indexed: 11/23/2022] Open
Abstract
Pathological lymph node involvement (pN1) after a pelvic lymph node dissection represents one of the most unfavorable prognostic factors for disease recurrence and cancer-specific mortality in prostate cancer. However, optimal management for pN1 patients remains unclear. Thus, the guideline from the European Association of Urology recommends discussing three following management options with pN1 patients after an extended pelvic lymph node dissection, based on nodal involvement characteristics: (i) offer adjuvant androgen-deprivation therapy, (ii) offer adjuvant androgen-deprivation therapy with additional radiotherapy and (iii) offer observation (expectant management) to a patient with ≤2 nodes and a prostate-specific antigen <0.1 ng/mL. Treatment intensification may reduce risks of recurrence and cancer-specific mortality, but it may increase adverse events and impair quality of life. Few randomized control trials for pN1 are under investigation. In addition, there are limited reports on the quality of life and patient-reported outcomes in patients with pN1. Therefore, more research is needed to establish an optimal therapeutic strategy for patients with pN1. This review summarizes current evidence on the treatments available for men with pN1, summarizes randomized control trials that included pN1 prostate cancer, and discusses future perspectives.
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10
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Małkiewicz B, Knura M, Łątkowska M, Kobylański M, Nagi K, Janczak D, Chorbińska J, Krajewski W, Karwacki J, Szydełko T. Patients with Positive Lymph Nodes after Radical Prostatectomy and Pelvic Lymphadenectomy-Do We Know the Proper Way of Management? Cancers (Basel) 2022; 14:2326. [PMID: 35565455 PMCID: PMC9104304 DOI: 10.3390/cancers14092326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/03/2022] [Accepted: 05/06/2022] [Indexed: 12/04/2022] Open
Abstract
Lymph node invasion in prostate cancer is a significant prognostic factor indicating worse prognosis. While it significantly affects both survival rates and recurrence, proper management remains a controversial and unsolved issue. The thorough evaluation of risk factors associated with nodal involvement, such as lymph node density or extracapsular extension, is crucial to establish the potential expansion of the disease and to substratify patients clinically. There are multiple strategies that may be employed for patients with positive lymph nodes. Nowadays, therapeutic methods are generally based on observation, radiotherapy, and androgen deprivation therapy. However, the current guidelines are incoherent in terms of the most effective management approach. Future management strategies are expected to make use of novel diagnostic tools and therapies, such as photodynamic therapy or diagnostic imaging with prostate-specific membrane antigen. Nevertheless, this heterogeneous group of men remains a great therapeutic concern, and both the clarification of the guidelines and the optimal substratification of patients are required.
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Affiliation(s)
- Bartosz Małkiewicz
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-566 Wroclaw, Poland; (M.Ł.); (M.K.); (K.N.); (D.J.); (J.C.); (W.K.); (T.S.)
| | - Miłosz Knura
- Department of Biochemistry, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland;
| | - Małgorzata Łątkowska
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-566 Wroclaw, Poland; (M.Ł.); (M.K.); (K.N.); (D.J.); (J.C.); (W.K.); (T.S.)
| | - Maximilian Kobylański
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-566 Wroclaw, Poland; (M.Ł.); (M.K.); (K.N.); (D.J.); (J.C.); (W.K.); (T.S.)
| | - Krystian Nagi
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-566 Wroclaw, Poland; (M.Ł.); (M.K.); (K.N.); (D.J.); (J.C.); (W.K.); (T.S.)
| | - Dawid Janczak
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-566 Wroclaw, Poland; (M.Ł.); (M.K.); (K.N.); (D.J.); (J.C.); (W.K.); (T.S.)
| | - Joanna Chorbińska
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-566 Wroclaw, Poland; (M.Ł.); (M.K.); (K.N.); (D.J.); (J.C.); (W.K.); (T.S.)
| | - Wojciech Krajewski
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-566 Wroclaw, Poland; (M.Ł.); (M.K.); (K.N.); (D.J.); (J.C.); (W.K.); (T.S.)
| | - Jakub Karwacki
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-566 Wroclaw, Poland; (M.Ł.); (M.K.); (K.N.); (D.J.); (J.C.); (W.K.); (T.S.)
| | - Tomasz Szydełko
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-566 Wroclaw, Poland; (M.Ł.); (M.K.); (K.N.); (D.J.); (J.C.); (W.K.); (T.S.)
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11
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Shiota M, Takamatsu D, Kimura T, Tashiro K, Matsui Y, Tomida R, Saito R, Tsutsumi M, Yokomizo A, Yamamoto Y, Edamura K, Miyake M, Morizane S, Yoshino T, Matsukawa A, Narita S, Matsumoto R, Kasahara T, Hashimoto K, Matsumoto H, Kato M, Akamatsu S, Joraku A, Kato M, Yamaguchi T, Saito T, Kaneko T, Takahashi A, Kato T, Sakamoto S, Enokida H, Kanno H, Terada N, Suekane S, Nishiyama N, Eto M, Kitamura H. Radiotherapy plus androgen-deprivation therapy for PSA persistence in lymph node-positive prostate cancer. Cancer Sci 2022; 113:2386-2396. [PMID: 35485635 PMCID: PMC9277249 DOI: 10.1111/cas.15383] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 04/05/2022] [Accepted: 04/18/2022] [Indexed: 11/29/2022] Open
Abstract
The treatment for lymph node involvement (LNI) after radical prostatectomy (RP) has not been established. This study aimed to reveal the outcomes of various management strategies among patients with LNI after RP. Retrospectively, 561 patients with LNI after pelvic lymph node dissection (PLND) with RP treated between 2006 and 2019 at 33 institutions participating in the Japanese Urological Oncology Group were investigated. Metastasis-free survival (MFS) was the primary outcome. Patients were stratified by PSA persistence after RP. Cox regression models were used to analyze the relationships between clinicopathological characteristics and survival. Survival analyses were conducted using the Kaplan-Meier method and log-rank test with or without propensity score matching. Prognoses, including MFS and overall survival, were prominently inferior among patients with persistent PSA than among those without persistent PSA. In multivariate analysis, androgen-deprivation therapy (ADT) plus radiotherapy (RT) was associated with better MFS than ADT alone among patients with persistent PSA (hazard ratio = 0.37; 95% confidence interval = 0.15-0.93; P = 0.034). Similarly, MFS and overall survival were significantly better for ADT plus RT than for ADT alone among patients with persistent PSA after propensity score matching. This study indicated that PSA persistence in LNI prostate cancer increased the risk of poor prognoses, and intensive treatment featuring the addition of RT to ADT might improve survival.
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Affiliation(s)
| | | | - Takahiro Kimura
- Department of Urology, The Jikei University School of Medicine, Tokyo
| | - Kojiro Tashiro
- Department of Urology, The Jikei University School of Medicine, Tokyo
| | | | | | - Ryoichi Saito
- Department of Urology and Andrology, Kansai Medical University, Osaka
| | | | | | | | | | - Makito Miyake
- Department of Urology, Nara Medical University, Kashihara
| | - Shuichi Morizane
- Division of Urology, Department of Surgery, Faculty of Medicine, Tottori University, Yonago
| | | | - Akihiro Matsukawa
- Department of Urology, Kashiwa Hospital, The Jikei University, Chiba
| | | | - Ryuji Matsumoto
- Department of Renal and Genitourinary Surgery, Hokkaido University, Sapporo
| | - Takashi Kasahara
- Division of Urology, Department of Regenerative and Transplant Medicine, Niigata University, Niigata
| | | | | | - Masashi Kato
- Department of Urology, Nagoya University, Nagoya
| | | | - Akira Joraku
- Department of Urology, Ibaraki Prefectural Central Hospital, Ibaraki Cancer Center, Kasama
| | - Manabu Kato
- Department of Nephro-Urologic Surgery and Andrology, Mie University, Tsu
| | | | - Toshihiro Saito
- Department of Urology, Niigata Cancer Center Hospital, Niigata
| | - Tomoyuki Kaneko
- Department of Urology, Teikyo University School of Medicine, Tokyo
| | | | - Takuma Kato
- Department of Urology, Kagawa University, Kagawa
| | | | | | | | - Naoki Terada
- Department of Urology, Miyazaki University, Miyazaki
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12
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Laine C, Gandaglia G, Valerio M, Heidegger I, Tsaur I, Olivier J, Ceci F, van den Bergh RCN, Kretschmer A, Thibault C, Chiu PK, Tilki D, Kasivisvanathan V, Preisser F, Zattoni F, Fankhauser C, Kesch C, Puche-Sanz I, Moschini M, Pradere B, Ploussard G, Marra G. Features and management of men with pN1 cM0 prostate cancer after radical prostatectomy and lymphadenectomy: a systematic review of population-based evidence. Curr Opin Urol 2022; 32:69-84. [PMID: 34812201 DOI: 10.1097/mou.0000000000000946] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW To investigate the features and optimal management of pN+ cM0 prostate cancer (PCa) according to registry-based studies. RECENT FINDINGS Up to 15% of PCa patients harbor lymph node invasion (pN+) at radical prostatectomy plus lymph node dissection. Nonetheless, the optimal management strategy in this setting is not well characterized. SUMMARY We performed a systematic review including n = 13 studies. Management strategies comprised 13 536 men undergoing observation, 11 149 adjuvant androgen deprivation therapy (aADT), 7,075 adjuvant radiotherapy (aRT) +aADT and 705 aRT. Baseline features showed aggressive PCa in the majority of men. At a median follow-up ranging 48-134months, Cancer-related death was 5% and overall-mortality 16.6%. aADT and aRT alone had no cancer-specific survival or overall survival advantages over observation only and over not performing aRT, respectively. aADT plus aRT yielded a survival benefit compared to observation and aADT, which in one study, were limited to certain intermediate-risk categories. Age, Gleason, Charlson score, positive surgical margins, pathological stage, and positive nodes number, but not prostate specific antigen, were most relevant prognostic factors. Our work further confirmed pN+ PCa is a multifaceted disease and will help future research in defining its optimal management based on different risk categories to maximize survival and patient's quality of life.
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Affiliation(s)
- Charles Laine
- Department of Urology, Institut Mutualiste Montsouris, Paris, France
| | - Giorgio Gandaglia
- Department of Urology, San Raffaele Hospital and Scientific Institute, Milan, Italy
| | - Massimo Valerio
- Department of Urology, Lausanne University Hospital, Lausanne, Switzerland
| | - Isabel Heidegger
- Department of Urology, Medical University Innsbruck, Innsbruck, Austria
| | - Igor Tsaur
- Department of Urology and Pediatric Urology, Mainz University Medicine, Mainz, Germany
| | | | - Francesco Ceci
- Department of Nuclear Medicine, European Institute of Oncology, Milan, Italy
| | | | | | - Constance Thibault
- Department of Medical Oncology, Hôpital Européen Georges-Pompidou, Paris, France
| | - Peter K Chiu
- Division of Urology, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Derya Tilki
- Department of Urology, Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | - Felix Preisser
- Department of Urology, Goethe University, Frankfurt, Germany
| | - Fabio Zattoni
- Urology Unit, Santa Maria della Misericordia University Hospital, Udine, Italy
| | | | - Claudia Kesch
- West German Cancer Center; Department of Urology, University of Duisburg-Essen and German Cancer Consortium (DKTK)-University Hospital Essen, Essen, Germany
| | - Ignacio Puche-Sanz
- Department of Urology, Bio-Health Research Institute, Hospital Universitario Virgen de las Nieves, University of Granada Granada, Spain
| | - Marco Moschini
- Department of Urology, San Raffaele Hospital and Scientific Institute, Milan, Italy
| | - Benjamin Pradere
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Guillaume Ploussard
- Department of Urology, La Croix du Sud Hospital, Toulouse, France and Institut Universitaire du Cancer Toulouse - Oncopole, Toulouse, France
| | - Giancarlo Marra
- Department of Urology, Institut Mutualiste Montsouris, Paris, France
- Department of Urology, San Giovanni Battista Hospital, University of Turin, Turin, Italy
- Department of Urology and Clinical Research Group on Predictive Onco-Urology, APHP, Sorbonne University, Paris, France
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13
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Plata Bello A, Touijer KA. The future of salvage lymph node dissection in the prostate-specific membrane antigen era. BJU Int 2021; 128:652-653. [PMID: 34708526 DOI: 10.1111/bju.15591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 08/09/2021] [Indexed: 01/04/2023]
Affiliation(s)
- Ana Plata Bello
- University Hospital of Canary Islands, La Laguna, Tenerife, Canary Islands, Spain
| | - Karim A Touijer
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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14
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Marra G, Valerio M, Heidegger I, Tsaur I, Mathieu R, Ceci F, Ploussard G, van den Bergh RCN, Kretschmer A, Thibault C, Ost P, Tilki D, Kasivisvanathan V, Moschini M, Sanchez-Salas R, Gontero P, Karnes RJ, Montorsi F, Gandaglia G. Management of Patients with Node-positive Prostate Cancer at Radical Prostatectomy and Pelvic Lymph Node Dissection: A Systematic Review. Eur Urol Oncol 2020; 3:565-581. [PMID: 32933887 DOI: 10.1016/j.euo.2020.08.005] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/07/2020] [Accepted: 08/11/2020] [Indexed: 12/16/2022]
Abstract
CONTEXT Optimal management of prostate cancer (PCa) patients with lymph node invasion at radical prostatectomy and pelvic lymph node dissection still remains unclear. OBJECTIVE To assess the effectiveness of postoperative treatment strategies for pathologically node-positive PCa patients. The secondary aim was to identify the most relevant prognostic factors to guide the management of pN1 patients. EVIDENCE ACQUISITION A systematic review was performed in January 2020 using Medline, Embase, and other databases. A total of 5063 articles were screened, and 26 studies including 12 537 men were selected for data synthesis and included in the current review according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) recommendations. EVIDENCE SYNTHESIS Ten-year biochemical recurrence (BCR)-free, clinical recurrence-free, cancer-specific (CSS), and overall (OS) survival rates ranged from 28% to 56%, 70% to 92%, 72% to 98%, and 60% to 87.6%, respectively. A total of seven, five, and six studies assessed the oncological outcomes of observation, adjuvant radiotherapy (aRT), or adjuvant androgen deprivation therapy (ADT), respectively. Initial observation followed by salvage therapies at the time of recurrence represents a safe option in selected patients with a low disease burden. The use of aRT with or without ADT might improve survival in men with locally advanced disease and a higher number of positive nodes. Risk stratification according to pathological Gleason score, number of positive nodes, pathological stage, and surgical margins status is the key to risk stratification and selection of the optimal postoperative therapy. Limitations of this systematic review are the retrospective design of the studies included and the lack of data on adverse events. CONCLUSIONS While the majority of men with pN1 disease would experience BCR after surgery, long-term disease-free survival has been reported in selected patients. Management options to improve oncological outcomes include observation versus adjuvant therapies such as aRT and/or ADT. Disease characteristics should be used to select the optimal postoperative management for pN1 PCa patients. PATIENT SUMMARY Finding node-positive prostate cancer after a radical prostatectomy often leads to high postoperative prostate-specific antigen levels and is overall a poor prognostic factor. However, this does not necessarily translate into poor survival for all men. Management can be tailored to the severity of disease and options include observation, androgen deprivation therapy, and/or radiotherapy.
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Affiliation(s)
- Giancarlo Marra
- Department of Urology, San Giovanni Battista Hospital, University of Turin, Turin, Italy.
| | | | - Isabel Heidegger
- Department of Urology, Medical University Innsbruck, Innsbruck, Austria
| | - Igor Tsaur
- Department of Urology and Pediatric Urology, Mainz University Medicine, Mainz, Germany
| | | | - Francesco Ceci
- Nuclear Medicine, Department of Medical Sciences, University of Turin, Italy
| | - Guillaume Ploussard
- Department of Urology, La Croix du Sud Hospital, Toulouse, France; Institut Universitaire du Cancer Toulouse-Oncopole, Toulouse, France
| | | | | | - Constance Thibault
- Department of Oncology, Hopital Europeen Georges Pompidou, Paris, France
| | - Piet Ost
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Veeru Kasivisvanathan
- Division of Surgery and Interventional Science, University College London, London, UK; Department of Urology, University College London Hospital, London, UK
| | - Marco Moschini
- Department of Urology, Institut Mutualiste Montsouris, Paris, France
| | | | - Paolo Gontero
- Department of Urology, San Giovanni Battista Hospital, University of Turin, Turin, Italy
| | | | - Francesco Montorsi
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Giorgio Gandaglia
- Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
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15
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Onol FF, Bhat S, Moschovas M, Rogers T, Albala D, Patel V. The ongoing dilemma in pelvic lymph node dissection during radical prostatectomy: who should decide and in which patients? J Robot Surg 2020; 14:549-558. [DOI: 10.1007/s11701-019-01041-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/18/2019] [Indexed: 01/13/2023]
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16
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[Trivialization of prostate cancer? : Stage shift and possible causes]. Urologe A 2019; 58:1461-1468. [PMID: 31531694 DOI: 10.1007/s00120-019-01039-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND According to the strongly negative grade D recommendation of the U.S. Preventive Services Task Force in 2012, the prostate-specific antigen (PSA) test was not only not recommended but was also warned against. As a result in the USA there was a stage shift towards more advanced tumor stages under the newly detected prostate cancers; however, in contrast to the highly questionable American PLCO study, the European ERSPC study showed a clear reduction in prostate cancer-related mortality. OBJECTIVE In this patient cohort it was investigated whether the tumor stage distribution in curatively treated prostate cancer has significantly changed, whether this has an influence on the perioperative results and complication rates and how these changes could have occurred. MATERIAL AND METHODS Patients after radical prostatectomy from 2008 to 2010 were compared to those from 2017. Demographic data, intraoperative courses, perioperative and postoperative complications and histopathological results were compared. RESULTS A total of 1276 operations were analyzed. Preoperative PSA levels showed a significant increase in 2017 (10.5 ± 13.4 ng/ml vs. 8.4 ± 9.1 ng/ml, p = 0.032). The pathological staging revealed a 20% increase in T3 tumors (49.4% versus 29.0%, p < 0.001). Correspondingly, moderately and poorly differentiated cancers and therefore those with higher aggressiveness were significantly more frequent with 11.2% (p < 0.001) and 10.4% (p < 0.001), respectively. The number of patients with lymph node metastases at prostatectomy even increased fourfold (4.5% vs. 16.9%, p < 0.001). CONCLUSION In the radical prostatectomy group, there was a shift to unfavorable and metastatic tumor stages. This negative trend seems largely to be caused by a lower acceptance of early detection by means of PSA determination.
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17
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Chalouhy C, Gurram S, Ghavamian R. Current controversies on the role of lymphadenectomy for prostate cancer. Urol Oncol 2018; 37:219-226. [PMID: 30579787 DOI: 10.1016/j.urolonc.2018.11.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/20/2018] [Accepted: 11/19/2018] [Indexed: 01/11/2023]
Abstract
Lymph node dissection is part of the standard treatment protocol for various cancers, but its role in prostate cancer has been debatable for some time. Pelvic lymphadenectomy has been shown to better help stage prostate cancer patients, but has yet to be definitively proven to be of any benefit for survival. Various templates for lymph node dissections exist, and though some national guidelines have endorsed an extended pelvic node dissection, the choice of template is still controversial. Pelvic lymphadenectomy may lead to a slightly higher rate complications and operative time, and their use must be judiciously applied to patients with a high enough risk of lymph node involvement. We present a comprehensive review of the literature regarding the benefits and harms of lymph node dissection in prostate cancer.
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Affiliation(s)
| | - Sandeep Gurram
- The Smith Institute for Urology, Zucker School of Medicine Hofstra/Northwell, New Hyde Park, NY
| | - Reza Ghavamian
- The Smith Institute for Urology, Zucker School of Medicine Hofstra/Northwell, New Hyde Park, NY.
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18
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Touijer K. Reply to Pim J. van Leeuwen and Henk G. van der Poel's Letter to the Editor re: Karim A. Touijer, Robert J. Karnes, Niccolo Passoni, et al. Survival Outcomes of Men with Lymph Node-positive Prostate Cancer After Radical Prostatectomy: A Comparative Analysis of Different Postoperative Management Strategies. Eur Urol 2018;73:890-6. Eur Urol 2018; 74:e18-e19. [PMID: 29691082 DOI: 10.1016/j.eururo.2018.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 04/02/2018] [Indexed: 11/24/2022]
Affiliation(s)
- Karim Touijer
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
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19
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Evaluation and Treatment for High-Risk Prostate Cancer. Prostate Cancer 2018. [DOI: 10.1007/978-3-319-78646-9_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
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20
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Eggener S. Nodal Metastases at Radical Prostatectomy: More Aggressive Disease Warrants Consideration of Multimodal Treatment. Eur Urol 2017; 73:897-898. [PMID: 29224914 DOI: 10.1016/j.eururo.2017.11.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 11/27/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Scott Eggener
- Section of Urology, University of Chicago, Chicago, IL, USA.
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21
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Smith JA. This Month in Adult Urology. J Urol 2017. [DOI: 10.1016/j.juro.2017.07.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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