Is long-term survival possible with external beam irradiation for stage D1 adenocarcinoma of the prostate?

Role of radiation therapy for the treatment of lymph nodes in urologic malignancies

Radiation therapy (RT) represents an important therapeutic component in the management of genitourinary (GU) malignancies. RT is used to treat patients with proven involvement of the regional lymph nodes or delivered electively to patients at risk for occult regional lymph node metastases. Advances in treatment planning and delivery of various types of RT provide the technology to precisely plan, target, and deliver RT with the goal of optimizing the radiation dose to the target while sparing normal tissue. This article provides an overview of the modalities, indications, and techniques of RT for treatment of the lymphatic basins in GU malignancies.

Lack of survival benefit of post-operative radiation therapy in prostate cancer patients with positive lymph nodes

Randomized data from SWOG 8794 and EORTC 22911 confirm the benefit of post-operative radiation therapy (RT) for selected patients with pT3 prostate cancer (CaP) after radical prostatectomy (RP). However, data regarding the potential benefit of RT for patients post-RP with positive lymph node (+LN) involvement are limited. We analyzed the Surveillance Epidemiology End Results (SEER) registry for population-based data on efficacy of post-operative RT for +LN patients after RP. As LN data have only been captured by SEER since 1988, we analyzed data for 1988-1992, with specific attention to 10-year relative survival (defined as observed survival divided by the survival of a gender-, age- and race-matched population cohort without disease). Specifically analyzed were data for 1921 patients with nonmetastatic prostate cancer who underwent surgery alone, or surgery followed by RT, and who had +LNs documented. SEER does not code the interval between surgery and RT, so the ratio of patients receiving salvage versus adjuvant therapy is unknown. Using follow-up data through 2002, post-diagnosis survival was examined by number of +LNs. There was no significant relative survival benefit for +LN patients receiving post-operative RT (chi(2)P=0.270). These data do not support routine use of post-operative RT for patients with +LNs in the surgical specimen.

Treatment options in lymph node-positive prostate cancer

With improved awareness and screening, the incidence of lymph node-positive prostate cancer has declined dramatically over the last 50 years. Stage of cancer, prostate-specific antigen, and grade are risk factors for positive lymph nodes; and those factors, along with the number of involved lymph nodes, are prognostic factors for outcome. Although the numbers have declined, the number of men with lymph node-positive prostate cancer remains significant, and the current challenge is how best to treat these patients. Commonly used treatments include any combination of androgen ablation, surgery, and radiation. There have been a few studies with chemotherapy, and no treatment has been proven superior to the others. Consequently, there remain several reasonable alternatives to treatment, and long-term survival is not unusual.

Long-term use of combined radiation therapy and hormonal therapy in the management of stage D1 prostate cancer

PURPOSE

To determine tumor response, patterns of relapse, and prognostic indicators in patients followed long-term after combined hormonal radiation therapy of adenocarcinoma of the prostate in men with tumor metastatic to pelvic lymph nodes.

METHODS AND MATERIALS

Seventy-nine patients with adenocarcinoma of the prostate with pathologically confirmed pelvic lymph node metastases were treated with combined radiation therapy and hormonal therapy. Of these, 55 patients (70%) had T3 disease, with the remainder having earlier-stage disease; 45 (57%) patients had N2 disease (Whitmore-Jewett staging). No distant metastases were detected at initial staging, and no patient had radiographic or pathologic involvement of the para-aortic nodes. Pelvic lymph nodes were irradiated to a dose 45-54 Gy, and the prostate was irradiated to a dose 65-71.8 Gy. Hormonal therapy began up to 2 months before radiation and continued indefinitely. Patients were allowed to select their hormonal therapy and could choose diethylstilbestrol (DES) (2 patients), orchiectomy (21 patients), luteinizing hormone-releasing hormone agonist (12 patients), or combined androgen blockade (44 patients). Prognostic factors examined included microscopic vs. measurable lymph node involvement, one-sided vs. two-sided disease, T stage, pretreatment PSA, method of androgen blockade, and Gleason score. Log-rank analysis was used to determine statistical significance with respect to overall survival, disease-free survival, clinical freedom from progression, and biochemical freedom from progression; Cox multivariate analysis was employed to determine potential confounders.

RESULTS

Median follow-up was 6.7 years. There were 25 recurrences among the 79 patients, including 7 biochemical recurrences without clinical evidence of disease, three local recurrences in the prostate, and distant metastases in 14 patients; 2 patients were deceased, with cause of death listed as prostate cancer, though the location of recurrence was unknown. Patients with biochemical failure before 5 years were more likely to fail distantly, 16% vs. 4% (p < 0.001). Overall actuarial survival at 5, 8, and 12 years was 86%, 72%, and 53%, respectively, whereas actuarial disease-free survival was 90%, 87%, and 81%. Ten patients died of intercurrent disease; these included 4 patients who died of a separate (nonpelvic) malignancy of nonadenocarcinomatous histology with no elevation in PSA. When the potential prognostic variables were examined, a trend toward increased biochemical recurrence in patients with Gleason score >or=8 was observed; this became statistically significant when the 4 patients with known residual lymph node disease after biopsy were excluded (p < 0.03). Gleason score remained the only significant indicator on multivariate analysis. A single long-term toxic event, recto-ureteral fistula, was observed.

CONCLUSION

Combined hormonal and radiation therapy continues to represent an effective treatment option for patients with adenocarcinoma of the prostate with metastasis confined to pelvic lymph nodes. All patient groups seem to have a better disease-free survival than that reported previously in single-modality hormone or radiation treatment series. There is a suggestion that patients with lower Gleason score have a lower risk for recurrence. Combined modality therapy may also extend disease-free survival and allow patients to maintain independent function.

Lymph node-positive prostate cancer: evaluation of the results of the combination of androgen deprivation therapy and radiation therapy

OBJECTIVE

To evaluate the outcome of patients with pathologic stage IV prostate cancer treated with androgen ablation plus external-beam radiation therapy.

PATIENTS AND METHODS

Sixty consecutive patients treated between August 1986 and February 1995 with androgen ablation plus radiation therapy for stage IV (T1-4 N1 M0) adenocarcinoma of the prostate were selected for outcome analysis in this retrospective study. Bilateral pelvic lymphadenectomy was performed in 56 patients (93%). The 4 remaining patients had pelvic adenopathy on computed tomography, which was confirmed histologically in all patients. The median pretreatment prostate-specific antigen (PSA) level was 28.8 ng/mL (mean, 55 ng/ mL; range, 0.1-428 ng/mL). All patients received radiation therapy to the prostate, and 29 (48%) had pelvic node radiation. Biochemical failure was defined according to the American Society for Therapeutic Radiology and Oncology criteria of 3 successive increases in the PSA level.

RESULTS

The median follow-up duration for surviving patients was 101.1 months (range, 20-134 months). Biochemical failure with (in 2 patients) or without (in 10 patients) clinically evident disease relapse was noted in 12 patients (20%). Four additional patients (7%) had clinical relapse without biochemical failure. Local recurrences were observed in 6 patients (10%), and this clinical impression was confirmed by biopsy in 4 patients. Thirteen patients (22%) died of causes related to prostate cancer. The biochemical relapse-free, clinical disease-free, overall, and cause-specific survival rates at 5 years were 82%, 84%, 76%, and 80%, respectively.

CONCLUSIONS

This observational case series of patients treated with the combination of external-beam radiation therapy and permanent androgen ablation for pathologic stage IV prostate cancer suggests that the addition of androgen deprivation therapy to radiation therapy may improve disease outcome. In the absence of randomized trial results, these observations may be beneficial in clinical decision making.

Cancer volume of lymph node metastasis predicts progression in prostate cancer

Clinical outcome is variable in prostate cancer patients with regional lymph node metastasis. We studied 269 patients who had regional lymph node metastasis at the time of radical retropubic prostatectomy and bilateral pelvic lymphadenectomy at the Mayo Clinic between January 1987 and December 1992. Two hundred fifty-three (94%) patients received androgen deprivation therapy within 90 days of radical prostatectomy. Patients ranged in age from 47 to 79 years (median, 67 years). Median follow-up was 6.1 years (range, 0.3-10.5 years). Nodal cancer volume (size) was measured by the grid-counting method. Cox proportional hazards models were used to determine the impact of numerous clinical and pathologic findings on systemic progression-free survival. Systemic progression was defined as the presence of distant metastasis documented by biopsies or radiographic examinations (abdominal computerized tomography, plain radiographs, or bone scan). Five-year progression-free survival was 90%. In predicting systemic progression using Cox multivariate analysis, only nodal cancer volume added significantly to the model containing the primary cancer variables (Gleason score, cancer volume, and DNA ploidy). The relative hazard rate for a doubling in nodal cancer volume was 1.6 (95% confidence interval, 1.3 to 2.0; p < 0.0001). Spearman rank analysis showed a correlation between nodal cancer volume and Gleason score of the primary cancer, the number of positive nodes, the aggregate length of metastases, and the largest nodal cancer diameter (correlation efficient = 0.37, 0.63, 0.96, and 0.95, respectively). Our data indicate that nodal cancer volume was the most significant nodal determinant of progression to distant metastasis in lymph node-positive prostate cancer patients. We recommend that the diameter of the largest metastasis be evaluated in patients with metastases, because this is a more powerful predictor of patient outcome than current methods, which recommend mere counting of the number of positive nodes.

[Locally advanced prostate carcinoma (T2b-T4 N0) without and with clinical evidence of local progression (Tx N+) with lymphatic metastasis. Is radiotherapy for pelvic lymphatic metastasis indicated or not?]

BACKGROUND

There is a greater controversy regarding the indication of radiotherapy of the pelvic lymphatics in patients with suspected lymph node metastases in locally advanced prostate cancer (T2b-4 N0) on the one hand and in patients with pathologically proven lymph node metastases in locoregional advanced prostate cancer (Tx pN+) on the other hand following definitive radiotherapy and radical prostatectomy. This paper investigates the possible indications for radiotherapy of the pelvic lymphatics in the light of data from the literature.

PATIENTS AND METHODS

Because data from several retrospective studies concerning radiotherapy of the pelvic lymphatics indicated a better outcome, the RTOG conducted 2 prospective randomised studies (RTOG 75-06, 77-06) to address these questions. However, the results of these studies showed no better survival or cause specific survival for patients treated for the paraaortal or pelvic lymphatics and therefore, radiotherapy of the pelvic lymphatics was no more advocated. A reanalysis showed several problems of the study design and it was concluded that the studies couldn't prove the question of elective radiotherapy of the pelvic lymphatics. In RTOG 77-06 patients with T1b/T2 tumors were investigated. Therefore, there is no prospective study investigating the elective radiotherapy in patients with T3-tumors, who are at high risk of pelvic lymph node metastases.

RESULTS

Today there is no indication for treating the paraaortal lymphatics in patients with locoregional advanced prostate cancer. Many radiotherapists perform the elective radiotherapy of pelvic lymphatics when the risk of metastases is above 15 to 20% because retrospective data indicate a better outcome. On the other hand, many others don't treat them because RTOG 75-06 and 77-06 didn't demonstrate a better outcome. Laparoscopic lymphadenectomy with low morbidity seems to be helpful as in pN0 patients radiotherapy is not necessary. Where performing laparoscopic pelvine lymphadenectomy is impossible the probability of the frequency of lymph node metastases can be estimated using the clinical tumor stage, the Gleason-score and the pretherapeutic PSA. In case of proven metastases (pN+) some retrospective data indicate that patients with micrometastasis could profit from aggressive treatment. In case of proven metastases and extirpation by lymphadenectomy it seems that patients with hormonal therapy and radiotherapy have a longer tumor-free interval. However, there are no data from randomized trials.

CONCLUSIONS

Every radiotherapist has to make his own decision for radiotherapy of the pelvic lymphatics as there is no standard treatment. Two randomised studies are open and recruiting patients. These are one study of the ARO, investigating patients with histologically proven lymph node metastases and one study of the RTOG (RTOG 9413), investigating patients with an estimated risk of lymph node metastases > 15%. In case of radiotherapy of the pelvic lymphatics a dose of 45 Gy for suspected metastases and 50.4 Gy for proven metastases is recommended.

Androgen ablation in addition to radiation therapy for prostate cancer: is there true benefit?

Prostate cancer patients may now be identified as having a high risk of failing single-modality treatment based on pretreatment prostate specific antigen (PSA), Gleason score, and palpable stage. In particular, a PSA greater than 20 ng/mL portends a biochemical failure rate of 50% to 80% when radiation therapy, surgery, or androgen ablation is administered individually. A number of randomized trials as well as retrospective data show that failure rates are significantly reduced by combining androgen ablation and radiation. The improved results, however, are complicated by the ability to salvage radiation alone-treated patients with androgen ablation and the possibility of less effective salvage (or no effective salvage in the case of permanent androgen ablation) for patients treated with androgen ablation plus radiation. Thus, survival, which is obscured by high rates of intercurrent deaths in this elderly population, is the most important end point in such studies. Two randomized trials, one from the Radiation Therapy Oncology Group (RTOG) and one from the European Organization for Research on Treatment for Cancer (EORTC), of radiation therapy plus adjuvant (as opposed to neoadjuvant) androgen ablation have reported survival gains over radiation therapy alone. In contrast, one neoadjuvant trial from the RTOG failed to show a survival benefit when androgen ablation was added to radiation therapy. In this study, however, androgen ablation was administered for only 4 to 5 months, which may be insufficient. The weight of the evidence to date indicates a true benefit with androgen ablation plus radiation therapy over radiation therapy alone. There are clearly many unanswered questions concerning the optimal timing of androgen ablation and radiation therapy (neoadjuvant versus adjuvant), length of time that androgen ablation should be administered (6 months versus 3 years versus permanent), type of androgen ablation (total androgen ablation or not), and appropriate patient population (definition of high risk). The planned future clinical trials will address many of these issues; however, the full potential of this approach requires an understanding of the fundamental mechanisms involved.

Ten-year outcomes for pathologic node-positive patients treated in RTOG 75-06

PURPOSE

This study was conducted to see what fraction of prostate cancer patients with biopsy-proven nodes are free of cancer 10 years after radiation treatment.

METHODS AND MATERIALS

RTOG protocol #75-06 included 90 patients with biopsy-proven pelvic nodal involvement treated with radiation. They have been continuously follow-up since treatment. When feasible, current prostate-specific antigen (PSA) levels have been solicited from patients clinically cancer-free (no evidence of disease, NED) at 10 years, to confirm cure.

RESULTS

The 10-year survival was 29%, the 10-year clinical NED survival 7%. PSA levels were obtained in 2 of 5 10-year clinical NED patients, they were both less than 0.8 ng/ml. The 2 proven cures were both clinical stage T-3, Gleason Score 6 and 8, and had 2 and 1 positive nodes, respectively. Multivariate analysis showed Gleason sum was significantly associated with clinical survival without disease.

CONCLUSION

A small fraction of node-positive patients are cured at 10-year follow-up by radiation therapy (2 of 90 with PSA +3 of 90 by clinical endpoints). Innovative treatment programs should be directed at node-positive patients in an effort to improve the fraction cured.

The use of combined radiation therapy and hormonal therapy in the management of lymph node-positive prostate cancer

PURPOSE

To determine the rate of tumor response and patterns of relapse following combined hormonal-radiation therapy of adenocarcinoma of the prostate and to measure the survival in a group of men with tumor metastatic to pelvic lymph nodes.

METHODS AND MATERIALS

66 patients with adenocarcinoma of the prostate with pathologically confirmed pelvic lymph node involvement were treated with combined radiation therapy and hormonal therapy. An additional five patients declined hormonal therapy. The patients treated with combined therapy represented a group with locally advanced disease including 44 patients (67%) with T3 or T4 tumors and 51 patients (80%) had N2 or N3 lymph node metastases. The pelvic lymph nodes were treated to a dose of 45 Gy and the prostate was boosted to a dose of 65 to 71 Gy. Hormonal therapy began up to 2 months before radiation and continued indefinitely. Patients were allowed to select their hormonal therapy and could choose DES (2 patients), orchiectomy (21 patients), LHRH agonist (7 patients) or combined androgen blockade (34 patients).

RESULTS

Median follow-up is 49 months (range 12 to 131 months) and 21 patients have been followed for longer than 5 years. There have been 15 recurrences the entire group including three local recurrences in the prostate, seven patients with distant metastases, four patients with biochemical recurrences without clinical evidence of disease, and one patient where the location was unknown. Two of the PSA recurrences occurred in patients who elected to discontinue hormones after less than 3 years of therapy. The overall survival at 5 and 8 years is 94 and 84%, the clinical disease free survival is 85 and 67%, and the biochemical disease-free survival is 78 and 47%. There was no increased toxicity of the combined modality regimen compared to the expected effects of radiation and hormonal therapy.

CONCLUSION

Combined hormonal and radiation therapy represents an effective treatment option for patients with adenocarcinoma of the prostate metastatic to pelvic lymph nodes. Combined modality therapy appears to extend the disease-free survival and allow patients to maintain their independent function.

Androgen suppression plus radiation versus radiation alone for patients with D1 (pN+) adenocarcinoma of the prostate (results based on a national prospective randomized trial, RTOG 85-31). Radiation Therapy Oncology Group

PURPOSE

To evaluate the effect of immediate androgen suppression in conjunction with standard external beam irradiation vs. radiation alone on a group of pathologically staged lymph node-positive patients with adenocarcinoma of the prostate.

METHODS AND MATERIALS

A national prospective randomized trial (RTOG 85-31) of standard external beam irradiation plus immediate androgen suppression vs. external beam irradiation alone was initiated in 1985 for patients with locally advanced adenocarcinoma of the prostate. One hundred seventy-three of the patients in this trial had biopsy-proven pathologically involved lymph nodes. Ninety-eight of these patients received radiation plus the immediate androgen suppression (LHRH agonist), while 75 received radiation alone with hormonal manipulation instituted at the time of relapse.

RESULTS

With a median followup of 4.9 years, estimated progression-free survival with PSA < 1.5 ng/ml at 5 years was 55% for the patients who received radiation plus immediate LHRH agonist vs. 11% of the patients who received radiation alone with hormonal manipulation at relapse (p = 0.0001). Because all of these patients had locally advanced disease (i.e., pathologically positive lymph nodes), stage does not explain this difference in outcome, and Gleason grade was not statistically different between the two groups. Estimated absolute survival at 5 years for the radiation and LHRH group was 73 vs. 65% for the radiation alone group who received androgen suppression at relapse. Estimated disease-specific survival at 5 years was 82% for the radiation and immediate LHRH agonist group and 77% for the radiation-alone group.

CONCLUSION

Patients with adenocarcinoma of the prostate and pathologically involved pelvic lymph nodes (pN+ or clinical stage D1) should be seriously considered for external beam irradiation plus immediate hormonal manipulation over radiation alone with hormonal manipulation at the time of relapse.

Combined hormonal and radiation therapy for lymph node-positive prostate cancer

OBJECTIVES

To evaluate the efficacy of combined radiation and hormonal therapy in patients with prostate cancer metastatic to the pelvic lymph nodes.

METHODS

Fifty consecutive patients with node-positive prostate cancer were evaluated by the Departments of Urology and Radiation Oncology at the University of Pennsylvania and offered combined hormonal and radiation therapy. All patients received pelvic radiation to 45 Gy, with a boost dose to the prostate to 65 to 71 gy. Forty-five of the patients were treated with concurrent hormonal therapy consisting of diethylstilbestrol (2 patients), orchiectomy (18 patients), leuprolide (5 patients), or combined androgen blockade (20 patients); the other 5 patients declined hormonal therapy. Patients represented a group with locally advanced disease with a high incidence of T3 tumors (66%), high grade (74%; Gleason score more than 7), high prostate-specific antigen (PSA) (40%; more than 30.0 ng/mL), and a high incidence of gross (36%) or bilateral (30%) adenopathy and a high incidence of multiply involved lymph nodes (62%).

RESULTS

Median follow-up of patients is 42 months (range, 10 to 102). All 5 patients declining hormonal therapy relapsed within 18 months and only 1 patient survived longer than 3 years. Among patients treated with combined hormonal and radiation therapy, the 6-year survival rate is 82%, the clinical disease-free survival at 6 years is 71%, and the probability of survival free of recurrence, with a PSA less than 0.2 ng/mL, is 62%. Only two PSA recurrences occurred, both in patients who elected to discontinue hormone therapy. There was no synergistic toxicity observed as a result of combined therapy.

CONCLUSIONS

Combined hormonal and radiation therapy offers the potential for extended disease-free survival and may represent an effective treatment option for patients with locally advanced prostate cancer.

The prognostic importance of Gleason grade in prostatic adenocarcinoma: a long-term follow-up study of 648 patients treated with radiation therapy

PURPOSE

It is common practice to histologically grade adenocarcinoma of the prostate using the Gleason system. Whereas the prognostic utility of this grading is well known, few studies have comprehensively evaluated it for patients undergoing definitive radiation therapy and generally accepted guidelines as to which Gleason grades should be "lumped" have not been established. This study reports the results of univariate and multivariate evaluation of the prognostic significance of Gleason grade in 648 patients followed for a median of 6.5 years after radiation therapy for T1 to T4, N0, or NX, MO prostate cancer.

METHODS AND MATERIALS

The correlation between Gleason grade and local recurrence, metastatic relapse, any disease relapse, and patient survival was evaluated using univariate and multivariate methods. Analysis was also stratified according to whether the grading was assigned on a needle biopsy or on a transurethral resection specimen.

RESULTS

The large number of Gleason grades required grouping of grades for meaningful analysis and we found that a four-tier system (grades 2 and 3, 155 patients; grades 4-6, 290 patients; grade 7, 92 patients; and grades 8-10, 111 patients) correlated best with outcome. In univariate analysis, this four-tier grouping correlated significantly with local recurrence, distant metastases, any relapse, and survival. The incidences of distant metastasis at 10 years were: grades 2 and 3, 13%; grades 4-6, 34%; grade 7, 52%; and, grades 8-10, 63%. The survival rates at 10 years were: grades 2 and 3, 64%; grades 4-6, 60%; grade 7, 46%; and grades 8-10, 24%. In multivariate analysis, Gleason grade was the single most important determinant of outcome for each endpoint. These results applied equally to needle biopsy and transurethral resection specimens.

CONCLUSION

Tumor grade is the single most significant determinant of outcome following radiotherapy for clinically localized prostate cancer. The Gleason system is a valid method for grading tumors to be irradiated. A four-tier grouping into grades 2 and 3, grades 4-6, grade 7, and grades 8-10 appears to be adequate and simple.

Primary radiation therapy in the treatment of localized prostatic cancer

Prostatic carcinoma is one of the leading causes of male cancer deaths. However, the routine diagnostic and therapeutic strategies have not yet been established. Although the outcome of surgical and radiotherapeutical approaches has frequently been reported to be comparable, the profile of side effects is different. This could offer the basis for selecting the treatment of choice in individual cases. During the last decade the radiotherapeutical technique has markedly improved, in part due to the achievements in the field of computer assisted tomography planning and conformal technique; the outcome of side-effects has decreased with concurrent increase in the rate of local control. The prescribing, recording and reporting of irradiation have also recently developed, as well as the staging of the disease. Therefore we consider it timely to review progress in this subject and to emphasize the role of radiotherapy in the treatment of localized prostatic cancer.

Influence of radiotherapy on node-positive prostate cancer treated with androgen ablation

PURPOSE

Patients with node-positive prostate cancer that is regionally localized (T1-4, N1-3, M0) have a relatively poor prognosis when a single-treatment modality such as radical surgery, definitive radiotherapy, or androgen ablation is used. While promising results using radical surgery and androgen ablation have been reported, there are no data to support an analogous approach using local radiotherapy and androgen ablation. In this retrospective review, the outcome after local radiotherapy and early androgen ablation (XRT/HORM) was compared to early androgen ablation alone (HORM).

METHODS AND MATERIALS

Between 1984 and 1992 there were 181 patients treated with HORM and 27 patients treated with XRT/HORM at the University of Texas M. D. Anderson Cancer Center. The nodal status of all patients was established pathologically by lymph node dissection, which was terminated after frozen section confirmation of involvement. In the majority of cases androgen ablation was by orchiectomy. The median dose to the prostate in XRT/HORM group was 66 Gy. The median follow-up was 45 months; 49 months for the HORM group and 25 months for the XRT/HORM group.

RESULTS

The distribution of prognostic factors between the HORM and XRT/HORM groups was similar, with the exception of tumor grade. There was a significantly larger proportion of high grade tumors in the HORM group. In terms of actuarial disease outcome, at 4 years the results of patients in the HORM group were significantly worse, including a rising prostate specific antigen (PSA) of 53%, any disease progression of 32%, a rising PSA or disease progression of 55%, and local progression of 22%. None of the patients in the XRT/HORM group failed biochemically or clinically. To determine the impact of grade on these findings, the analyses were repeated, using only those with grade 2 tumors. A similar pattern was evidenced with significantly worse actuarial outcome at 4 years for the HORM group using the endpoints of a rising PSA (46%), any disease progression (24%), and a rising PSA or disease progression (47%).

CONCLUSION

Node-positive prostate cancer patients with regionally localized disease fared significantly better when combined local radiotherapy and early androgen ablation were used, as compared to early androgen ablation alone. Although the number of patients in the XRT/HORM group was small and follow-up was short, the combined treatment had a dramatic effect on disease outcome and, therefore, a larger prospective randomized trial is warranted.

Treatment related sequelae following external beam radiation for prostate cancer: a review with an update in patients with stages T1 and T2 tumor

The primary goal of radical radiation therapy in men with localized prostate carcinoma is cure and a secondary but important goal is to achieve cure without treatment related sequelae, such as loss of continence, rectal injury, loss of potency and the need for castration. A literature review of 2,611 men undergoing irradiation for all stages of localized prostatic carcinoma documented a 0.2% incidence of treatment related mortality, 1.9% severe complications, 0.9% incontinence and 33 to 60% maintenance of full potency 5 or more years after treatment. A separate analysis was made of 331 patients with only early tumors (stages T1 and T2) treated with conventional external beam radiation therapy to doses of 63 to 74 Gy. from 2 individual centers (Massachusetts General Hospital and M.D. Anderson Hospital) and 1 multi-institutional group (Radiation Therapy Oncology Group). Median followup was 6.1 years; however, in 2 series followup ranged to 14 years. This analysis revealed frequencies of treatment associated sequelae of 0% for mortality, 0% severe complications, 0.4% urinary incontinence, 5.4% genitourinary structures (1.2% persisting), 5.1% hematuria (0.9% persisting) and 5.4% rectal bleeding (0.6% persisting). This composite analysis of men undergoing irradiation for stages T1 and T2 tumors with conventional fractionation and doses indicates that acute morbidity is minor and usually transient, severe injury is rare, most late gastrointestinal and genitourinary symptoms of radiation injury are neither permanent nor debilitating, and few symptoms of radiation injury develop beyond 5 years from treatment. These data, combined with the low progression rates (using prostate specific antigen criteria) following irradiation of men with early tumors, further substantiate the primary role of radical radiotherapy in the treatment of surgical risk adversive patients.

Early androgen ablation for stage D1 (N1 to N3, M0) prostate cancer: prognostic variables and outcome

To elucidate the outcome for patients with stage D1 (N1 to N3, M0) prostate cancer we reviewed 179 patients with lymphadenectomy proved pelvic nodal metastases who underwent immediate androgen ablation as the only initial treatment. With a median followup of 43 months, the 5 and 8-year actuarial rates of freedom from disease progression were 55% and 25%, respectively, and the median interval to disease progression was 67 months. The 5 and 8-year survival rates were 85% and 57%, respectively. Median survival after disease progression was 36 months. Local and distant disease progression was equally important. At 5 and 8 years the incidence of local progression was 32% and 51%, respectively, while metastatic rates at the same intervals wer 22% and 44%, respectively. Multivariate regression revealed that tumor grade and transurethral resection in preoperative stage C disease correlated with disease progression. Pretreatment prostate specific antigen (PSA) levels were not predictive of outcome. The fact that transurethral resection predicted for local as well as distant failure suggests that the procedure selects for rather than aggravates adverse disease. Posttreatment PSA levels were a sensitive index of response to treatment and of subsequent outcome. All patients who failed to achieve undetectable PSA levels had relapse by 8 years, whereas those whose levels became undetectable experienced only a 5% incidence of disease progression. These data show that androgen ablation alone is not curative for node positive disease but is associated with significant disease control and good short-term (5-year) survival. The primary tumor is an important source of androgen insensitive cells and comprehensive treatment strategies for this stage of disease require attention to the primary tumor as well as microscopic metastases.

The effects of local and regional treatment on the metastatic outcome in prostatic carcinoma with pelvic lymph node involvement

PURPOSE

The effect of local and regional treatment on the development of distant metastases in patients with localized node negative and node positive carcinoma of the prostate is examined.

METHODS AND MATERIALS

Distant metastases-free survival was evaluated in 1078 patients with Stage B-C node negative (733 patients) or node positive (345 patients) carcinoma of the prostate, staged with pelvic lymph node dissection and treated with retropublic 125I implantation at the Memorial Sloan-Kettering Cancer Center between 1970 and 1985.

RESULTS

The 15-year actuarial distant metastases-free survival rate for the entire group of patients was 27%. Lymph node involvement was the most significant covariate affecting distant metastases-free survival, although local failure, stage, and grade were also independent variables. Distant metastases-free survival varied with the extent of lymph node involvement (N0 vs. N1, p < 0.0001; N1 vs. N2, p < 0.0001). However, the difference between N1 and N2 patients was due to a faster rate of development of distant metastases in N2 patients. The ultimate 10-year distant metastases-free survival rate was similar for the two patient groups (11% for N1 and 9% for N2). Local failure correlated with the metastatic outcome in patients with B-C/N0 disease (p < 0.00001), but not in N1 or N2 patients. Although distant metastases-free survival in locally controlled N1 patients was improved compared to N2 patients (p = 0.004), when stratified by primary tumor stage and grade, the differences were no longer significant.

CONCLUSION

Essentially all node positive patients with carcinoma of the prostate will develop distant metastatic disease if followed for sufficiently long periods of time. This is consistent with the hypothesis that in such patients distant micrometastatic dissemination already exists at the time of initial diagnosis. The data suggest that clinical trials designed to test whether improvements in local therapy impact on survival should be restricted to node negative patients. The data also raise concerns regarding the therapeutic value of elective whole pelvic irradiation.