1
|
Seyedin SN, Watkins JM, Mayo Z, Snow AN, Laszewski M, Russo JK, Mott SL, Tracy CR, Smith MC, Buatti JM, Caster JM. A Recursive Partitioning Analysis Demonstrating Risk Subsets for 8-Year Biochemical Relapse After Margin-Positive Radical Prostatectomy Without Adjuvant Hormone or Radiation Therapy. Adv Radiat Oncol 2021; 6:100778. [PMID: 34934861 PMCID: PMC8655410 DOI: 10.1016/j.adro.2021.100778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 08/09/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose The cohort of patients with locally advanced prostate cancer (PC) and positive surgical margin(s) at radical prostatectomy (RP) who would benefit from salvage or adjuvant treatment is unclear. This study examines the risk of prostate-specific antigen (PSA) relapse in a large population of men with PC after margin-positive RP. Methods and Materials Using a multi-institutional database, patients with clinically localized PC who underwent RP between 2002 and 2010 with recorded follow-up PSA were retrospectively selected. Patients were excluded for pathologic seminal vesicle or lymph node involvement, metastatic disease, pre-RP PSA ≥ 30, or adjuvant (nonsalvage) radiation therapy or hormone therapy. The primary endpoint was biochemical relapse free survival (bRFS), where PSA failure was defined as PSA > 0.10 ng/mL and rising, or at salvage intervention. The Kaplan-Meier method was employed for bRFS estimates; recursive partitioning analysis using cumulative or single maximal margin extent (ME) and Gleason grade (GG) at RP was applied to identify variables associated with bRFS. Results At median follow-up of 105 months, 210 patients with positive margins at RP were eligible for analysis, and 89 had experienced PSA relapse. Median age was 61 years (range, 43-76), and median pre-RP PSA 5.8 ng/mL (1.6-26.0). Recursive partitioning analysis yielded 5 discrete risk groups, with the lowest risk group (GG1, ≤ 2 mm ME) demonstrating a bRFS of 92% at 8 years compared with the highest risk group (GG3-5, ≥ 3 mm ME) of 11%. Conclusions This retrospective study suggests that it may be possible to risk-stratify patients undergoing margin-positive RP using commonly acquired clinical and pathologic variables. Patients with low-grade tumors and minimally involved margins have a very low recurrence risk and may be able to forego postprostatectomy radiation. Meanwhile, those with higher grade and greater involvement could benefit from adjuvant or early salvage radiation therapy.
Collapse
|
2
|
Liu CY, Chen YT, Su SH, Yu KJ, Chang YH, Lin PH, Shao IH, Kan HC, Chu YC, Huang LK, Chuang CK, Pang ST. Is immediate adjuvant radiotherapy necessary for men with positive surgical margin after robotic-assisted radical prostatectomy? FORMOSAN JOURNAL OF SURGERY 2021. [DOI: 10.4103/fjs.fjs_99_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
3
|
Tao R, Dai J, Bai Y, Yang J, Sun G, Zhang X, Zhao J, Zeng H, Shen P. The prognosis benefits of adjuvant versus salvage radiotherapy for patients after radical prostatectomy with adverse pathological features: a systematic review and meta-analysis. Radiat Oncol 2019; 14:197. [PMID: 31706339 PMCID: PMC6842460 DOI: 10.1186/s13014-019-1384-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 09/23/2019] [Indexed: 02/05/2023] Open
Abstract
Background The appropriate timing of radiotherapy (RT) for patients after radical prostatectomy (RP) with adverse pathological features (APFs) remains controversial. This systematic review was conducted to compare the efficacy of adjuvant radiotherapy (ART) and salvage radiotherapy (SRT). Methods PubMed, EMBASE, Web of Science and the Cochrane Library electronic databases were searched to retrieve the required. The hazard ratio (HR) and corresponding 95% confidence interval (CI) of overall survival (OS), biochemical recurrence-free survival (BRFS) and distant metastases-free survival (DMFS) were extracted. The survival benefits of ART with SRT (including early salvage radiotherapy (ESRT)) were analyzed. The process of the meta-analysis was performed with RevMan version 5.3. Results A total of fifteen retrospective studies were finally included in the final analysis including 5586 patients. The pooled analysis indicated that ART could achieve better control of prostate cancer and improve OS (p = 0.0006), BRFS (p < 0.0001) and DMFS (p < 0.0001), when compared to SRT. The subgroup analysis of the 5-year OS rate demonstrated that the ART group still had survival advantages compared to the SRT group (p = 0.0006). However, ART and SRT were comparable in 10-year OS rate (p = 0.07). ART had advantages over SRT in both 5-year (p = 0.0003) and 10-year BRFS (p = 0.0003). The subgroup analysis with different follow-up starting points from RP or RT was essentially consistent with the above results. The pooled analysis also showed that ART was superior to ESRT on OS (p = 0.008) and DMFS (p = 0.03), and comparable to ESRT on BRFS (p = 0.1). Conclusions According to this meta-analysis, ART could be served as a preferential treatment for patients with APFs after RP to improve prognosis. Certainly, high-quality, multicenter randomized controlled trials (RCTs) are expecting to confirm the outcomes of our meta-analysis in the future.
Collapse
Affiliation(s)
- Ronggui Tao
- Department of Urology, Institute of Urology, and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, 610041, China
| | - Jindong Dai
- Department of Urology, Institute of Urology, and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, 610041, China
| | - Yunjin Bai
- Department of Urology, Institute of Urology, and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, 610041, China
| | - Jiyu Yang
- Department of Urology, Institute of Urology, and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, 610041, China
| | - Guangxi Sun
- Department of Urology, Institute of Urology, and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, 610041, China
| | - Xingming Zhang
- Department of Urology, Institute of Urology, and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, 610041, China
| | - Jinge Zhao
- Department of Urology, Institute of Urology, and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, 610041, China
| | - Hao Zeng
- Department of Urology, Institute of Urology, and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, 610041, China
| | - Pengfei Shen
- Department of Urology, Institute of Urology, and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, 610041, China.
| |
Collapse
|
4
|
Berg S, Nabi J, Trinh QD. Comparing Adjuvant vs Early-Salvage Radiotherapy After Radical Prostatectomy. JAMA Oncol 2018; 4:1619-1620. [PMID: 30422246 DOI: 10.1001/jamaoncol.2018.3536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Sebastian Berg
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Junaid Nabi
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Quoc-Dien Trinh
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
5
|
Hwang WL, Tendulkar RD, Niemierko A, Agrawal S, Stephans KL, Spratt DE, Hearn JW, Koontz BF, Lee WR, Michalski JM, Pisansky TM, Liauw SL, Abramowitz MC, Pollack A, Moghanaki D, Anscher MS, Den RB, Zietman AL, Stephenson AJ, Efstathiou JA. Comparison Between Adjuvant and Early-Salvage Postprostatectomy Radiotherapy for Prostate Cancer With Adverse Pathological Features. JAMA Oncol 2018; 4:e175230. [PMID: 29372236 PMCID: PMC5885162 DOI: 10.1001/jamaoncol.2017.5230] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 11/16/2017] [Indexed: 11/14/2022]
Abstract
Importance Prostate cancer with adverse pathological features (ie, pT3 and/or positive margins) after prostatectomy may be managed with adjuvant radiotherapy (ART) or surveillance followed by early-salvage radiotherapy (ESRT) for biochemical recurrence. The optimal timing of postoperative radiotherapy is unclear. Objective To compare the clinical outcomes of postoperative ART and ESRT administered to patients with prostate cancer with adverse pathological features. Design, Setting, and Participants This multi-institutional, propensity score-matched cohort study involved 1566 consecutive patients who underwent postprostatectomy ART or ESRT at 10 US academic medical centers between January 1, 1987, and December 31, 2013. Propensity score 1-to-1 matching was used to account for covariates potentially associated with treatment selection. Data were collected from January 1 to September 30, 2016. Data analysis was conducted from October 1, 2016, to October 21, 2017. Main Outcomes and Measures Freedom from postirradiation biochemical failure, freedom from distant metastases, and overall survival. All outcomes were measured from date of surgery to address lead-time bias. Results Of 1566 patients, 1195 with prostate-specific antigen levels of 0.1 to 0.5 ng/mL received ESRT and 371 patients with prostate-specific antigen levels lower than 0.1 ng/mL received ART. The median age (interquartile range) was 60 (55-65) years. After propensity score matching, the median (interquartile range) follow-up after surgery was similar between the ESRT and ART groups (73.3 [44.9-106.6] months vs 65.8 [40-107] months; P = .22). Adjuvant RT, compared with ESRT, was associated with higher freedom from biochemical failure (12-year actuarial rates: 69% [95% CI, 60%-76%] vs 43% [95% CI, 35%-51%]; effect size, 26%), freedom from distant metastases (95% [95% CI, 90%-97%] vs 85% [95% CI, 76%-90%]; effect size, 10%), and overall survival (91% [95% CI, 84%-95%] vs 79% [95% CI, 69%-86%]; effect size, 12%). Adjuvant RT, lower Gleason score and T stage, nodal irradiation, and postoperative androgen deprivation therapy were favorable prognostic features on multivariate analysis for biochemical failure. Sensitivity analysis demonstrated that the decreased risk of biochemical failure associated with ART remained significant unless more than 56% of patients in the ART group were cured by surgery alone. This threshold is greater than the estimated 12-year freedom from biochemical failure rate of 33% to 52% after radical prostatectomy alone, as determined by a contemporary dynamic nomogram. Conclusions and Relevance Adjuvant RT, compared with ESRT, was associated with reduced biochemical recurrence, distant metastases, and death for high-risk patients, pending prospective validation. These findings suggest that a greater proportion of patients with prostate cancer who have adverse pathological features may benefit from postprostatectomy ART rather than surveillance followed by ESRT.
Collapse
Affiliation(s)
- William L. Hwang
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rahul D. Tendulkar
- Departments of Radiation Oncology and Urology, Cleveland Clinic, Cleveland, Ohio
| | - Andrzej Niemierko
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shree Agrawal
- Department of Radiation Oncology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Kevin L. Stephans
- Departments of Radiation Oncology and Urology, Cleveland Clinic, Cleveland, Ohio
| | - Daniel E. Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Jason W. Hearn
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Bridget F. Koontz
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - W. Robert Lee
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Jeff M. Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | | | - Stanley L. Liauw
- Department of Radiation Oncology, University of Chicago, Chicago, Illinois
| | | | - Alan Pollack
- Department of Radiation Oncology, University of Miami, Miami, Florida
| | - Drew Moghanaki
- Department of Radiation Oncology, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Virginia
| | - Mitchell S. Anscher
- Department of Radiation Oncology, Virginia Commonwealth University Medical Center, Richmond
| | - Robert B. Den
- Department of Radiation Oncology, Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Anthony L. Zietman
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew J. Stephenson
- Departments of Radiation Oncology and Urology, Cleveland Clinic, Cleveland, Ohio
| | - Jason A. Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
6
|
Dess RT, Morgan TM, Nguyen PL, Mehra R, Sandler HM, Feng FY, Spratt DE. Adjuvant Versus Early Salvage Radiation Therapy Following Radical Prostatectomy for Men with Localized Prostate Cancer. Curr Urol Rep 2018; 18:55. [PMID: 28589403 DOI: 10.1007/s11934-017-0700-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Radical prostatectomy (RP) is now the most common definitive treatment for high-risk prostate cancer. Unfortunately, many men will have residual microscopic disease after surgery alone. Despite level 1 evidence supporting the use of adjuvant radiation therapy (ART), <10% of men with adverse pathology (positive margins or T3 disease) receive ART in the USA. Early salvage radiation therapy (eSRT) at the time of biochemical recurrence has been proposed as an alternative strategy despite the lack of published randomized trials to support this approach. Multiple randomized trials are ongoing or recently completed to compare ART to eSRT, but given the long natural history of prostate cancer, long-term oncologic outcomes from these trials will not be reported for several years. In this review, we discuss the shifting trends in the diagnosis of high-risk prostate cancer given a decline in PSA screening, use of RP for high-risk disease, and compare and contrast the retrospective and randomized evidence regarding ART and SRT.
Collapse
Affiliation(s)
- Robert T Dess
- Department of Radiation Oncology, University of Michigan School of Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Todd M Morgan
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Rohit Mehra
- Department of Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Howard M Sandler
- Department of Radiation Oncology, Cedars Sinai, Los Angeles, CA, USA
| | - Felix Y Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan School of Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.
| |
Collapse
|
7
|
Long-term Outcome of Prostate Cancer Patients Who Exhibit Biochemical Failure Despite Salvage Radiation Therapy After Radical Prostatectomy. Am J Clin Oncol 2017; 40:612-620. [PMID: 26165416 DOI: 10.1097/coc.0000000000000207] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Salvage radiation therapy (SRT) is an effective treatment for recurrent prostate cancer (PCa) after radical prostatectomy. We report the long-term outcome of men who developed biochemical recurrence (BCR) after SRT and were treated >14 years ago. METHODS In total, 61 patients treated with SRT from 1992 to 2000 at our institution were identified. Survival was calculated by Kaplan-Meier method. Log-rank test and Cox regression were used to determine significance of clinical parameters. RESULTS The median follow-up was 126 months (interquartile range, 66-167 mo). Thirty-four (56%) had prostate-specific antigen (PSA) failure after SRT. At 10 years, overall survival (OS) was 67%, freedom from PSA failure (FFPF) was 33%, prostate cancer-specific survival (PCSS) was 84%, and distant metastases-free survival (DMFS) was 84%. Pathologic T-stage, Gleason score, seminal vesicle involvement, and pre-SRT PSA were associated with FFPF. For patients who failed SRT, the median time to BCR after SRT was 30 mo. A total of 19 (68%) received androgen deprivation therapy. The median OS was 13.6 years. At 10 years from time of BCR, OS was 59%, PCSS was 73%, DMFS was 75%, and castration-resistant-free survival was 70%. Early SRT failure correlated with significantly decreased DMFS and PCSS. Ten-year DMFS from SRT was 43% (BCR≤1 y) versus 91% (BCR>1 y). CONCLUSIONS Extended follow-up demonstrates that despite SRT failure, PCSS remains high in select patients. Early failure (≤1 y after SRT) predicted for significantly worse outcome and may represent a subgroup with more aggressive disease that may be considered for further prospective clinical studies.
Collapse
|
8
|
Rodriguez JF, Liauw SL, Eggener SE. Managing Cancer Relapse After Radical Prostatectomy: Adjuvant Versus Salvage Radiation Therapy. Urol Clin North Am 2017; 44:597-609. [PMID: 29107276 DOI: 10.1016/j.ucl.2017.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
An increasing proportion of men are undergoing radical prostatectomy for locally advanced prostate cancer. More than half of men with adverse pathologic features are expected to experience disease recurrence within 10 years. This article discusses the use of postoperative radiation therapy to decrease this risk. Evidence from 3 randomized trials and multiple retrospective studies indicates that either adjuvant or salvage radiation improve biochemical progression-free survival and may improve overall survival. Novel imaging and genomic analysis can improve patient selection for either modality, however current tests are unable to identify all patients who may benefit from additional local therapy.
Collapse
Affiliation(s)
- Joseph F Rodriguez
- Section of Urology, University of Chicago, The University of Chicago Medicine, 5841 South Maryland Avenue, MC 6038, Chicago, IL 60637, USA.
| | - Stanley L Liauw
- Department of Radiation and Cellular Oncology, University of Chicago, The University of Chicago Medicine, 5758 South Maryland Avenue, MC 9006, Chicago, IL 60637, USA
| | - Scott E Eggener
- Section of Urology, University of Chicago, The University of Chicago Medicine, 5841 South Maryland Avenue, MC 6038, Chicago, IL 60637, USA
| |
Collapse
|
9
|
Bhindi B, Carlson RE, Mason RJ, Schulte PJ, Gettman MT, Frank I, Tollefson MK, Thompson RH, Boorjian SA, Leibovich BC, Karnes RJ. Long-term Follow-up of a Matched Cohort Study Evaluating the Role of Adjuvant Radiotherapy for Organ-confined Prostate Cancer With a Positive Surgical Margin. Urology 2017; 109:145-152. [DOI: 10.1016/j.urology.2017.06.054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 06/01/2017] [Accepted: 06/06/2017] [Indexed: 10/19/2022]
|
10
|
Isharwal S, Stephenson AJ. Post-prostatectomy radiation therapy for locally recurrent prostate cancer. Expert Rev Anticancer Ther 2017; 17:1003-1012. [PMID: 28922958 DOI: 10.1080/14737140.2017.1378575] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Approximately 15-30% of men with localized prostate cancer will experience biochemical recurrence (BCR) after radical prostatectomy. Postoperative radiation therapy is used in men with adverse pathological features to reduce the risk of BCR or with curative intent in men with known BCR. In this study, we review the evidence for the adjuvant and salvage radiation therapy after radical prostatectomy. Areas covered: A literature review of the Medline and Embase databases was performed. The search strategy included the following terms: prostate cancer, adjuvant radiotherapy, salvage radiotherapy, radical prostatectomy, biochemical recurrence, and prostate cancer recurrence. Prospective randomized trials for the adjuvant radiotherapy and observational studies supporting salvage radiotherapy were included for discussion. Expert commentary: As postoperative radiotherapy is associated with non-trivial risks of acute and long-term toxicity and given the absence of compelling data supporting adjuvant over early salvage radiotherapy, the authors advocate, with rare exceptions, close observation and timely (early) salvage radiotherapy for patients with BCR and long life expectancy. Adjuvant radiotherapy may be considered in patients at high-risk for recurrence. Observation is appropriate in patients with limited life expectancy and/or absence of adverse features.
Collapse
Affiliation(s)
- Sudhir Isharwal
- a Department of Urology , Glickman Urology and Kidney Institute, Cleveland Clinic , Cleveland , OH , USA
| | - Andrew J Stephenson
- a Department of Urology , Glickman Urology and Kidney Institute, Cleveland Clinic , Cleveland , OH , USA
| |
Collapse
|
11
|
Postoperative Radiotherapy in Locally Advanced Prostate Cancer: A Question of Who and When. Eur Urol 2016; 71:894-895. [PMID: 27866843 DOI: 10.1016/j.eururo.2016.11.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 11/04/2016] [Indexed: 11/20/2022]
|
12
|
Buscariollo DL, Drumm M, Niemierko A, Clayman RH, Galland-Girodet S, Rodin D, Feldman AS, M Dahl D, McGovern FJ, F Olumi A, Eidelman A, Shipley WU, Zietman AL, Efstathiou JA. Long-term results of adjuvant versus early salvage postprostatectomy radiation: A large single-institutional experience. Pract Radiat Oncol 2016; 7:e125-e133. [PMID: 28274403 DOI: 10.1016/j.prro.2016.10.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 10/05/2016] [Accepted: 10/14/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE The purpose of this study was to evaluate freedom from biochemical failure (FFBF), freedom from androgen deprivation therapy (FFADT), freedom from distant metastases (FFDM), and overall survival (OS) after adjuvant radiation therapy (ART) versus early salvage radiation therapy (ESRT) in men with prostate cancer and adverse pathologic features (pT3 and/or positive surgical margins). METHODS AND MATERIALS Of 718 patients consecutively treated with postoperative radiation therapy (RT) for prostate cancer between 1992 and 2013, we retrospectively identified 171 men receiving ART and 230 receiving ESRT (RT delivered at a prostate-specific antigen level ≤0.5 ng/mL) who had adverse pathologic features. Postirradiation FFBF (BF was defined as prostate-specific antigen level rise to ≥0.2 ng/mL), FFADT, FFDM, and OS were compared using Kaplan-Meier and Cox regression methods. Propensity score (PS)-matching was performed to estimate treatment effects while accounting for covariates predicting treatment allocation. RESULTS Median follow-up was 7.4 and 8.0 years for patients treated with ART and ESRT, respectively. Ten-year FFBF (69% vs 56%, P = .003) and 10-year FFADT (88% vs 81%, P = .046) rates were higher after ART; however, FFDM and OS did not significantly differ. After PS-matching, ART was associated with improved FFBF (P < .0001), FFADT (P = .0001), and FFDM (P = .02). Findings were confirmed in multivariable analyses in unmatched and PS-matched cohorts. Sensitivity analyses showed that FFBF benefit associated with ART lost statistical significance only after 38% of ART patients were assumed to have been cured by surgery and excluded from the model. This corresponds to the upper bound of patients with adverse pathologic features who did not recur after observation in prior randomized trials. CONCLUSIONS Postoperative RT confers excellent long-term cancer control. These results suggest ART may be associated with improved FFBF, FFADT, and FFDM, but comparable OS. Given the retrospective study design, these findings should be interpreted with caution. Optimal timing of postoperative RT further awaits results of ongoing trials.
Collapse
Affiliation(s)
- Daniela L Buscariollo
- Harvard Radiation Oncology Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael Drumm
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrzej Niemierko
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | | | | | - Danielle Rodin
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Adam S Feldman
- Department of Urology, Massachusetts General Hospital, Boston, Massachusetts
| | - Douglas M Dahl
- Department of Urology, Massachusetts General Hospital, Boston, Massachusetts
| | - Francis J McGovern
- Department of Urology, Massachusetts General Hospital, Boston, Massachusetts
| | - Aria F Olumi
- Department of Urology, Massachusetts General Hospital, Boston, Massachusetts
| | - Alec Eidelman
- Tufts University School of Dental Medicine, Boston, Massachusetts
| | - William U Shipley
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Anthony L Zietman
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts.
| |
Collapse
|
13
|
Vargas HA, Martin-Malburet AG, Takeda T, Corradi RB, Eastham J, Wibmer A, Sala E, Zelefsky MJ, Weber WA, Hricak H. Localizing sites of disease in patients with rising serum prostate-specific antigen up to 1ng/ml following prostatectomy: How much information can conventional imaging provide? Urol Oncol 2016; 34:482.e5-482.e10. [PMID: 27346339 DOI: 10.1016/j.urolonc.2016.05.026] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 05/17/2016] [Accepted: 05/24/2016] [Indexed: 02/01/2023]
Abstract
PURPOSE Accurate identification of the source of a detectable serum prostate-specific antigen (PSA) in the postprostatectomy setting is a major challenge among the urologic community. The aim of this study was to assess positivity rates of imaging examinations performed in patients with early PSA rise after prostatectomy and to summarize the management strategies adopted in this clinical scenario. METHODS Institutional Review Board-approved retrospective study of 142 postprostatectomy patients with PSA rise up to 1ng/ml who underwent evaluation with combination of multiparametric pelvic magnetic resonance imaging (MRI)±whole-body or bone MRI, bone scintigraphy, computed tomography (CT) chest-abdomen-pelvis, 18F-fludeoxyglucose-positron emission tomography (PET)/CT or 18F-sodium fluoride-PET/CT at a single tertiary cancer center. Imaging results were summarized per modality and compared with pathology findings. RESULTS Pelvic MRI was positive in 15/142 (11%) patients (14 patients with local recurrence in the surgical bed and 1 patient with pelvic osseous metastases). Of these 15, 10 patients underwent additional imaging examinations; none revealed positive findings. Of the 127 patients with negative pelvic MRI, 54 (43%) underwent additional imaging examinations; only 1/54 had positive findings (false-positive T8 lesion on bone scintigraphy and FDG-PET/CT; biopsy was negative for cancer). Overall, 12/16 patients with positive imaging findings and 75/126 (60%) patients with negative imaging received treatment (radiation, hormones or chemotherapy). CONCLUSION The conventional imaging identified sites of disease, almost always in the form of local recurrence, in a minority of patients with early PSA rise postprostatectomy.
Collapse
Affiliation(s)
| | | | - Toshikazu Takeda
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Renato B Corradi
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY
| | - James Eastham
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andreas Wibmer
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Evis Sala
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Michael J Zelefsky
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Wolfgang A Weber
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Hedvig Hricak
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| |
Collapse
|
14
|
Herrera FG, Berthold DR. Radiation Therapy after Radical Prostatectomy: Implications for Clinicians. Front Oncol 2016; 6:117. [PMID: 27242957 PMCID: PMC4860423 DOI: 10.3389/fonc.2016.00117] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 04/25/2016] [Indexed: 12/11/2022] Open
Abstract
Depending on the pathological findings, up to 60% of prostate cancer patients who undergo radical prostatectomy (RP) will develop biochemical relapse and require further local treatment. Radiotherapy (RT) immediately after RP may potentially eradicate any residual localized microscopic disease in the prostate bed, and it is associated with improved biochemical, clinical progression-free survival, and overall survival in patients with high-risk pathological features according to published randomized trials. Offering immediate adjuvant RT to all men with high-risk pathological factors we are over-treating around 50% of patients who would anyway be cancer-free, exposing them to unnecessary toxicity and adding costs to the health-care system. The current dilemma is, thus, whether to deliver adjuvant immediate RT solely on the basis of high-risk pathology, but in the absence of measurable prostate-specific antigen, or whether early salvage radiotherapy would yield equivalent outcomes. Randomized trials are ongoing to definitely answer this question. Retrospective analyses suggest that there is a dose–response favoring doses >70 Gy to the prostate bed. The evidence regarding the role of androgen deprivation therapy is emerging, and ongoing randomized trials are underway.
Collapse
Affiliation(s)
- Fernanda G Herrera
- Radiation Oncology Services, Department of Oncology, Lausanne University Hospital , Lausanne , Switzerland
| | - Dominik R Berthold
- Medical Oncology Services, Department of Oncology, Lausanne University Hospital , Lausanne , Switzerland
| |
Collapse
|
15
|
Blackwell RH, Gange W, Kandabarow AM, Harkenrider MM, Gupta GN, Quek ML, Flanigan RC. Adjuvant radiotherapy for pathologically advanced prostate cancer improves biochemical recurrence free survival compared to salvage radiotherapy. World J Clin Urol 2016; 5:45-52. [DOI: 10.5410/wjcu.v5.i1.45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 11/24/2015] [Accepted: 01/11/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the long-term outcomes of patients receiving adjuvant and salvage radiotherapy following prostatectomy with adverse pathologic features and an undetectable prostate specific antigen (PSA).
METHODS: A retrospective review was performed of patients who received post-prostatectomy radiation at Loyola University Medical Center between 1992 and 2013. Adverse pathologic features (Gleason score ≥ 8, seminal vesicle invasion, extracapsular extension, pathologic T4 disease, and/or positive surgical margins) and an undetectable PSA following prostatectomy were required for inclusion. Adjuvant patients received therapy with an undetectable PSA, salvage patients following biochemical recurrence (BCR). Post-radiation BCR, overall survival, bone metastases, and initiation of hormonal therapy were assessed. Kaplan-Meier time-to-event analyses and stepwise Cox proportional hazards regression (HR) were performed.
RESULTS: Post-prostatectomy patients (n = 134) received either adjuvant (n = 47) or salvage (n = 87) radiation. Median age at radiotherapy (RT) was 63 years, and median follow-up was 53 mo. Five-year post-radiation BCR-free survival was 78% for adjuvant vs 50% salvage radiotherapy (SRT) (Logrank P = 0.001). Patients with radiation administered following a detectable PSA had an increased risk of BCR compared to undetectable: PSA > 0.0-0.2: HR = 4.1 (95%CI: 1.5-11.2; P = 0.005); PSA > 0.2-1.0: HR = 4.4 (95%CI: 1.6-11.9; P = 0.003); and PSA > 1.0: HR = 52 (95%CI: 12.9-210; P < 0.001). There was no demonstrable difference in rates of overall survival, bone metastases or utilization of hormonal therapy between adjuvant and SRT patients.
CONCLUSION: Adjuvant RT improves BCR-free survival compared to SRT in patients with adverse pathologic features and an undetectable post-prostatectomy PSA.
Collapse
|
16
|
Raziee H, Berlin A. Gaps between Evidence and Practice in Postoperative Radiotherapy for Prostate Cancer: Focus on Toxicities and the Effects on Health-Related Quality of Life. Front Oncol 2016; 6:70. [PMID: 27047800 PMCID: PMC4805642 DOI: 10.3389/fonc.2016.00070] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 03/10/2016] [Indexed: 12/24/2022] Open
Abstract
Adjuvant radiotherapy (ART) after prostatectomy for patients with high-risk features [extracapsular extension (ECE), seminal vesicle invasion (SVI), and positive margin] has been shown to be associated with improved biochemical disease-free survival in three large randomized trials and with improved overall survival in one. Similarly, salvage radiotherapy (SRT) can effectively achieve biochemical control in a significant proportion of patients with a rising PSA after surgery. Nonetheless, both approaches of postoperative RT remain highly underutilized. This might be partly due to concerns with overtreatment inherent to adjuvant approaches, and/or hesitance about causing radiation toxicities and their subsequent effects on the patient's quality of life. Herein, we review the literature lending evidence to these arguments. We show recent series of ART/SRT and their low rates of acute and long-term toxicities, translating only in transient decline in quality-of-life (QoL) outcomes. We conclude that concerns with side effects should not preclude the recommendation of an effective and curative-intent therapy for men with prostate cancer initially treated with radical surgery.
Collapse
Affiliation(s)
- Hamid Raziee
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Alejandro Berlin
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| |
Collapse
|
17
|
Herranz-Amo F, Molina-Escudero R, Ogaya-Pinies G, Ramírez-Martín D, Verdú-Tartajo F, Hernández-Fernández C. Prediction of biochemical recurrence after radical prostatectomy. New tool for selecting candidates for adjuvant radiation therapy. Actas Urol Esp 2016; 40:82-7. [PMID: 26424411 DOI: 10.1016/j.acuro.2015.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 07/21/2015] [Accepted: 07/22/2015] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To design a risk summation to select patients for adjuvant radiation therapy after prostatectomy. MATERIALS AND METHOD A retrospective study was conducted on 629 patients with localised prostate cancer (pN0-pNx) who were treated with prostatectomy and with a prostate-specific antigen (PSA) value <0.2ng/mL at 2-3 months. Biochemical recurrence was defined as a PSA >0.4ng/mL. A multivariate Cox regression analysis was performed. A score (0-2) was assigned according to the hazard ratio of the significant variables. The score summation defined the risk summation. RESULTS A total of 19.7% of the patients were pT3, 24.2% had a Gleason score ≥ 8, and 26.3% had positive surgical margins. The median follow-up was 82 months. Some 26.6% of the patients experienced biochemical recurrence. The identified prognostic variables independent of biochemical recurrence were a Gleason score =7 (4+3) (HR, 2.01; P=.008), a Gleason score ≥ 8 (HR, 3.07; P <.001), a pT3b stage (HR, 1.93; p=.008) and a positive surgical margin (HR, 2.20; P<.001). We assigned 0 points to patients without risk prognosis variables; 1 point to patients with Gleason scores =7 (4+3), pT3b or positive surgical margins; and 2 points to patients with Gleason scores ≥ 8. The patients with a risk summation ≤ 2 had >50% survival free of biochemical recurrence at 5 and 8 years. In contrast, the patients with a risk summation ≥ 3 had <44% survival free of biochemical recurrence. CONCLUSION The patients with a risk summation ≤ 2 did not benefit from adjuvant radiation therapy, while the patients with a risk summation ≥ 3 might benefit from adjuvant radiation therapy.
Collapse
Affiliation(s)
- F Herranz-Amo
- Servicio de Urología, Hospital General Universitario Gregorio Marañón, Madrid, España.
| | - R Molina-Escudero
- Servicio de Urología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - G Ogaya-Pinies
- Servicio de Urología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - D Ramírez-Martín
- Servicio de Urología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - F Verdú-Tartajo
- Servicio de Urología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - C Hernández-Fernández
- Servicio de Urología, Hospital General Universitario Gregorio Marañón, Madrid, España
| |
Collapse
|
18
|
Arcangeli S, Ramella S, De Bari B, Franco P, Alongi F, D’Angelillo RM. A cast of shadow on adjuvant radiotherapy for prostate cancer: A critical review based on a methodological perspective. Crit Rev Oncol Hematol 2016; 97:322-7. [DOI: 10.1016/j.critrevonc.2015.09.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 08/14/2015] [Accepted: 09/29/2015] [Indexed: 10/22/2022] Open
|
19
|
Ku JY, Lee CH, Ha HK. Long-term oncologic outcomes of postoperative adjuvant versus salvage radiotherapy in prostate cancer: Systemic review and meta-analysis of 5-year and 10-year follow-up data. Korean J Urol 2015; 56:735-41. [PMID: 26568790 PMCID: PMC4643168 DOI: 10.4111/kju.2015.56.11.735] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 10/25/2015] [Indexed: 12/26/2022] Open
Abstract
PURPOSE To evaluate the oncologic outcomes between adjuvant radiotherapy (ART) and salvage radiotherapy (SRT) in patients with locally advanced prostate cancer or with adverse pathologic factors including positive surgical margin and high Gleason score. MATERIALS AND METHODS We searched the literature published from January 2000 until December 2014 at MEDLINE, PubMed, Web of Science, Embase, ProQuest, and Cochrane Library. To be specific, included were studies comparing ART and SRT settings if they followed up oncologic outcomes more than 5 years. RESULTS Overall, 3 retrospective, nonrandomized, observational studies, 1 matched control analysis, and 3 prospective randomized controlled studies met our inclusion criteria including a total of 2,380 patients (1,192 ART vs. 1,188 SRT). Higher favorable results were found in ART than in SRT was seen in the 5-year and 10-year biochemical recurrence (BCR)-free survival (risk ratio [RR], 0.61 and 0.70; 95% confidence interval [CI], 0.54-0.69 and 0.63-0.76). ART had a significantly higher 5-year progression-free survival rate than that in SRT (RR, 0.64; 95% CI, 0.51-0.80), but this was not the same for the 10-year progression-free survival rate (RR, 0.88; 95% CI, 0.72-1.08). There was no significant difference for the 5-year and 10-year overall survival rates between ART and SRT (RR, 0.80 and 0.94; 95% CI, 0.59-1.07 and 0.80-1.11). CONCLUSIONS ART showed favorable results in BCR-free survival during the 5-year follow-up period. However, the 10-year progression-free survival and overall survival did not show any difference between ART and SRT.
Collapse
Affiliation(s)
- Ja Yoon Ku
- Department of Urology, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Chan Ho Lee
- Department of Urology, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Hong Koo Ha
- Department of Urology, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| |
Collapse
|
20
|
Salomon L, Ploussard G, Hennequin C, Richaud P, Soulié M. Traitements complémentaires de la chirurgie du cancer de la prostate et chirurgie de la récidive. Prog Urol 2015; 25:1086-107. [DOI: 10.1016/j.purol.2015.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 08/06/2015] [Indexed: 10/22/2022]
|
21
|
Detti B, Bonomo P, Masi L, Doro R, Cipressi S, Iermano C, Bonucci I, Franceschini D, Di Brina L, Baki M, Simontacchi G, Meattini I, Carini M, Serni S, Nicita G, Livi L. CyberKnife stereotactic radiotherapy for isolated recurrence in the prostatic bed. World J Urol 2015; 34:311-7. [PMID: 26062525 DOI: 10.1007/s00345-015-1613-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 06/02/2015] [Indexed: 01/25/2023] Open
Abstract
PURPOSE To report a clinical experience of stereotactic body radiation therapy (SBRT) for isolated recurrence in the prostatic bed from prostate cancer. MATERIALS AND METHODS Between November 2011 and November 2013, 16 patients were treated with SBRT for a macroscopic isolated recurrence of prostate cancer in the prostatic bed. All patients were initially treated with radical prostatectomy, and half of them also received radiotherapy. Two schedules of SBRT were used: 30 Gy in 5 fractions in previously irradiated patients, 35 Gy in five fractions in radiotherapy-naïve patients. RESULTS At a median follow-up of 10 months (range 2-21 months), a significant biochemical response was found in all but one patient. At imaging evaluation, no local progression was noted: 10 patients showed partial response while four stable disease. At the moment of analysis, all 16 patients were alive. Seven of them experienced distant relapse, while nine maintained biochemical control, with no further therapy. Median time to relapse was 9.3 months (range 3-15.2 months). The treatment was well tolerated: One patient experienced G2 acute genitourinary and gastrointestinal toxicity. CONCLUSIONS Our experience shows that SBRT with CyberKnife for isolated nodal relapse is a safe and well-tolerated treatment.
Collapse
Affiliation(s)
- B Detti
- Radiotherapy Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Largo G.A. Brambilla 3, Florence, Italy
| | - P Bonomo
- Radiotherapy Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Largo G.A. Brambilla 3, Florence, Italy
| | - L Masi
- CyberKnife Center- I.F.C.A (Istituto Fiorentino di Cura ed Assistenza), University of Florence, Florence, Italy
| | - R Doro
- CyberKnife Center- I.F.C.A (Istituto Fiorentino di Cura ed Assistenza), University of Florence, Florence, Italy
| | - S Cipressi
- CyberKnife Center- I.F.C.A (Istituto Fiorentino di Cura ed Assistenza), University of Florence, Florence, Italy
| | - C Iermano
- CyberKnife Center- I.F.C.A (Istituto Fiorentino di Cura ed Assistenza), University of Florence, Florence, Italy
| | - I Bonucci
- CyberKnife Center- I.F.C.A (Istituto Fiorentino di Cura ed Assistenza), University of Florence, Florence, Italy
| | - D Franceschini
- Radiotherapy Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Largo G.A. Brambilla 3, Florence, Italy.
| | - L Di Brina
- Radiotherapy Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Largo G.A. Brambilla 3, Florence, Italy
| | - M Baki
- Radiotherapy Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Largo G.A. Brambilla 3, Florence, Italy
| | - G Simontacchi
- Radiotherapy Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Largo G.A. Brambilla 3, Florence, Italy
| | - I Meattini
- Radiotherapy Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Largo G.A. Brambilla 3, Florence, Italy
| | - M Carini
- Urology Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - S Serni
- Urology Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - G Nicita
- Urology Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - L Livi
- Radiotherapy Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Largo G.A. Brambilla 3, Florence, Italy
| |
Collapse
|
22
|
Hsu CC, Paciorek AT, Cooperberg MR, Roach M, Hsu ICJ, Carroll PR. Postoperative radiation therapy for patients at high-risk of recurrence after radical prostatectomy: does timing matter? BJU Int 2015; 116:713-20. [PMID: 25600860 DOI: 10.1111/bju.13043] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate among radical prostatectomy (RP) patients at high-risk of recurrence whether the timing of postoperative radiation therapy (RT) (adjuvant, early salvage with detectable post-RP prostate-specific antigen [PSA], or 'late' salvage with a PSA level of >1.0 ng/mL) is significantly associated with overall survival (OS), prostate-cancer specific survival or metastasis-free survival, in a longitudinal cohort. PATIENTS AND METHODS Of 6 176 RP patients in the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE), 305 patients with high-risk pathological features (margin positivity, Gleason score 8-10, or pT3-4) who underwent postoperative RT were examined, either in the adjuvant (≤6 months after RP with undetectable PSA levels, 76 patients) or salvage setting (>6 months after RP or pre-RT PSA level of >0.1 ng/mL, 229 patients). Early (PSA level of ≤1.0 ng/mL, 180 patients) or late salvage RT (PSA level >1.0 ng/mL, 49 patients) was based on post-RP, pre-RT PSA level. Multivariable Cox regression examined associations with all-cause mortality and prostate cancer-specific mortality and/or metastases (PCSMM). RESULTS After a median of 74 months after RP, 65 men had died (with 37 events of PCSMM). Adjuvant and salvage RT patients had comparable high-risk features. Compared with adjuvant, salvage RT (early or late) had an increased association with all-cause mortality (hazard ratio [HR] 2.7, P = 0.018) and with PCSMM (HR 4.0, P = 0.015). PCSMM-free survival differed by further stratification of timing, with 10-year estimates of 88%, 84%, and 71% for adjuvant, early salvage, and late salvage RT, respectively (P = 0.026). For PCSMM-free survival and OS, compared with adjuvant RT, late salvage RT had statistically significantly increased risk; however, early salvage RT did not. CONCLUSION This analysis suggests that patients who underwent early salvage RT with PSA levels of <1.0 ng/mL may have comparable metastasis-free survival and OS compared with adjuvant RT; however, late salvage RT with a PSA level of >1.0 ng/mL is associated with worse clinical outcomes.
Collapse
Affiliation(s)
- Charles C Hsu
- Department of Radiation Oncology, Helen Diller Family Comprehensive Cancer Center, University of California at San Francisco, San Francisco, CA, USA.,Department of Radiation Oncology, College of Medicine, University of Arizona, Tucson, AZ
| | - Alan T Paciorek
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California at San Francisco, San Francisco, CA, USA
| | - Matthew R Cooperberg
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California at San Francisco, San Francisco, CA, USA
| | - Mack Roach
- Department of Radiation Oncology, Helen Diller Family Comprehensive Cancer Center, University of California at San Francisco, San Francisco, CA, USA
| | - I-Chow J Hsu
- Department of Radiation Oncology, Helen Diller Family Comprehensive Cancer Center, University of California at San Francisco, San Francisco, CA, USA
| | - Peter R Carroll
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California at San Francisco, San Francisco, CA, USA
| |
Collapse
|
23
|
Adjuvant versus salvage radiation therapy for prostate cancer patients with adverse pathologic features: comparative analysis of long-term outcomes. Am J Clin Oncol 2015; 38:55-60. [PMID: 24051934 DOI: 10.1097/coc.0b013e318287bb6b] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To compare long-term outcomes of men with adverse pathologic features after adjuvant radiation therapy (ART) versus salvage radiation therapy (SRT) after radical prostatectomy at our institution. METHODS Patients treated with postprostatectomy radiation therapy with pT3 tumors, or pT2 with positive surgical margins, were identified. Cumulative freedom from biochemical failure (FFBF), freedom from metastatic failure (FFMF), and overall survival rates were estimated utilizing the Kaplan-Meier method. Multivariate analyses were performed to determine independent prognostic factors correlated with study endpoints. Propensity score analyses were performed to adjust for confounding because of nonrandom treatment allocation. RESULTS A total of 186 patients with adverse pathologic features treated with ART or SRT were identified. The median follow-up time after radical prostatectomy was 103 and 88 months after completion of radiation therapy. The Kaplan-Meier estimates for 10-year FFBF was 73% and 41% after ART and SRT, respectively (log-rank, P=0.0001). Ten-year FFMF was higher for patients who received ART versus SRT (98.6% vs. 80.9%, P=0.0028). On multivariate analyses there was no significant difference with respect to treatment group in terms of FFBF, FFMF, and overall survival after adjusting for propensity score. CONCLUSIONS Although unadjusted analyses showed improved FFBF with ART, the propensity score-adjusted analyses demonstrated that long-term outcomes of patients treated with ART and SRT do not differ significantly. These results, with decreased effect size of ART after adjusting for propensity score, demonstrate the potential impact of confounding on observational research.
Collapse
|
24
|
Den RB, Yousefi K, Trabulsi EJ, Abdollah F, Choeurng V, Feng FY, Dicker AP, Lallas CD, Gomella LG, Davicioni E, Karnes RJ. Genomic classifier identifies men with adverse pathology after radical prostatectomy who benefit from adjuvant radiation therapy. J Clin Oncol 2015; 33:944-51. [PMID: 25667284 PMCID: PMC4884273 DOI: 10.1200/jco.2014.59.0026] [Citation(s) in RCA: 159] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
PURPOSE The optimal timing of postoperative radiotherapy (RT) after radical prostatectomy (RP) is unclear. We hypothesized that a genomic classifier (GC) would provide prognostic and predictive insight into the development of clinical metastases in men receiving post-RP RT and inform decision making. PATIENTS AND METHODS GC scores were calculated from 188 patients with pT3 or margin-positive prostate cancer, who received post-RP RT at Thomas Jefferson University and Mayo Clinic between 1990 and 2009. The primary end point was clinical metastasis. Prognostic accuracy of the models was tested using the concordance index for censored data and decision curve analysis. Cox regression analysis tested the relationship between GC and metastasis. RESULTS The cumulative incidence of metastasis at 5 years after RT was 0%, 9%, and 29% for low, average, and high GC scores, respectively (P = .002). In multivariable analysis, GC and pre-RP prostate-specific antigen were independent predictors of metastasis (both P < .01). Within the low GC score (< 0.4), there were no differences in the cumulative incidence of metastasis comparing patients who received adjuvant or salvage RT (P = .79). However, for patients with higher GC scores (≥ 0.4), cumulative incidence of metastasis at 5 years was 6% for patients treated with adjuvant RT compared with 23% for patients treated with salvage RT (P < .01). CONCLUSION In patients treated with post-RP RT, GC is prognostic for the development of clinical metastasis beyond routine clinical and pathologic features. Although preliminary, patients with low GC scores are best treated with salvage RT, whereas those with high GC scores benefit from adjuvant therapy. These findings provide the first rational selection of timing for post-RP RT.
Collapse
Affiliation(s)
- Robert B Den
- Robert B. Den, Edouard J. Trabulsi, Adam P. Dicker, Costas D. Lallas, and Leonard G. Gomella, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Firas Abdollah, Vattikuti Urology Institute, Henry Ford Hospital, Detroit; Felix Y. Feng, University of Michigan, Ann Arbor, MI; R. Jeffrey Karnes, Mayo Clinic, Rochester, MN; and Kasra Yousefi, Voleak Choeurng, and Elai Davicioni, GenomeDx Biosciences, Vancouver, British Columbia, Canada.
| | - Kasra Yousefi
- Robert B. Den, Edouard J. Trabulsi, Adam P. Dicker, Costas D. Lallas, and Leonard G. Gomella, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Firas Abdollah, Vattikuti Urology Institute, Henry Ford Hospital, Detroit; Felix Y. Feng, University of Michigan, Ann Arbor, MI; R. Jeffrey Karnes, Mayo Clinic, Rochester, MN; and Kasra Yousefi, Voleak Choeurng, and Elai Davicioni, GenomeDx Biosciences, Vancouver, British Columbia, Canada
| | - Edouard J Trabulsi
- Robert B. Den, Edouard J. Trabulsi, Adam P. Dicker, Costas D. Lallas, and Leonard G. Gomella, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Firas Abdollah, Vattikuti Urology Institute, Henry Ford Hospital, Detroit; Felix Y. Feng, University of Michigan, Ann Arbor, MI; R. Jeffrey Karnes, Mayo Clinic, Rochester, MN; and Kasra Yousefi, Voleak Choeurng, and Elai Davicioni, GenomeDx Biosciences, Vancouver, British Columbia, Canada
| | - Firas Abdollah
- Robert B. Den, Edouard J. Trabulsi, Adam P. Dicker, Costas D. Lallas, and Leonard G. Gomella, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Firas Abdollah, Vattikuti Urology Institute, Henry Ford Hospital, Detroit; Felix Y. Feng, University of Michigan, Ann Arbor, MI; R. Jeffrey Karnes, Mayo Clinic, Rochester, MN; and Kasra Yousefi, Voleak Choeurng, and Elai Davicioni, GenomeDx Biosciences, Vancouver, British Columbia, Canada
| | - Voleak Choeurng
- Robert B. Den, Edouard J. Trabulsi, Adam P. Dicker, Costas D. Lallas, and Leonard G. Gomella, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Firas Abdollah, Vattikuti Urology Institute, Henry Ford Hospital, Detroit; Felix Y. Feng, University of Michigan, Ann Arbor, MI; R. Jeffrey Karnes, Mayo Clinic, Rochester, MN; and Kasra Yousefi, Voleak Choeurng, and Elai Davicioni, GenomeDx Biosciences, Vancouver, British Columbia, Canada
| | - Felix Y Feng
- Robert B. Den, Edouard J. Trabulsi, Adam P. Dicker, Costas D. Lallas, and Leonard G. Gomella, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Firas Abdollah, Vattikuti Urology Institute, Henry Ford Hospital, Detroit; Felix Y. Feng, University of Michigan, Ann Arbor, MI; R. Jeffrey Karnes, Mayo Clinic, Rochester, MN; and Kasra Yousefi, Voleak Choeurng, and Elai Davicioni, GenomeDx Biosciences, Vancouver, British Columbia, Canada
| | - Adam P Dicker
- Robert B. Den, Edouard J. Trabulsi, Adam P. Dicker, Costas D. Lallas, and Leonard G. Gomella, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Firas Abdollah, Vattikuti Urology Institute, Henry Ford Hospital, Detroit; Felix Y. Feng, University of Michigan, Ann Arbor, MI; R. Jeffrey Karnes, Mayo Clinic, Rochester, MN; and Kasra Yousefi, Voleak Choeurng, and Elai Davicioni, GenomeDx Biosciences, Vancouver, British Columbia, Canada
| | - Costas D Lallas
- Robert B. Den, Edouard J. Trabulsi, Adam P. Dicker, Costas D. Lallas, and Leonard G. Gomella, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Firas Abdollah, Vattikuti Urology Institute, Henry Ford Hospital, Detroit; Felix Y. Feng, University of Michigan, Ann Arbor, MI; R. Jeffrey Karnes, Mayo Clinic, Rochester, MN; and Kasra Yousefi, Voleak Choeurng, and Elai Davicioni, GenomeDx Biosciences, Vancouver, British Columbia, Canada
| | - Leonard G Gomella
- Robert B. Den, Edouard J. Trabulsi, Adam P. Dicker, Costas D. Lallas, and Leonard G. Gomella, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Firas Abdollah, Vattikuti Urology Institute, Henry Ford Hospital, Detroit; Felix Y. Feng, University of Michigan, Ann Arbor, MI; R. Jeffrey Karnes, Mayo Clinic, Rochester, MN; and Kasra Yousefi, Voleak Choeurng, and Elai Davicioni, GenomeDx Biosciences, Vancouver, British Columbia, Canada
| | - Elai Davicioni
- Robert B. Den, Edouard J. Trabulsi, Adam P. Dicker, Costas D. Lallas, and Leonard G. Gomella, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Firas Abdollah, Vattikuti Urology Institute, Henry Ford Hospital, Detroit; Felix Y. Feng, University of Michigan, Ann Arbor, MI; R. Jeffrey Karnes, Mayo Clinic, Rochester, MN; and Kasra Yousefi, Voleak Choeurng, and Elai Davicioni, GenomeDx Biosciences, Vancouver, British Columbia, Canada
| | - R Jeffrey Karnes
- Robert B. Den, Edouard J. Trabulsi, Adam P. Dicker, Costas D. Lallas, and Leonard G. Gomella, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Firas Abdollah, Vattikuti Urology Institute, Henry Ford Hospital, Detroit; Felix Y. Feng, University of Michigan, Ann Arbor, MI; R. Jeffrey Karnes, Mayo Clinic, Rochester, MN; and Kasra Yousefi, Voleak Choeurng, and Elai Davicioni, GenomeDx Biosciences, Vancouver, British Columbia, Canada
| |
Collapse
|
25
|
Kang JJ, Reiter RE, Steinberg ML, King CR. Ultrasensitive prostate specific antigen after prostatectomy reliably identifies patients requiring postoperative radiotherapy. J Urol 2014; 193:1532-8. [PMID: 25463990 DOI: 10.1016/j.juro.2014.11.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Integrating ultrasensitive prostate specific antigen with surveillance in patients at high risk after radical prostatectomy potentially optimizes treatment by correctly identifying recurrence, promoting an early salvage strategy and minimizing overtreatment. We tested the power of postoperative ultrasensitive prostate specific antigen to identify eventual biochemical failure. MATERIALS AND METHODS We identified 247 patients at high risk with a median followup of 44 months who underwent radical prostatectomy from 1991 to 2013. Each patient had extraprostatic extension and/or a positive margin. Surgical technique, initial prostate specific antigen, pathology findings and postoperative prostate specific antigen were analyzed. The ultrasensitive prostate specific antigen assay threshold was 0.01 ng/ml. Conventional biochemical relapse was defined as prostate specific antigen 0.2 ng/ml or greater. Kaplan-Meier and Cox multivariate analyses were done to compare the rates of ultrasensitive prostate specific antigen recurrence and conventional biochemical relapse. RESULTS Sensitivity analysis revealed that ultrasensitive prostate specific antigen 0.03 ng/ml or greater was the optimal threshold to identify recurrence. A first postoperative ultrasensitive value of 0.03 ng/ml or greater, Gleason grade, T stage, initial prostate specific antigen and margin status predicted conventional biochemical relapse. On multivariate analysis only a first postoperative ultrasensitive value of 0.03 ng/ml or greater, Gleason grade and T stage independently predicted conventional biochemical relapse. First postoperative ultrasensitive prostate specific antigen 0.03 ng/ml or greater conferred the highest risk (HR 8.5, p < 0.0001) and identified conventional biochemical relapse with greater sensitivity than undetectable first conventional prostate specific antigen (70% vs 46%). Any postoperative prostate specific antigen 0.03 ng/ml or greater captured all failures missed by the first postoperative value (100% sensitivity) with accuracy (96% specificity). Defining failure at an ultrasensitive value of 0.03 ng/ml or greater yielded a median lead time advantage of 18 months (mean 24) over the conventional definition of prostate specific antigen 0.2 ng/ml or greater. CONCLUSIONS Ultrasensitive prostate specific antigen 0.03 ng/ml or greater is an independent factor that identifies biochemical relapse more accurately than any traditional risk factors and confers a significant lead time advantage. This factor enables critical decisions on the timing of and indication for postoperative radiotherapy in patients at high risk after radical prostatectomy.
Collapse
Affiliation(s)
- Jung Julie Kang
- University of Los Angeles David Geffen School of Medicine, Los Angeles, California.
| | - Robert E Reiter
- Department of Urology, University of Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - Michael L Steinberg
- Department of Radiation Oncology, University of Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - Christopher R King
- Department of Radiation Oncology, University of Los Angeles David Geffen School of Medicine, Los Angeles, California
| |
Collapse
|
26
|
Su MZ, Kneebone AB, Woo HH. Adjuvant versus salvage radiotherapy following radical prostatectomy: do the AUA/ASTRO guidelines have all the answers? Expert Rev Anticancer Ther 2014; 14:1265-1270. [DOI: 10.1586/14737140.2014.972381] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
|
27
|
Sowerby RJ, Gani J, Yim H, Radomski SB, Catton C. Long-term complications in men who have early or late radiotherapy after radical prostatectomy. Can Urol Assoc J 2014; 8:253-8. [PMID: 25210549 DOI: 10.5489/cuaj.1764] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Choosing adjuvant radiotherapy (RT) or salvage RT after radical prostatectomy (RP) for locally advanced prostate cancer is controversial. Performing RT early after RP may increase the risk of urinary complications compared to RT performed later. We evaluated the urinary complication rates of men treated with surgery followed by early or late RT. METHODS Using a retrospective chart review, we compared rates of urinary incontinence (UI), bladder neck contracture (BNC), or urethral stricture in men with prostate cancer treated with early RT (<6 months after RP) or late RT (≥6 months after RP), 3 years after RT. RESULTS In total, 652 patients (between 2000 and 2007) underwent early RT (162, 24.8%) or late RT (490, 75.2%) after RP. The mean time to early RT was 3.6 months (range: 1-5 months) and to late RT was 30.1 months (range: 6-171 months). At 3 years post-RT, UI rates were similar in the early RT and the late RT groups (24.5% vs. 23.3%, respectively, p = 0.79). Prior to RT, 27/652 (4%) patients had a BNC and 11/652 (1.7%) had a urethral stricture, of which only 1 BNC persisted at 3 years post-RT. After RT, 17/652 (2.6%) BNC and 4/652 (0.6%) urethral stricture developed; of these, 6 BNC and 2 urethral strictures persisted at 3 years. CONCLUSION Rates of UI, BNC, and urethral stricture were similar with early and late RT at 3 years post-RT. These findings suggest that the timing of RT after RP does not alter the incidences of these urinary complications and can aid in the decision-making process regarding adjuvant RT versus salvage RT.
Collapse
Affiliation(s)
- Robert J Sowerby
- Division of Urology, Department of Surgery, Toronto Western Hospital and University of Toronto, Toronto, ON
| | - Johan Gani
- Department of Surgery, Austin Health, Victoria, Australia
| | - Harold Yim
- Division of Urology, Department of Surgery, Toronto Western Hospital and University of Toronto, Toronto, ON
| | - Sidney B Radomski
- Division of Urology, Department of Surgery, Toronto Western Hospital and University of Toronto, Toronto, ON
| | - Charles Catton
- Radiation Medicine Program, Princess Margaret Hospital and University of Toronto, Toronto, ON
| |
Collapse
|
28
|
Gandaglia G, Karakiewicz PI, Briganti A, Trudeau V, Trinh QD, Kim SP, Montorsi F, Nguyen PL, Abdollah F, Sun M. Early radiotherapy after radical prostatectomy improves cancer-specific survival only in patients with highly aggressive prostate cancer: validation of recently released criteria. Int J Urol 2014; 22:89-95. [PMID: 25141965 DOI: 10.1111/iju.12605] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 07/27/2014] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To test the effect of radiotherapy administered within 6 months after radical prostatectomy on cancer-specific mortality in prostate cancer patients after stratification according to a risk score. METHODS Overall, 7616 patients with pT3/4 N0/1 prostate cancer treated with radical prostatectomy between 1995 and 2009 within the Surveillance Epidemiology and End Results Medicare-linked database were included in the study. Competing-risks regression models were carried out to test the effect of early radiotherapy on cancer-specific mortality in the entire cohort, and after stratifying patients according to the risk score based on the number and nature of adverse pathological characteristics (Gleason score 8-10; pT3b/4, lymph node invasion). RESULTS The risk score was associated with increasing 5- and 10-year cancer-specific mortality rates (P < 0.001). When considering only patients with a risk score ≥ 2, 5- and 10-year cancer-specific mortality rates were significantly lower for individuals undergoing early radiotherapy compared with their counterparts not receiving early radiotherapy (2.9 and 6.9 vs 5.7 and 16.2%, respectively; P = 0.002). The corresponding number required to treat to prevent one death from prostate cancer at 10-year follow up was 10. Early radiotherapy was not associated with lower cancer-specific mortality rates overall and in patients with a risk score <2. This was confirmed in multivariable analyses, where early radiotherapy decreased the risk of cancer-specific mortality only in patients with a risk score ≥ 2 (P ≤ 0.02). CONCLUSIONS The presence of two or more of the following pathological features might be used to identify patients who benefit from early radiotherapy: Gleason score 8-10, pT3b/4 and lymph node invasion.
Collapse
Affiliation(s)
- Giorgio Gandaglia
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada; Department of Urology, Vita Salute San Raffaele University, Milan, Italy
| | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Chen C, Lin T, Zhou Y, Li D, Xu K, Li Z, Fan X, Zhong G, He W, Chen X, He X, Huang J. Adjuvant and salvage radiotherapy after prostatectomy: a systematic review and meta-analysis. PLoS One 2014; 9:e104918. [PMID: 25121769 PMCID: PMC4133270 DOI: 10.1371/journal.pone.0104918] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 07/11/2014] [Indexed: 12/31/2022] Open
Abstract
PURPOSE In men with adverse prognostic factors (APFs) after radical prostatectomy (RP), the most appropriate timing to administer radiotherapy remains a subject for debate. We conducted a systemic review and meta-analysis to evaluate the therapeutic strategies: adjuvant radiotherapy (ART) and salvage radiotherapy (SRT). MATERIALS AND METHODS We comprehensively searched PubMed, EMBASE, Web of Science and the Cochrane Library and performed the meta-analysis of all randomized controlled trials (RCTs) and retrospective comparative studies assessing the prognostic factors of ART and SRT. RESULTS Between May 1998 and July 2012, 2 matched control studies and 16 retrospective studies including a total of 2629 cases were identified (1404 cases for ART and 1185 cases for SRT). 5-year biochemical failure free survival (BFFS) for ART was longer than that for SRT (Hazard Ratio [HR]: 0.37; 95% CI, 0.30-0.46; p<0.00001, I(2) = 0%). 3-year BFFS was significantly longer in the ART (HR: 0.38; 95% CI, 0.28-0.52; p<0.00001, I(2) = 0%). Overall survival (OS) was also better in the ART (RR: 0.53; 95% CI, 0.41-0.68; p<0.00001, I(2) = 0%), as did disease free survival (DFS) (RR: 0.53; 95% CI, 0.43-0.66; p<0.00001, I(2) = 0%). Exploratory subgroup analysis and sensitivity analysis revealed the similar results with original analysis. CONCLUSION ART therapy offers a safe and efficient alternative to SRT with longer 3-year and 5-year BFFS, better OS and DFS. Our recommendation is to suggest ART for patients with APFs and may reduce the need for SRT. Given the inherent limitations of the included studies, future well-designed RCTs are awaited to confirm and update this analysis.
Collapse
Affiliation(s)
- Changhao Chen
- Department of Urology, Sun Yat-sen Memorial Hospital, Guangzhou, China
| | - Tianxin Lin
- Department of Urology, Sun Yat-sen Memorial Hospital, Guangzhou, China
| | - Yu Zhou
- Department of Hepatobiliary Surgery, Sun Yat-sen Memorial Hospital, Guangzhou, China
| | - Doudou Li
- Department of Oncology, Sun Yat-sen Memorial Hospital, Guangzhou, China
| | - Kewei Xu
- Department of Urology, Sun Yat-sen Memorial Hospital, Guangzhou, China
| | - Zhihua Li
- Department of Oncology, Sun Yat-sen Memorial Hospital, Guangzhou, China
| | - Xinxiang Fan
- Department of Urology, Sun Yat-sen Memorial Hospital, Guangzhou, China
| | - Guangzheng Zhong
- Department of Urology, Sun Yat-sen Memorial Hospital, Guangzhou, China
| | - Wang He
- Department of Urology, Sun Yat-sen Memorial Hospital, Guangzhou, China
| | - Xu Chen
- Department of Urology, Sun Yat-sen Memorial Hospital, Guangzhou, China
| | - Xianyin He
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Jian Huang
- Department of Urology, Sun Yat-sen Memorial Hospital, Guangzhou, China
| |
Collapse
|
30
|
Abstract
Positive surgical margins after radical prostatectomy Positive surgical margins (PSMs) in radical prostatectomy specimens are usually considered a negative prognostic parameter. However, their definition and the management of patients with PSMs remain unclear. The aim of the present review is to define pathological features of PSMs, to report their incidence and risk factors and to update PSMs prognostic meaning and possible treatment modalities. The average incidence of PSMs in contemporary series ranges from 6.5% to 32%. The likelihood of PSMs is influenced by pre-operative PSA (total-PSA and PSA-density), tumor features (volume, grade and stage), previous prostatic surgery (open or TURP), patients’ characteristics (BMI and pelvis shape) and surgeons’ skill. Although PSMs are a predictor of biochemical recurrence, their impact on cause specific survival is highly variable and largely influenced by the tumor Gleason Score. Adjuvant radiotherapy is an effective treatment in PSMs patients but early salvage radiotherapy may be an alternative option that guarantees equivalent survival benefits with less side effects. Further studies are required to define the best candidates to adjuvant or early salvage radiation therapy.
Collapse
|
31
|
Lohm G, Lütcke J, Jamil B, Höcht S, Neumann K, Hinkelbein W, Wiegel T, Bottke D. Salvage radiotherapy in patients with prostate cancer and biochemical relapse after radical prostatectomy. Strahlenther Onkol 2014; 190:727-31. [DOI: 10.1007/s00066-014-0612-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 01/30/2014] [Indexed: 11/24/2022]
|
32
|
Cormier L, Bastide C, Beuzeboc P, Fromont G, Hennequin C, Mongiat-Artus P, Peyromaure M, Ploussard G, Renard-Penna R, Richaud P, Rozet F, Soulié M, Salomon L. [Prostate cancer surgical margin: review by the CCAFU (Oncology Committee of the French Association of Urology)]. Prog Urol 2013; 24:334-45. [PMID: 24821555 DOI: 10.1016/j.purol.2013.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2013] [Revised: 10/27/2013] [Accepted: 11/11/2013] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Literature showed the impact of surgical margin status on prognosis after radical prostatectomy (mostly on biochemical survival). Margin status is an easy self-evaluation of surgical practice to assess. The aim of this paper was to define what a positive surgical margin (PSM) is and how to prevent the occurrence, to precise the impact on survival and how to treat. METHOD A literature analysis with Pubmed has been performed to 2012, furthermore conclusions of the main congresses with selection committee and review publication have also been studied. RESULTS PSM is defined as "tumor cells touching the ink on the specimen edge". The most frequent reported incidence is between 15 to 20%. Margin status remains one of the major criteria to determine the need of adjuvant radiotherapy after surgery. Quality of life is not or only lightly modified by radiotherapy with the current techniques. Adjuvant radiotherapy improves biological survival but is synonymous with overtreatment in many times. Salvage radiotherapy has to be quickly performed after Prostate Specific Antigen (PSA) relapse (PSA<1 ng/mL even<0.5 ng/mL). CONCLUSION This literature review did not allow to suggest superiority of one surgical technique over another. In the same way, the kind of dissection i.e. bladder neck or neurovascular bundle preservation does no clearly modify PSM rate. However, it seems logical to "customize" dissection according to prostate cancer characteristics (D'Amico criteria for instance) guided with multiparametric MRI. Intrafascial dissection has to be applied only to low risk. Lastly, the debate between adjuvant or salvage radiotherapy is always ongoing.
Collapse
Affiliation(s)
- L Cormier
- Sous-comité « prostate » du CCAFU, hôpital du Bocage, CHU de Dijon, 14, rue Gaffarel, BP 77908, 21079 Dijon cedex, France.
| | - C Bastide
- Sous-comité « prostate » du CCAFU, CHU de Marseille, 13015 Marseille, France.
| | - P Beuzeboc
- Sous-comité « prostate » du CCAFU, institut Curie, 75248 Paris, France.
| | - G Fromont
- Sous-comité « prostate » du CCAFU, CHU de Tours, 37044 Tours, France.
| | - C Hennequin
- Sous-comité « prostate » du CCAFU, CHU Saint-Louis, 75475 Paris, France.
| | - P Mongiat-Artus
- Sous-comité « prostate » du CCAFU, CHU Saint-Louis, 75475 Paris, France.
| | - M Peyromaure
- Sous-comité « prostate » du CCAFU, CHU de Cochin, 75014 Cochin, France.
| | - G Ploussard
- Sous-comité « prostate » du CCAFU, CHU Saint-Louis, 75475 Paris, France.
| | - R Renard-Penna
- Sous-comité « prostate » du CCAFU, CHU La Pitié, 75013 Paris, France.
| | - P Richaud
- Sous-comité « prostate » du CCAFU, institut Bergonié, 33076 Bordeaux, France.
| | - F Rozet
- Sous-comité « prostate » du CCAFU, institut Monstsouris, 75014 Paris, France.
| | - M Soulié
- Sous-comité « prostate » du CCAFU, CHU de Toulouse, 31403 Toulouse, France.
| | - L Salomon
- Sous-comité « prostate » du CCAFU, CHU Mondor, 94010 Paris, France.
| | | |
Collapse
|
33
|
Bartkowiak D, Bottke D, Wiegel T. Radiotherapy in the management of prostate cancer after radical prostatectomy. Future Oncol 2013; 9:669-79. [PMID: 23647296 DOI: 10.2217/fon.13.3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The choice of treatment options for prostate cancer patients who have undergone radical prostatectomy depends on their risk profile, which is determined by the tumor node metastasis (TNM) status, histopathologic findings, and the pre- and post-radical prostatectomy PSA characteristics. The results of large clinical studies with a 10-year follow-up or more are the backbone of predictive models for risk estimates that incorporate these criteria and also for guideline recommendations. For low-to-intermediate-risk prostate cancer patients and older patients, observation with--in case of biochemical recurrence--early salvage radiotherapy can be advised after R0 resection, thus, avoiding overtreatment. After R1 resection, adjuvant radiotherapy should be considered. Patients with two or more positive lymph nodes and/or with distant metastasis may benefit from adjuvant hormone deprivation therapy. Beyond this rough outline, detailed analysis of subgroups is still required (and ongoing) to enable individually optimized treatment.
Collapse
Affiliation(s)
- Detlef Bartkowiak
- Radiation Oncology Department, University Hospital Ulm, Ulm, Germany.
| | | | | |
Collapse
|
34
|
Identifying Appropriate Patients for Early Salvage Radiotherapy after Prostatectomy. J Urol 2013; 190:1410-5. [DOI: 10.1016/j.juro.2013.04.078] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2013] [Indexed: 11/15/2022]
|
35
|
Ploussard G, Catto JW. The quest for an optimal definition of prostate-specific antigen failure following radical prostatectomy: the risk of not seeing the forest for the trees. Eur Urol 2013; 66:211-3. [PMID: 24075576 DOI: 10.1016/j.eururo.2013.09.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2013] [Accepted: 09/11/2013] [Indexed: 11/18/2022]
Affiliation(s)
- Guillaume Ploussard
- Department of Urology, Saint-Louis Hospital, Assistance Publique Hopitaux de Paris, Paris, France.
| | - James W Catto
- Academic Urology Unit and Academic Unit of Molecular Oncology, The Medical School, University of Sheffield, Sheffield, UK
| |
Collapse
|
36
|
Zaorsky NG, Trabulsi EJ, Lin J, Den RB. Multimodality therapy for patients with high-risk prostate cancer: current status and future directions. Semin Oncol 2013; 40:308-21. [PMID: 23806496 DOI: 10.1053/j.seminoncol.2013.04.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Prostate cancer is the most commonly diagnosed cancer and second most common cause of cancer death in American men. Although high-risk disease accounts for less than 15% of diagnoses, high-risk prostate cancer patients have a cancer-specific mortality rate of 15% at 10 years. There is currently no consensus on the optimal management of high-risk disease because (1) there are different primary modalities available (ie, surgery, radiation), for which there are no randomized trials comparing efficacy; and (2) unstandardized timing of different therapies (ie, neoadjuvant v concurrent v adjuvant), which makes comparisons of efficacy problematic. Increased understanding into the mechanisms leading to the formation of advanced metastatic disease has spurred the development of agents to target these pathways. However, new questions regarding optimal management of disease arise with regard to the role of these therapies in combination with "conventional" primary modalities for earlier stage, high-risk prostate cancer patients. In this article, we review the transforming world of multimodality therapy in high-risk prostate cancer.
Collapse
Affiliation(s)
- Nicholas G Zaorsky
- Department of Radiation Oncology, Kimmel Cancer Center, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
| | | | | | | |
Collapse
|
37
|
Pfister D, Bolla M, Briganti A, Carroll P, Cozzarini C, Joniau S, van Poppel H, Roach M, Stephenson A, Wiegel T, Zelefsky MJ. Early salvage radiotherapy following radical prostatectomy. Eur Urol 2013; 65:1034-43. [PMID: 23972524 DOI: 10.1016/j.eururo.2013.08.013] [Citation(s) in RCA: 147] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 08/06/2013] [Indexed: 12/17/2022]
Abstract
CONTEXT Depending on the pathologic tumour stage, up to 60% of prostate cancer patients who undergo radical prostatectomy will develop biochemical relapse and require further local treatment. OBJECTIVES We reviewed the results of early salvage radiation therapy (RT), defined as prostate-specific antigen (PSA) values prior to RT ≤ 0.5 ng/ml in the setting of lymph node-negative disease. EVIDENCE ACQUISITION Ten retrospective studies, including one multicentre analysis, were used for this analysis. Among them, we received previously unpublished patient characteristics and updated outcome data from five retrospective single-centre trials to perform a subgroup analysis for early salvage RT. EVIDENCE SYNTHESIS Patients treated with early salvage RT have a significantly improved biochemical recurrence-free survival (BRFS) rate compared with those receiving salvage RT initiated after PSA values are >0.5 ng/ml. Similarly, within the cohort of patients with pre-RT PSA values <0.5 ng/ml, improved BRFS rates were noted among those with lower rather higher pre-RT PSA levels. It is possible that higher RT dose levels and the use of adjunctive androgen-deprivation therapy improve biochemical control outcomes in the salvage setting. CONCLUSIONS Based on a literature review, improved 5-yr BRFS rates are observed for patients who receive early salvage RT compared with patients treated with salvage RT with a pre-RT PSA value >0.5 ng/ml. Whether the routine application of early salvage RT in patients with initially undetectable PSA levels will be associated with demonstrable clinical benefit awaits the results of ongoing prospective trials.
Collapse
Affiliation(s)
- David Pfister
- Department of Urology, RWTH Aachen University, Aachen, Germany.
| | - Michel Bolla
- Department of Radiation Oncology, Centre Hospitalier Universitaire A Michallon, Grenoble, France
| | - Alberto Briganti
- Department of Urology, Università Vita-Salute San Raffaele, Milan, Italy
| | - Peter Carroll
- Department of Urology and Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA
| | - Cesare Cozzarini
- Department of Radiotherapy, San Raffaele Scientific Institute, Milan, Italy
| | - Steven Joniau
- Department of Urology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Hein van Poppel
- Department of Urology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Mack Roach
- Department of Radiation Oncology and Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA
| | - Andrew Stephenson
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Thomas Wiegel
- Department of Radiation Oncology, University Hospital, Ulm, Germany
| | - Michael J Zelefsky
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| |
Collapse
|
38
|
Yossepowitch O, Briganti A, Eastham JA, Epstein J, Graefen M, Montironi R, Touijer K. Positive surgical margins after radical prostatectomy: a systematic review and contemporary update. Eur Urol 2013; 65:303-13. [PMID: 23932439 DOI: 10.1016/j.eururo.2013.07.039] [Citation(s) in RCA: 265] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2013] [Accepted: 07/25/2013] [Indexed: 02/03/2023]
Abstract
CONTEXT The clinical significance of positive surgical margins (PSMs) in radical prostatectomy (RP) specimens and the management of affected patients remain unclear. OBJECTIVE To address pitfalls in the pathologic interpretation of margin status; provide an update on the incidence, predictors, and long-term oncologic implications of PSMs in the era of robot-assisted laparoscopic RP (RALRP); and suggest a practical evidence-based approach to patient management. EVIDENCE ACQUISITION A systematic review of the literature was performed in April 2013 using Medline/PubMed, Web of Science, and Scopus databases and the Cochrane Database of Systematic Reviews. Studies focusing on PSMs in RP pertinent to the objectives of this review were included. Particular attention was paid to publications within the last 5 yr and those concerning RALRP. EVIDENCE SYNTHESIS A total of 74 publications were retrieved. Standardized measures to overcome variability in the pathologic interpretation of surgical margins have recently been established by the International Society of Urological Pathology. The average rate of PSMs in contemporary RALRP series is 15% (range: 6.5-32%), which is higher in men with a more advanced pathologic stage and equivalent to the rate reported in prior open and laparoscopic prostatectomy series. The likelihood of PSMs is strongly influenced by the surgeon's experience irrespective of the surgical approach. Technical modifications using the robotic platform and the role of frozen-section analysis to reduce the margin positivity rate continue to evolve. Positive margins are associated with a twofold increased hazard of biochemical relapse, but their association with more robust clinical end points is controversial. Level 1 evidence suggests that adjuvant radiation therapy (RT) may favorably affect prostate-specific antigen recurrence rates, but whether the therapy also affects systemic progression, prostate cancer-specific mortality, and overall survival remains debatable. CONCLUSIONS Although positive margins in prostate cancer are considered an adverse oncologic outcome, their long-term impact on survival is highly variable and largely influenced by other risk modifiers. Adjuvant RT appears to be effective, but further study is required to determine whether early salvage RT is an equivalent alternative.
Collapse
Affiliation(s)
- Ofer Yossepowitch
- Department of Urology, Rabin Medical Center, Petach-Tikva, Israel, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Alberto Briganti
- Department of Urology, Università Vita Salute San Raffaele, Milan, Italy
| | - James A Eastham
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Jonathan Epstein
- Department of Pathology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Markus Graefen
- Martini Clinic, Prostate Cancer Center, University of Hamburg, Hamburg, Germany
| | - Rodolfo Montironi
- Section of Pathological Anatomy, Polytechnic University of the Marche Region, Ancona, Italy
| | - Karim Touijer
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| |
Collapse
|
39
|
Swanson GP, Lerner SP. Positive margins after radical prostatectomy: Implications for failure and role of adjuvant treatment. Urol Oncol 2013; 31:531-41. [DOI: 10.1016/j.urolonc.2011.06.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Revised: 05/20/2011] [Accepted: 06/13/2011] [Indexed: 11/29/2022]
|
40
|
Adjuvant radiotherapy or early salvage radiotherapy in pT3R0 or pT3R1 prostate cancer. Curr Opin Urol 2013; 23:360-5. [DOI: 10.1097/mou.0b013e328361d3ed] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
|
41
|
Chin JL. Following radical prostatectomy, to beam or not to beam? Eur Urol 2013; 64:565-6. [PMID: 23623480 DOI: 10.1016/j.eururo.2013.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 04/11/2013] [Indexed: 12/01/2022]
|
42
|
Chin JL. Salvage versus adjuvant radiotherapy after radical prostatectomy: argument for adjuvant radiotherapy. Can Urol Assoc J 2013; 3:241-244. [PMID: 19543472 DOI: 10.5489/cuaj.1081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Joseph L Chin
- Professor and Chair, Division of Surgical Oncology, University of Western Ontario, London, Ont
| |
Collapse
|
43
|
|
44
|
Agoua N, Vian E, Dumoulin M, Blanchet P. Résultats de la radiothérapie de rattrapage pour récidive biologique après prostatectomie radicale dans la population africaine-caribéene de la Guadeloupe. Prog Urol 2013; 23:128-36. [DOI: 10.1016/j.purol.2012.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2012] [Revised: 08/09/2012] [Accepted: 09/09/2012] [Indexed: 10/27/2022]
|
45
|
Bolla M, van Poppel H, Tombal B, Vekemans K, Da Pozzo L, de Reijke TM, Verbaeys A, Bosset JF, van Velthoven R, Colombel M, van de Beek C, Verhagen P, van den Bergh A, Sternberg C, Gasser T, van Tienhoven G, Scalliet P, Haustermans K, Collette L. Postoperative radiotherapy after radical prostatectomy for high-risk prostate cancer: long-term results of a randomised controlled trial (EORTC trial 22911). Lancet 2012; 380:2018-27. [PMID: 23084481 DOI: 10.1016/s0140-6736(12)61253-7] [Citation(s) in RCA: 639] [Impact Index Per Article: 53.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND We report the long-term results of a trial of immediate postoperative irradiation versus a wait-and-see policy in patients with prostate cancer extending beyond the prostate, to confirm whether previously reported progression-free survival was sustained. METHODS This randomised, phase 3, controlled trial recruited patients aged 75 years or younger with untreated cT0-3 prostate cancer (WHO performance status 0 or 1) from 37 institutions across Europe. Eligible patients were randomly assigned centrally (1:1) to postoperative irradiation (60 Gy of conventional irradiation to the surgical bed for 6 weeks) or to a wait-and-see policy until biochemical progression (increase in prostate-specific antigen >0·2 μg/L confirmed twice at least 2 weeks apart). We analysed the primary endpoint, biochemical progression-free survival, by intention to treat (two-sided test for difference at α=0.05, adjusted for one interim analysis) and did exploratory analyses of heterogeneity of effect. This trial is registered with ClinicalTrials.gov, number NCT00002511. FINDINGS 1005 patients were randomly assigned to a wait-and-see policy (n=503) or postoperative irradiation (n=502) and were followed up for a median of 10·6 years (range 2 months to 16·6 years). Postoperative irradiation significantly improved biochemical progression-free survival compared with the wait-and-see policy (198 [39·4%] of 502 patients in postoperative irradiation group vs 311 [61·8%] of 503 patients in wait-and-see group had biochemical or clinical progression or died; HR 0·49 [95% CI 0·41-0·59]; p<0·0001). Late adverse effects (any type of any grade) were more frequent in the postoperative irradiation group than in the wait-and-see group (10 year cumulative incidence 70·8% [66·6-75·0] vs 59·7% [55·3-64·1]; p=0.001). INTERPRETATION Results at median follow-up of 10·6 years show that conventional postoperative irradiation significantly improves biochemical progression-free survival and local control compared with a wait-and-see policy, supporting results at 5 year follow-up; however, improvements in clinical progression-free survival were not maintained. Exploratory analyses suggest that postoperative irradiation might improve clinical progression-free survival in patients younger than 70 years and in those with positive surgical margins, but could have a detrimental effect in patients aged 70 years or older. FUNDING Ligue Nationale contre le Cancer (Comité de l'Isère, Grenoble, France) and the European Organisation for Research and Treatment of Cancer (EORTC) Charitable Trust.
Collapse
Affiliation(s)
- Michel Bolla
- Department of Radiation Oncology, Centre Hospitalier Universitaire A Michallon, Grenoble, France.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
CORTÉS-GONZÁLEZ JEFFR, CASTELLANOS ENRIQUE, SANDBERG KATINKA, ERIKSSON MARIEHJELM, WIKLUND PETER, CARLSSON STEFAN, COHN-CEDERMARK GABRIELLA, HARMENBERG ULRIKA, GUSTAFSSON OVE, LEVITT SEYMOURH, LENNERNÄS BO, BRANDBERG YVONNE, MÁRQUEZ MARCELA, KÄLKNER KARLMIKAEL, NILSSON STEN. Early salvage radiation therapy combined with short-term hormonal therapy in recurrent prostate cancer after radical prostatectomy: Single-institution 4-year data on outcome, toxicity, health-related quality of life and co-morbidities from 184 consecutive patients treated with 70 Gy. Int J Oncol 2012; 42:109-17. [DOI: 10.3892/ijo.2012.1694] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Accepted: 06/21/2012] [Indexed: 11/12/2022] Open
|
47
|
Radiotherapy after radical prostatectomy: immediate or early delayed? Strahlenther Onkol 2012; 188:1096-101. [DOI: 10.1007/s00066-012-0234-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 09/17/2012] [Indexed: 11/25/2022]
|
48
|
Detti B, Scoccianti S, Cassani S, Cipressi S, Villari D, Lapini A, Saieva C, Cai T, Pertici M, Giacomelli I, Livi L, Ceroti M, Nicita G, Carini M, Biti G. Adjuvant and salvage radiotherapy after prostatectomy: outcome analysis of 307 patients with prostate cancer. J Cancer Res Clin Oncol 2012; 139:147-57. [PMID: 22986810 DOI: 10.1007/s00432-012-1309-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 09/03/2012] [Indexed: 11/29/2022]
Abstract
AIM In men with adverse pathology after radical prostatectomy, the most appropriate timing to administer radiotherapy (RT) remains a topic of debate. We analyzed in terms of efficacy, prognostic factors and toxicity the two therapeutic strategies: immediate postoperative radiotherapy (PORT) and salvage radiotherapy (SART). MATERIALS AND METHODS Between January 1995 and November 2010, 307 patients underwent adjuvant or salvage radiotherapy, after prostatectomy. RESULTS In the PORT group, 42 patients (20.7 %) had biochemical failure, with a median time to biochemical failure of 1.8 years; two parameters (age at diagnosis and PSA pre-RT) resulted to be significant at the survival analysis for overall survival (p = 0.003 and p = 0.046, respectively). In the SART group, 33 patients (31.7 %) had biochemical relapse; sixteen patients died of prostate cancer; postoperative hormones therapy, conformal radiotherapy and level of PSA pre-RT >1.0 ng/ml resulted to be significant at the survival analysis, p = 0.009, p = 0.039 and p = 0.002, respectively. CONCLUSION Our study is limited by its retrospective and nonrandomized design. As such, decisions to treat with adjuvant or salvage radiotherapy and the time to initiate therapy were based on patient preference and physician counseling. Our recommendation is to suggest adjuvant radiotherapy for all patients with adverse prognostic factors and to reserve salvage radiotherapy for low-risk patients, when the biochemical recurrence occurs.
Collapse
Affiliation(s)
- Beatrice Detti
- Radioterapia, Azienda Ospedaliero-Universitaria di Careggi, Viale Morgagni 85, 50144 Florence, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
King CR. The Timing of Salvage Radiotherapy After Radical Prostatectomy: A Systematic Review. Int J Radiat Oncol Biol Phys 2012; 84:104-11. [DOI: 10.1016/j.ijrobp.2011.10.069] [Citation(s) in RCA: 180] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Revised: 09/23/2011] [Accepted: 10/28/2011] [Indexed: 12/20/2022]
|
50
|
Briganti A, Wiegel T, Joniau S, Cozzarini C, Bianchi M, Sun M, Tombal B, Haustermans K, Budiharto T, Hinkelbein W, Di Muzio N, Karakiewicz PI, Montorsi F, Van Poppel H. Early salvage radiation therapy does not compromise cancer control in patients with pT3N0 prostate cancer after radical prostatectomy: results of a match-controlled multi-institutional analysis. Eur Urol 2012; 62:472-87. [PMID: 22633803 DOI: 10.1016/j.eururo.2012.04.056] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2012] [Accepted: 04/26/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Previous randomised trials demonstrated that adjuvant radiation therapy (aRT) improves cancer control in patients with pT3 prostate cancer (PCa). However, there is currently no evidence supporting early salvage radiation therapy (eSRT) as equivalent to aRT in improving freedom from biochemical recurrence (BCR) after radical prostatectomy (RP). OBJECTIVE To evaluate BCR-free survival for aRT versus observation followed by eSRT in cases of relapse in patients undergoing RP for pT3pN0, R0-R1 PCa. DESIGN, SETTING, AND PARTICIPANTS Using a European multi-institutional cohort, 890 men with pT3pN0, R0-R1 PCa were identified. INTERVENTION All patients underwent RP. Subsequently, patients were stratified into two groups: aRT versus initial observation followed by eSRT in cases of relapse. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES: Propensity-matched analysis was employed, and patients were stratified into two groups: aRT versus observation and eventual eSRT, defined as RT given at a postoperative serum prostate-specific antigen (PSA) ≤ 0.5 ng/ml at least 6 mo after RP. BCR, defined as PSA >0.20 ng/ml and rising after administration of RT, was compared between aRT and initial observation followed by eSRT in cases of relapse using Kaplan-Meier and Cox regression methods. RESULTS AND LIMITATIONS Overall, 390 (43.8%) and 500 (56.2%) patients were treated with aRT and initial observation, respectively. Within the latter group, 225 (45.0%) patients experienced BCR and underwent eSRT. In the postpropensity-matched cohort, the 2- and 5-yr BCR-free survival rates were 91.4% and 78.4% in aRT versus 92.8% and 81.8% in patients who underwent initial observation and eSRT in cases of relapse, respectively (p=0.9). No differences in the 2- and 5-yr BCR-free survival rates were found, even when patients were stratified according to pT3 substage and surgical margin status (all p ≥ 0.4). These findings were also confirmed in multivariable analyses (p=0.6). Similar results were achieved when the cut-off to define eSRT was set at 0.3 ng/ml (all p ≥ 0.5). CONCLUSIONS The current study suggests that timely administration of eSRT is comparable to aRT in improving BCR-free survival in the majority of pT3pN0 PCa patients. Therefore, eSRT may not compromise cancer control but significantly reduces overtreatment associated with aRT.
Collapse
Affiliation(s)
- Alberto Briganti
- Department of Urology, Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|