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Hsu M, Shan X, Zhang R, Berlin E, Goel A, Agarwal M, Wong YN, Christodouleas JP, Vaughn DJ, Narayan V, Takvorian SU, Vapiwala N, Pantel AR, Haas NB. Prostate Cancer Recurrence: Examining the Role of Salvage Radiotherapy Field and Risk Factors for Regional Disease Recurrence Captured on 18F-DCFPyL PET/CT. Clin Genitourin Cancer 2024; 22:102108. [PMID: 38843766 DOI: 10.1016/j.clgc.2024.102108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 04/23/2024] [Accepted: 04/27/2024] [Indexed: 06/19/2024]
Abstract
PURPOSE The role of elective pelvic nodal irradiation in salvage radiotherapy (sRT) remains controversial. Utilizing 18F-DCFPyL PET/CT, this study aimed to investigate differences in disease distribution after whole pelvic (WPRT) or prostate bed (PBRT) radiotherapy and to identify risk factors for pelvic lymph node (LN) relapse. METHODS This retrospective study included patients with PSA > 0.1 ng/mL post-radical prostatectomy (RP) or post-RP and sRT who underwent 18F-DCFPyL PET/CT. Disease distribution on 18F-DCFPyL PET/CT after sRT was compared using Chi-square tests. Risk factors were tested for association with pelvic LN relapse after RP and salvage PBRT using logistic regression. RESULTS 979 18F-DCFPyL PET/CTs performed at our institution between 1/1/2022 - 3/24/2023 were analyzed. There were 246 patients meeting criteria, of which 84 received salvage RT after RP (post-salvage RT group) and 162 received only RP (post-RP group). Salvage PBRT patients (n = 58) had frequent pelvic nodal (53.6%) and nodal-only (42.6%) relapse. Salvage WPRT patients (n = 26) had comparatively lower rates of pelvic nodal (16.7%, p = 0.002) and nodal-only (19.2%, p = 0.04) relapse. The proportion of distant metastases did not differ between the two groups. Multiple patient characteristics, including ISUP grade and seminal vesicle invasion, were associated with pelvic LN disease in the post-RP group. CONCLUSION At PSA persistence or progression, salvage WPRT resulted in lower rates of nodal involvement than salvage PBRT, but did not reduce distant metastases. Certain risk factors increase the likelihood of pelvic LN relapse after RP and can help inform salvage RT field selection.
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Affiliation(s)
- Miles Hsu
- Department of Hematology/Oncology, University of Pennsylvania, Philadelphia, PA
| | - Xinhe Shan
- Department of Medicine, Montefiore Einstein, New York, NY
| | - Rebecca Zhang
- Department of Radiology, University of Pennsylvania, Philadelphia, PA
| | - Eva Berlin
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Arun Goel
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | | | - Yu-Ning Wong
- Department of Hematology/Oncology, University of Pennsylvania, Philadelphia, PA
| | | | - David J Vaughn
- Department of Hematology/Oncology, University of Pennsylvania, Philadelphia, PA
| | - Vivek Narayan
- Department of Hematology/Oncology, University of Pennsylvania, Philadelphia, PA
| | - Samuel U Takvorian
- Department of Hematology/Oncology, University of Pennsylvania, Philadelphia, PA
| | - Neha Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Austin R Pantel
- Department of Radiology, University of Pennsylvania, Philadelphia, PA
| | - Naomi B Haas
- Department of Hematology/Oncology, University of Pennsylvania, Philadelphia, PA.
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Scharl S, Zamboglou C, Strouthos I, Farolfi A, Serani F, Koerber SA, Debus J, Peeken JC, Vogel MME, Kroeze SGC, Guckenberger M, Krafcsik M, Hruby G, Emmett L, Schmidt-Hegemann NS, Trapp C, Spohn SKB, Henkenberens C, Mayer B, Shelan M, Aebersold DM, Thamm R, Wiegel T. European association of urology risk stratification predicts outcome in patients receiving PSMA-PET-planned salvage radiotherapy for biochemical recurrence following radical prostatectomy. Radiother Oncol 2024; 194:110215. [PMID: 38458259 DOI: 10.1016/j.radonc.2024.110215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 03/01/2024] [Accepted: 03/03/2024] [Indexed: 03/10/2024]
Abstract
PURPOSE The European Association of Urology (EAU) proposed a risk stratification (high vs. low risk) for patients with biochemical recurrence (BR) following radical prostatectomy (RP). Here we investigated whether this stratification accurately predicts outcome, particularly in patients staged with PSMA-PET. METHODS For this study, we used a retrospective database including 1222 PSMA-PET-staged prostate cancer patients who were treated with salvage radiotherapy (SRT) for BR, at 11 centers in 5 countries. Patients with lymph node metastases (pN1 or cN1) or unclear EAU risk group were excluded. The remaining cohort comprised 526 patients, including 132 low-risk and 394 high-risk patients. RESULTS The median follow-up time after SRT was 31.0 months. The 3-year biochemical progression-free survival (BPFS) was 85.7 % in EAU low-risk versus 69.4 % in high-risk patients (p = 0.002). The 3-year metastasis-free survival (MFS) was 94.4 % in low-risk versus 87.6 % in high-risk patients (p = 0.005). The 3-year overall survival (OS) was 99.0 % in low-risk versus 99.6 % in high-risk patients (p = 0.925). In multivariate analysis, EAU risk group remained a statistically significant predictor of BPFS (p = 0.003, HR 2.022, 95 % CI 1.262-3.239) and MFS (p = 0.013, HR 2.986, 95 % CI 1.262-7.058). CONCLUSION Our data support the EAU risk group definition. EAU risk grouping for BCR reliably predicted outcome in patients staged lymph node-negative after RP and with PSMA-PET before SRT. To our knowledge, this is the first study validating the EAU risk grouping in patients treated with PSMA-PET-planned SRT.
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Affiliation(s)
- Sophia Scharl
- Department of Radiation Oncology, University Hospital Ulm, Germany.
| | - Constantinos Zamboglou
- Department of Radiation Oncology, Medical Center -Faculty of Medicine, University of Freiburg, Germany
| | - Iosif Strouthos
- Department of Radiation Oncology, German Oncology Center, University Hospital of the European University, Limassol, Cyprus
| | - Andrea Farolfi
- Nuclear Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesca Serani
- Nuclear Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Stefan A Koerber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Department of Radiation Oncology, Barmherzige Brüder Hospital Regensburg, Regensburg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan C Peeken
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Germany
| | - Marco M E Vogel
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich (TUM), Germany
| | | | | | - Manuel Krafcsik
- Department of Radiation Oncology, University Hospital Ulm, Germany
| | - George Hruby
- Department of Radiation Oncology, Royal North Shore Hospital - University of Sydney, Australia
| | - Louise Emmett
- St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Nina-Sophie Schmidt-Hegemann
- Department of Department of Radiotherapy and Oncology, University Hospital, LMU Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, 81377 Munich, Germany; Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Christian Trapp
- Department of Department of Radiotherapy and Oncology, University Hospital, LMU Munich, Germany
| | - Simon K B Spohn
- Department of Radiation Oncology, Medical Center -Faculty of Medicine, University of Freiburg, Germany
| | - Christoph Henkenberens
- Department of Radiotherapy and Special Oncology, Medical School Hannover, Hannover, Germany
| | - Benjamin Mayer
- Institute for Epidemiology and Medical Biometry, University Ulm, Ulm, Germany
| | - Mohamed Shelan
- Department of Radiation Oncology, Inselspital Bern, Bern University Hospital, University of Bern, Switzerland
| | - Daniel M Aebersold
- Department of Radiation Oncology, Inselspital Bern, Bern University Hospital, University of Bern, Switzerland
| | - Reinhard Thamm
- Department of Radiation Oncology, University Hospital Ulm, Germany
| | - Thomas Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Germany
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Blas L, Shiota M, Tanegashima T, Tsukahara S, Ueda S, Mutaguchi J, Goto S, Kobayashi S, Matsumoto T, Inokuchi J, Eto M. Validation of schedules for optimal prostate-specific antigen monitoring after radical prostatectomy. Int J Urol 2024; 31:404-408. [PMID: 38154806 DOI: 10.1111/iju.15379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 12/14/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Early detection of biochemical recurrence (BCR) after radical prostatectomy (RP) is crucial for early treatment and improving survival outcomes. The optimal prostate-specific antigen (PSA) monitoring remains unclear, and several models have been proposed. We aimed to externally validate four models for optimal PSA monitoring after RP and propose modifications to improve them. METHODS We reviewed the clinicopathological data of 896 patients who underwent robot-assisted RP between 2009 and 2022. We examined all PSA values and estimated the PSA value for four monitoring schedules at each time point in the virtual follow-up. We defined the ideal PSA for BCR detection between 0.2 and 0.4 ng/mL. RESULTS During the median follow-up of 21.4 months, 128 (14.3%) patients presented BCR. The original and modified Keio models, National Cancer Center Hospital model, and American Urological Association/American Society for Radiation Oncology model detected BCR in 14 (10.9%), three (2.3%), 12 (9.4%), and 11 (8.6%) patients with PSA >0.4 ng/mL. Most patients experienced BCR detected with PSA >0.4 ng/mL during the first year postoperative. The modification of interval within 6 months postoperative avoided BCR detection with PSA >0.4 ng/mL within the first year postoperative in 8/9 (88.9%), 1/2 (50.0%), 5/6 (83.3%), and 4/4 (100%) for the original and modified Keio models, National Cancer Center Hospital model, and American Urological Association/American Society for Radiation Oncology model, respectively. CONCLUSION We validated four models for PSA monitoring after RP to detect BCR and suggested modifications to avoid detections out of the desired range of PSA. These modifications could help to establish an optimal PSA monitoring schedule after RP.
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Affiliation(s)
- Leandro Blas
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masaki Shiota
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tokiyoshi Tanegashima
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shigehiro Tsukahara
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shohei Ueda
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Jun Mutaguchi
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shunsuke Goto
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Satoshi Kobayashi
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takashi Matsumoto
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Junichi Inokuchi
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masatoshi Eto
- Department of Urology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Kano H, Kadono Y, Naito R, Makino T, Iwamoto H, Yaegashi H, Kawaguchi S, Nohara T, Shigehara K, Izumi K, Mizokami A. Salvage Androgen Deprivation Therapy as Potential Treatment for Recurrence after Robot-Assisted Radical Prostatectomy. Cancers (Basel) 2024; 16:1304. [PMID: 38610982 PMCID: PMC11011007 DOI: 10.3390/cancers16071304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/20/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND The efficacy of intermittent androgen deprivation therapy (ADT) for biochemical recurrence (BCR) after robot-assisted radical prostatectomy (RARP) is unknown, and its usefulness in Japanese practice needs to be investigated. METHODS We conducted a retrospective analysis of 85 patients who underwent RARP and were selected for intermittent ADT for postoperative recurrence at Kanazawa University Hospital between 2009 and 2019. Intermittent ADT was administered for 2 years. If prostate-specific antigen levels increased post-treatment, intermittent ADT was reinitiated. The median follow-up period was 47 months. RESULTS The 73 patients had completed the initial course of ADT, and 12 were under initial ADT. The 5-year castration-resistant prostate-cancer-free survival rates, cancer-specific survival, and overall survival were 92.7%, 98.3%, and 94.7%, respectively. A subgroup analysis of 69 patients who completed intermittent ADT was conducted to evaluate the BCR rate following initial ADT. The 5-year BCR-free survival rate was 53.2%. Multivariate analysis identified testosterone ≤ 0.03 ng/mL during ADT as the sole predictor of BCR after ADT. CONCLUSIONS Salvage intermittent ADT may be an effective treatment option for BCR after RARP. In addition, it would be useful to confirm strong testosterone suppression as a criterion for transition to intermittent therapy.
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Affiliation(s)
- Hiroshi Kano
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa 920-8640, Japan; (H.K.); (R.N.); (T.M.); (H.I.); (H.Y.); (S.K.); (T.N.); (K.S.); (K.I.); (A.M.)
| | - Yoshifumi Kadono
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa 920-8640, Japan; (H.K.); (R.N.); (T.M.); (H.I.); (H.Y.); (S.K.); (T.N.); (K.S.); (K.I.); (A.M.)
- Department of Nephrology and Urology, Japanese Red Cross Fukui Hospital, Fukui 918-8501, Japan
| | - Renato Naito
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa 920-8640, Japan; (H.K.); (R.N.); (T.M.); (H.I.); (H.Y.); (S.K.); (T.N.); (K.S.); (K.I.); (A.M.)
| | - Tomoyuki Makino
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa 920-8640, Japan; (H.K.); (R.N.); (T.M.); (H.I.); (H.Y.); (S.K.); (T.N.); (K.S.); (K.I.); (A.M.)
| | - Hiroaki Iwamoto
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa 920-8640, Japan; (H.K.); (R.N.); (T.M.); (H.I.); (H.Y.); (S.K.); (T.N.); (K.S.); (K.I.); (A.M.)
| | - Hiroshi Yaegashi
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa 920-8640, Japan; (H.K.); (R.N.); (T.M.); (H.I.); (H.Y.); (S.K.); (T.N.); (K.S.); (K.I.); (A.M.)
| | - Shohei Kawaguchi
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa 920-8640, Japan; (H.K.); (R.N.); (T.M.); (H.I.); (H.Y.); (S.K.); (T.N.); (K.S.); (K.I.); (A.M.)
| | - Takahiro Nohara
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa 920-8640, Japan; (H.K.); (R.N.); (T.M.); (H.I.); (H.Y.); (S.K.); (T.N.); (K.S.); (K.I.); (A.M.)
| | - Kazuyoshi Shigehara
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa 920-8640, Japan; (H.K.); (R.N.); (T.M.); (H.I.); (H.Y.); (S.K.); (T.N.); (K.S.); (K.I.); (A.M.)
| | - Kouji Izumi
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa 920-8640, Japan; (H.K.); (R.N.); (T.M.); (H.I.); (H.Y.); (S.K.); (T.N.); (K.S.); (K.I.); (A.M.)
| | - Atsushi Mizokami
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa 920-8640, Japan; (H.K.); (R.N.); (T.M.); (H.I.); (H.Y.); (S.K.); (T.N.); (K.S.); (K.I.); (A.M.)
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Watanabe K, Kamitani N, Ikeda N, Kawata Y, Tokiya R, Hayashi T, Miyaji Y, Tamada T, Katsui K. Long-term outcomes of salvage transurethral high-dose-rate brachytherapy combined with external beam radiation therapy for anastomotic recurrence of prostate cancer after radical prostatectomy: A retrospective analysis. Brachytherapy 2024; 23:179-187. [PMID: 38245406 DOI: 10.1016/j.brachy.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 09/13/2023] [Accepted: 12/05/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND High-dose-rate brachytherapy (HDR-BT) delivers high-dose radiation to local lesions within a short treatment period. There are no reports of salvage transurethral HDR-BT for biochemical recurrence (BCR) after radical prostatectomy. Thus, we aimed to evaluate the usefulness of salvage transurethral HDR-BT with external beam radiation therapy (EBRT) for anastomotic prostate cancer recurrence. METHODS AND MATERIALS Patients with postoperative prostate cancer who underwent salvage transurethral HDR-BT with EBRT for anastomotic recurrence at our hospital between January 2002 and July 2009 were retrospectively evaluated. The Kaplan-Meier method was used to estimate biochemical freedom from failure (bFFF), cause-specific survival (CSS), and overall survival (OS) rates. RESULTS Nine patients were included in this study. The median follow-up period and age were 13.1 (range 4.3-18.4) years and 67 (range 63-78) years, respectively. The dose of HDR-BT ranged from 13 to 24 Gy per 2 to 5 fractions, while that of EBRT ranged from 30 to 44 Gy per 15 to 22 fractions. The 1-year, 5-year, and 10-year bFFF rates were 77.8%, 41.7%, and 13.9%, respectively. The 10-year and 15-year CSS rates were 100% each. The 10-year and 15-year OS rates were 100% and 64.3%, respectively. Six patients were diagnosed with BCR. Two patients experienced Grade 3 hematuria as a late adverse event. There was no exacerbation of urinary incontinence. CONCLUSIONS No prostate cancer-related deaths were observed, even after a long-term follow-up. Salvage transurethral HDR-BT after radical prostatectomy is safe and feasible and may be a useful treatment option.
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Affiliation(s)
- Kenta Watanabe
- Department of Radiology, Kawasaki Medical School, Kurashiki City, Okayama 701-0192, Japan
| | - Nobuhiko Kamitani
- Department of Radiology, Kawasaki Medical School, Kurashiki City, Okayama 701-0192, Japan.
| | - Naoki Ikeda
- Department of Radiology, Kawasaki Medical School, Kurashiki City, Okayama 701-0192, Japan
| | - Yujiro Kawata
- Department of Radiology, Kawasaki Medical School, Kurashiki City, Okayama 701-0192, Japan
| | - Ryoji Tokiya
- Department of Radiology, Kawasaki Medical School, Kurashiki City, Okayama 701-0192, Japan
| | - Takafumi Hayashi
- Department of Radiology, Kawasaki Medical School, Kurashiki City, Okayama 701-0192, Japan
| | - Yoshiyuki Miyaji
- Department of Urology, Kawasaki Medical School, Kurashiki City, Okayama 701-0192, Japan
| | - Tsutomu Tamada
- Department of Radiology, Kawasaki Medical School, Kurashiki City, Okayama 701-0192, Japan
| | - Kuniaki Katsui
- Department of Radiology, Kawasaki Medical School, Kurashiki City, Okayama 701-0192, Japan
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Lohm G, Knörnschild F, Neumann K, Budach V, Schwartz S, Burock S, Böhmer D. Salvage Radiotherapy for Relapsed Prostate Cancer after Radical Prostatectomy Is Associated with Normal Life Expectancy. Cancers (Basel) 2024; 16:534. [PMID: 38339285 PMCID: PMC10854858 DOI: 10.3390/cancers16030534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/19/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
In patients with prostate cancer (PCa), salvage radiotherapy (SRT) for biochemical progression (BP) after radical prostatectomy (RP) improves PCa-specific survival. However, no prospective randomized trials have compared the effect of SRT with untreated patients. In this analysis of 151 patients who received SRT for post-RP BP, we compared their overall survival (OS) with virtual, age-matched controls (n = 151,000) retrieved from government life tables. We also investigated the risk factors associated with BP and OS and compared the prostate-specific antigen (PSA) doubling times (DTs) before and after SRT for patients with BP. The median follow-up was 9.3 years for BP and 17.4 years for OS. The risk factors significantly affecting BP were Gleason score (p < 0.001), pre-SRT PSA (p = 0.003), and negative surgical margins (p = 0.003). None of these risk factors were associated with OS. In 93 patients with BP after SRT, the median PSADT was significantly prolonged compared with pre-SRT values (3.7 vs. 8.3 months, p < 0.001). The OS did not differ between patients and controls (p = 0.112), and life expectancy was similar, likely due to the survival benefit of SRT. The prolonged PSADT after SRT further supports the beneficial role of SRT in this patient population. However, subsequent treatments were not systematically recorded, which may have affected the results.
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Affiliation(s)
- Gunnar Lohm
- Department of Radiation Oncology, Johanniter-Hospital Genthin-Stendal, 39576 Stendal, Germany
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Franz Knörnschild
- Department of Hematology, Oncology and Tumor Immunology (Campus Benjamin Franklin), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (F.K.); (S.S.)
| | - Konrad Neumann
- Institute of Biometry and Clinical Epidemiology, Charité—Universitätsmedizin Berlin, 10117 Berlin, Germany;
| | - Volker Budach
- Radiation Oncology Vosspalais, Private Clinic, Voss-St. 44, 10177 Berlin, Germany;
| | - Stefan Schwartz
- Department of Hematology, Oncology and Tumor Immunology (Campus Benjamin Franklin), Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (F.K.); (S.S.)
- German Cancer Research Center (DKFZ) and German Cancer Consortium (DKTK), 69120 Heidelberg, Germany
| | - Susen Burock
- Clinical Trial Office (Campus Mitte), Charité—Universitätsmedizin Berlin, 10117 Berlin, Germany;
| | - Dirk Böhmer
- Department of Radiation Oncology (Campus Benjamin Franklin), Charité—Universitätsmedizin Berlin, 10117 Berlin, Germany;
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Szymaniak JA, Washington SL, Cowan JE, Cooperberg MR, Lonergan PE, Nguyen HG, Meng MV, Carroll PR. The natural history of a delayed detectable PSA after radical prostatectomy. Prostate Cancer Prostatic Dis 2023; 26:759-764. [PMID: 36765111 PMCID: PMC10638081 DOI: 10.1038/s41391-022-00638-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 12/05/2022] [Accepted: 12/30/2022] [Indexed: 02/12/2023]
Abstract
INTRODUCTION Men with a detectable PSA after radical prostatectomy (RP) are often offered salvage therapy while those with an undetectable PSA are monitored. We aim to better characterize the natural history of men with an initially undetectable PSA who subsequently developed a detectable PSA > 6 months after RP. METHODS Retrospective analysis of men who underwent RP for clinically localized prostate cancer at the University of California, San Francisco from 2000 to 2022. The primary outcome was biochemical recurrence, defined as 2 consecutive PSA > = 0.03 ng/mL starting 6 months after surgery. Secondary outcomes were salvage treatment, post-salvage treatment, metastasis free survival (MFS), prostate cancer specific mortality (PCSM), and all-cause mortality (ACM). This cohort was compared to a previously described cohort who had an immediately detectable post-operative PSA. RESULTS From our cohort of 3348 patients, we identified 2868 men who had an undetectable post-op PSA. Subsequently, 642 men had a delayed detectable PSA at a median of 25 months (IQR 15, 43) with median follow-up of 72 months after RP. PSA at time of failure was <0.10 ng/mL for 65.7% of men. Of those with a delayed detectable PSA, 46% underwent salvage treatment within 10 years after RP at a median PSA of 0.08 ng/mL (IQR 0.05, 0.14). High CAPRA-S score (HR 1.09, CI 1.02-1.17, p = 0.02) and PSA doubling time (PSA-DT) of <6 months (HR 7.58, CI 5.42-10.6, p < 0.01) were associated with receiving salvage treatment. After salvage treatment, 62% of men had recurrent PSA failure within 10 years. Overall, MFS was 92%, PCSM 3%, and ACM 6% at 10 years. For those who received tertiary treatment for recurrent PSA failure, MFS was 54%, PCSM 23% and ACM 23% at 10 years' time. CONCLUSIONS Men who develop a detectable PSA > 6 months post-operatively may have excellent long-term outcomes, even in the absence of salvage therapy.
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Affiliation(s)
- Julie A Szymaniak
- Department of Urology, University of California, San Francisco, CA, USA.
| | - Samuel L Washington
- Department of Urology, University of California, San Francisco, CA, USA
- Department of Epidemiology & Biostatistics, University of California, San Francisco, CA, USA
| | - Janet E Cowan
- Department of Urology, University of California, San Francisco, CA, USA
| | | | - Peter E Lonergan
- Department of Urology, St. James's Hospital, Dublin, Ireland
- Department of Surgery, Trinity College, Dublin, Ireland
| | - Hao G Nguyen
- Department of Urology, University of California, San Francisco, CA, USA
| | - Maxwell V Meng
- Department of Urology, University of California, San Francisco, CA, USA
| | - Peter R Carroll
- Department of Urology, University of California, San Francisco, CA, USA
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Ah-Thiane L, Sargos P, Chapet O, Jolicoeur M, Terlizzi M, Salembier C, Boustani J, Prevost C, Gaudioz S, Derashodian T, Palumbo S, De Hertogh O, Créhange G, Zilli T, Supiot S. Managing postoperative biochemical relapse in prostate cancer, from the perspective of the Francophone group of Urological radiotherapy (GFRU). Cancer Treat Rev 2023; 120:102626. [PMID: 37734178 DOI: 10.1016/j.ctrv.2023.102626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 09/23/2023]
Abstract
Up to 50% of patients treated with radical surgery for localized prostate cancer may experience biochemical recurrence that requires appropriate management. Definitions of biochemical relapse may vary, but, in all cases, consist of an increase in a PSA without clinical or radiological signs of disease. Molecular imaging through to positron emission tomography has taken a preponderant place in relapse diagnosis, progressively replacing bone scan and CT-scan. Prostate bed radiotherapy is currently a key treatment, the action of which should be potentiated by androgen deprivation therapy. Nowadays perspectives consist in determining the best combination therapies, particularly thanks to next-generation hormone therapies, but not exclusively. Several trials are ongoing and should address these issues. We present here a literature review aiming to discuss the current management of biochemical relapse in prostate cancer after radical surgery, in lights of recent findings, as well as future perspectives.
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Affiliation(s)
- Loic Ah-Thiane
- Department of Radiation Oncology, ICO René Gauducheau, St-Herblain, France
| | - Paul Sargos
- Department of Radiation Oncology, Bergonie Institute, Bordeaux, France
| | - Olivier Chapet
- Department of Radiation Oncology, CHU Lyon Sud, Pierre-Bénite, France
| | - Marjory Jolicoeur
- Department of Radiation Oncology, Charles Le Moyne Hospital, Montreal, Canada
| | - Mario Terlizzi
- Department of Radiation Oncology, Gustave Roussy Cancer Center, Villejuif, France
| | - Carl Salembier
- Department of Radiation Oncology, Europe Hospitals Brussels, Belgium
| | - Jihane Boustani
- Department of Radiation Oncology, CHU Besançon, Besançon, France
| | - Célia Prevost
- Department of Radiation Oncology, CHU Lyon Sud, Pierre-Bénite, France
| | - Sonya Gaudioz
- Department of Radiation Oncology, CHU Lyon Sud, Pierre-Bénite, France
| | - Talar Derashodian
- Department of Radiation Oncology, Sindi Ahluwalia Hawkins Centre, Kelowna, Canada
| | - Samuel Palumbo
- Department of Radiation Oncology, CHU UCL Namur-Sainte Elisabeth, Namur, Belgium
| | - Olivier De Hertogh
- Department of Radiation Oncology, CHR Verviers East Belgium, Verviers, Belgium
| | - Gilles Créhange
- Department of Radiation Oncology, Curie Institute, Saint-Cloud, France
| | - Thomas Zilli
- Department of Radiation Oncology, Geneva University Hospital, Geneva, Switzerland
| | - Stéphane Supiot
- Department of Radiation Oncology, ICO René Gauducheau, St-Herblain, France.
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Sopeña Sutil R, Vázquez-Martul D, De Pablos-Rodríguez P, Peña Vallejo E, Altez Fernández C, Gómez-Ferrer Lozano A, Téigell Tobar J, Rollón Prieto G, Coy García A, Ramírez Backhaus M, Chantada Abal V, Rodríguez Antolín A. European Association of Urology biochemical recurrence risk groups after radical prostatectomy: External validation and identification of independent risk factors for progression and death. Actas Urol Esp 2023; 47:422-429. [PMID: 36746348 DOI: 10.1016/j.acuroe.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/10/2023] [Accepted: 01/11/2023] [Indexed: 02/07/2023]
Abstract
BACKGROUND The EAU proposed a progression and death risk classification in patients with biochemical recurrence after radical prostatectomy (PR). OBJECTIVE To validate the EAU BCR-risk classification in our setting and to find factors related to progression and death. MATERIAL AND METHODS Multicenter, retrospective, observational study including 2140 patients underwent RP between 2011 and 2015. Patients with BCR were identified and stratified in low risk (PSA-DT >1yr and pGS <8) or high-risk (PSA-DT ≤1yr or pGS ≥8) grouping. PSA and metastatic free survival (PSA-PFS, MFS), cancer specific survival (CSS) and overall survival (OS) were calculated (Kaplan Meier curves and log-rank test). Independent risk factors were identified (Cox regression). RESULTS 427 patients experienced BCR (32.3% low-risk and 67.7% high-risk). Median PSA-PFS was 135,0 mo (95% CI 129,63-140,94) and 115,0 mo (95% CI 104,02-125,98) (p<0,001), for low and high-risk groups, respectively. There were also significant differences in MFS and OS. The EAU BCR risk grouping was independent factor for PSA-progression (HR 2.55, p 0.009). Time from PR to BCR, was an independent factor for metastasis onset (HR 0.43, 95% CI 0.18-0.99; p 0.044) and death (HR 0.17, 95% CI 0.26.0.96; 23 p 0.048). Differences in MFS (p 0.001) and CSS (p 0.004) were found for <12, ≥12-<36 and ≥36 months from PR to BCR. Others independent factors were early salvage radiotherapy and PSA at BCR. CONCLUSIONS High-risk group is a prognostic factor for biochemical progression, but it has a limited accuracy on MP and death in our setting. The inclusion of other factors could increase its predictive power.
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Affiliation(s)
- R Sopeña Sutil
- Urology Department, Hospital Universitario 12 de Octubre, Spain.
| | - D Vázquez-Martul
- Urology Department, Complejo Hospitalario Universitario de A Coruña, Spain
| | | | - E Peña Vallejo
- Urology Department, Hospital Universitario 12 de Octubre, Spain
| | - C Altez Fernández
- Urology Department, Complejo Hospitalario Universitario de A Coruña, Spain
| | | | - J Téigell Tobar
- Urology Department, Hospital Universitario 12 de Octubre, Spain
| | - G Rollón Prieto
- Urology Department, Complejo Hospitalario Universitario de A Coruña, Spain
| | - A Coy García
- Urology Department, Instituto Valenciano de Oncología, Valencia, Spain
| | | | - V Chantada Abal
- Urology Department, Complejo Hospitalario Universitario de A Coruña, Spain
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10
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Dubinsky P, Vojtek V, Belanova K, Janickova N, Balazova N, Tomkova Z. Hypofractionated Post-Prostatectomy Radiotherapy in 16 Fractions: A Single-Institution Outcome. Life (Basel) 2023; 13:1610. [PMID: 37511985 PMCID: PMC10381816 DOI: 10.3390/life13071610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND The optimal hypofractionated schedule of post-prostatectomy radiotherapy remains to be established. We evaluated treatment outcomes and toxicity of moderately hypofractionated post-prostatectomy radiotherapy in 16 daily fractions delivered with intensity-modulated radiotherapy. The treatment schedule selection was motivated by limited technology resources and was radiobiologically dose-escalated. METHODS One hundred consecutive M0 patients with post-prostatectomy radiotherapy were evaluated. Radiotherapy indication was adjuvant (ART) in 19%, early-salvage (eSRT) in 46% and salvage (SRT) in 35%. The dose prescription for prostate bed planning target volume was 52.8 Gy in 16 fractions of 3.3 Gy. The Common Terminology Criteria v. 4 for Adverse Events scale was used for toxicity grading. RESULTS The median follow-up was 61 months. Five-year biochemical recurrence-free survival (bRFS) was 78.6%, distant metastases-free survival (DMFS) was 95.7% and overall survival was 98.8%. Treatment indication (ART or eSRT vs. SRT) was the only significant factor for bRFS (HR 0.15, 95% CI 0.05-0.47, p = 0.001) and DMFS (HR 0.16, 95% CI 0.03-0.90; p = 0.038). Acute gastrointestinal (GI) toxicity grade 2 was recorded in 24%, grade 3 in 2%, acute genitourinary (GU) toxicity grade 2 in 10% of patients, and no grade 3. A cumulative rate of late GI toxicity grade ≥ 2 was observed in 9% and late GU toxicity grade ≥ 2 in 16% of patients. CONCLUSIONS The observed results confirmed efficacy and showed a higher than anticipated rate of early GI, late GI, and GU toxicity of post-prostatectomy radiobiologically dose-escalated hypofractionated radiotherapy in 16 daily fractions.
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Affiliation(s)
- Pavol Dubinsky
- Department of Radiation Oncology, East Slovakia Institute of Oncology, 041 91 Kosice, Slovakia
- Faculty of Health, Catholic University in Ruzomberok, 034 01 Ruzomberok, Slovakia
| | - Vladimir Vojtek
- Department of Radiation Oncology, East Slovakia Institute of Oncology, 041 91 Kosice, Slovakia
| | - Katarina Belanova
- Department of Radiation Oncology, East Slovakia Institute of Oncology, 041 91 Kosice, Slovakia
| | - Natalia Janickova
- Department of Radiation Oncology, East Slovakia Institute of Oncology, 041 91 Kosice, Slovakia
| | - Noemi Balazova
- Department of Radiation Oncology, East Slovakia Institute of Oncology, 041 91 Kosice, Slovakia
| | - Zuzana Tomkova
- Department of Radiation Oncology, East Slovakia Institute of Oncology, 041 91 Kosice, Slovakia
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11
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Turkbey B, Oto A, Allen BC, Akin O, Alexander LF, Ari M, Froemming AT, Fulgham PF, Gettle LM, Maranchie JK, Rosenthal SA, Schieda N, Schuster DM, Venkatesan AM, Lockhart ME. ACR Appropriateness Criteria® Post-Treatment Follow-up of Prostate Cancer: 2022 Update. J Am Coll Radiol 2023; 20:S164-S186. [PMID: 37236741 DOI: 10.1016/j.jacr.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 05/28/2023]
Abstract
Prostate cancer has a wide spectrum ranging between low-grade localized disease and castrate-resistant metastatic disease. Although whole gland and systematic therapies result in cure in the majority of patients, recurrent and metastatic prostate cancer can still occur. Imaging approaches including anatomic, functional, and molecular modalities are continuously expanding. Currently, recurrent and metastatic prostate cancer is grouped in three major categories: 1) Clinical concern for residual or recurrent disease after radical prostatectomy, 2) Clinical concern for residual or recurrent disease after nonsurgical local and pelvic treatments, and 3) Metastatic prostate cancer treated by systemic therapy (androgen deprivation therapy, chemotherapy, immunotherapy). This document is a review of the current literature regarding imaging in these settings and the resulting recommendations for imaging. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Baris Turkbey
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
| | - Aytekin Oto
- Panel Chair, University of Chicago, Chicago, Illinois
| | - Brian C Allen
- Panel Vice-Chair, Duke University Medical Center, Durham, North Carolina
| | - Oguz Akin
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Mim Ari
- The University of Chicago, Chicago, Illinois, Primary care physician
| | | | - Pat F Fulgham
- Urology Clinics of North Texas, Dallas, Texas; American Urological Association
| | | | | | - Seth A Rosenthal
- Sutter Medical Group, Sacramento, California; Commission on Radiation Oncology
| | - Nicola Schieda
- Ottawa Hospital Research Institute and the Department of Radiology, The University of Ottawa, Ottawa, Ontario, Canada
| | - David M Schuster
- Emory University, Atlanta, Georgia; Commission on Nuclear Medicine and Molecular Imaging
| | | | - Mark E Lockhart
- Specialty Chair, University of Alabama at Birmingham, Birmingham, Alabama
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12
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Salvage Radiotherapy versus Observation for Biochemical Recurrence following Radical Prostatectomy for Prostate Cancer: A Matched Pair Analysis. Cancers (Basel) 2022; 14:cancers14030740. [PMID: 35159007 PMCID: PMC8833698 DOI: 10.3390/cancers14030740] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/23/2022] [Accepted: 01/26/2022] [Indexed: 02/01/2023] Open
Abstract
Simple Summary Salvage radiotherapy improves oncologic outcomes in prostate cancer patients who develop biochemical recurrence after radical prostatectomy. However, the evidence on hard clinical endpoints is scarce. Within this study, we compare the long-term oncologic outcomes of patients with biochemical recurrence after prostatectomy, who were treated with either salvage radiotherapy or no radiotherapy. Our results show that patients who were treated with salvage radiotherapy after the development of biochemical recurrence following radical prostatectomy had a lower risk of developing metastasis and lower risk of death within the follow-up. These findings further underline the curative potential of salvage radiotherapy in the case of biochemical recurrence after radical prostatectomy, and should be discussed with these patients. Abstract Background: Salvage radiotherapy (SRT) improves oncologic outcomes in prostate cancer (PCa) patients who develop biochemical recurrence (BCR) after radical prostatectomy (RP). However, evidence on hard clinical endpoints is scarce. We compare long-term oncologic outcomes of SRT versus no radiotherapy (noRT) in patients with BCR after RP. Patients and methods: Within a multi-institutional database, we identified patients with BCR after RP between 1989 and 2016 for PCa. Patients with lymph node invasion, with adjuvant radiotherapy, or with additional androgen deprivation therapy at BCR were excluded. In all patients with SRT, SRT was delivered to the prostatic bed only. Propensity score matching (PSM) was performed to account for differences in pathologic tumor characteristics. Kaplan–Meier analyses and Cox regression models tested the effect of SRT versus no RT on metastasis-free (MFS) and overall survival (OS). Results: Of 1832 patients with BCR, 32.9% (n = 603) received SRT without ADT. The median follow-up was 95.9 months. Median total SRT dose was 70.2 Gy. After 1:1 PSM, at 15 years after RP, MFS and OS rates were 84.3 versus 76.9% (p < 0.001) and 85.3 versus 74.4% (p = 0.04) for SRT and noRT, respectively. In multivariable Cox regression models, SRT was an independent predictor for metastasis (HR: 0.37, p < 0.001) and OS (HR: 0.64, p = 0.03). Conclusion: This is the first matched-pair analysis investigating the impact of SRT versus observation only in post-RP recurrent PCa. After compensating for established risk factors, SRT was associated with better long-term MFS and OS. These results on clinical endpoints underline the curative potential of SRT.
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13
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Breen WG, Stish BJ, Harmsen WS, Froemming AT, Mynderse LA, Choo CR, Davis BJ, Pisansky TM. The prognostic value, sensitivity, and specificity of multiparametric magnetic resonance imaging before salvage radiotherapy for prostate cancer. Radiother Oncol 2021; 161:9-15. [PMID: 34023327 DOI: 10.1016/j.radonc.2021.05.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 04/27/2021] [Accepted: 05/16/2021] [Indexed: 12/12/2022]
Abstract
AIM To determine the operational characteristics of pelvic magnetic resonance imaging (MRI) prior to salvage radiation therapy (SRT) for biochemically recurrent prostate cancer following radical prostatectomy. METHODS AND MATERIALS We reviewed the medical records of 386 patients who underwent MRI prior to SRT. We assessed associations of pre-SRT MRI findings with biochemical recurrence (BCR), distant metastasis (DM), prostate cancer-specific mortality (PCSM), and salvage androgen deprivation therapy (ADT) use following SRT. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of MRI for detecting local recurrence were also calculated. RESULTS Pre-SRT MRI was positive for local recurrence in 216 patients (56%), indeterminate in 46 (12%), and negative in 124 (32%). On univariate analysis, BCR following SRT was significantly less likely for patients with positive (HR: 0.58, 95% CI: 0.42-0.8) or indeterminate (HR: 0.6: 0.36-1) MRI findings, compared to patients with negative imaging (p = 0.003). These associations remained significant on multivariate analysis (p < 0.05) and across pre-SRT PSA groups. For the entire cohort, the sensitivity of MRI for local recurrence was 61.0% (53.5-68.1%), specificity 60.0% (44.3-73.0%), PPV 86.1% (78.9-91.5%) and NPV 27.6% (19.0-37.5%). Sensitivity of MRI was better in men with higher pre-SRT PSA (80.0% for PSA > 1.0), and specificity was improved with lower pre-SRT PSA (73.9% for PSA 0.1-0.5). CONCLUSIONS Positive or indeterminate MRI findings prior to SRT were associated with improved biochemical control following SRT, across PSA levels. The sensitivity and specificity of MRI for local recurrence were 61% and 58.7%, respectively.
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Affiliation(s)
- William G Breen
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA
| | - Bradley J Stish
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA.
| | - William S Harmsen
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, USA
| | | | | | - C Richard Choo
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA
| | - Brian J Davis
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA
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14
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Inokuchi J, Yokomizo A, Nishiyama N, Kitamura H, Eto M, Nishiyama H, Tomita Y. Perioperative therapies for urological cancers. Jpn J Clin Oncol 2020; 50:357-367. [PMID: 32115649 DOI: 10.1093/jjco/hyaa013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/04/2020] [Accepted: 01/23/2020] [Indexed: 12/25/2022] Open
Abstract
Although surgery with curative intent is critical for management of many localized cancers, multimodal therapy including neoadjuvant and adjuvant therapy has been introduced to increase the effectiveness of local control of surgery and prolong survival. However, strong evidence supporting the utility of such multimodal therapy is limited. The utility of perioperative chemotherapy has been extensively investigated in bladder cancer, and several randomized controlled trials have indicated the benefit of neoadjuvant cisplatin-based chemotherapy in muscle-invasive bladder cancer. Regrettably, perioperative therapy for other urological cancers is controversial; therefore, no definitive conclusions have been drawn. Recently, the number of trials has rapidly increased due to the development of immune checkpoint inhibitors, used alone or in combination with other modalities. In this review, we summarize the current status and supporting evidence for perioperative therapies such as neoadjuvant and adjuvant therapies for urological cancers, including prostate cancer, urothelial cancer and renal cell carcinoma.
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Affiliation(s)
- Junichi Inokuchi
- Department of Urology, Graduate School of Medical Sciences, Kyushu University
| | | | - Naotaka Nishiyama
- Department of Urology, Graduate School of Medicine and Pharmaceutical Sciences for Research, University of Toyama, Toyama
| | - Hiroshi Kitamura
- Department of Urology, Graduate School of Medicine and Pharmaceutical Sciences for Research, University of Toyama, Toyama
| | - Masatoshi Eto
- Department of Urology, Graduate School of Medical Sciences, Kyushu University
| | - Hiroyuki Nishiyama
- Department of Urology, Faculty of Medicine, University of Tsukuba, Ibaraki
| | - Yoshihiko Tomita
- Departments of Urology and Molecular Oncology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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15
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Yokomizo A, Wakabayashi M, Satoh T, Hashine K, Inoue T, Fujimoto K, Egawa S, Habuchi T, Kawashima K, Ishizuka O, Shinohara N, Sugimoto M, Yoshino Y, Nihei K, Fukuda H, Tobisu KI, Kakehi Y, Naito S. Salvage Radiotherapy Versus Hormone Therapy for Prostate-specific Antigen Failure After Radical Prostatectomy: A Randomised, Multicentre, Open-label, Phase 3 Trial (JCOG0401) †. Eur Urol 2019; 77:689-698. [PMID: 31866092 DOI: 10.1016/j.eururo.2019.11.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 11/29/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND No standard therapy has been established for localised prostate cancer patients with prostate-specific antigen (PSA) failure after radical prostatectomy (RP). OBJECTIVE To determine whether radiotherapy ± hormone therapy is superior to hormone therapy alone in such patients. DESIGN, SETTING, AND PARTICIPANTS This study is a multicentre, randomised, open-label, phase 3 trial. Patients with localised prostate cancer whose PSA concentrations had decreased to <0.1 ng/ml after RP, and then increased to 0.4-1.0 ng/ml, were randomised to the salvage hormone therapy (SHT) group (80 mg bicalutamide [BCL] followed by luteinising hormone-releasing hormone agonist in case of BCL failure) or the salvage radiation therapy (SRT) ± SHT group (64.8 Gy of SRT followed by the same regimen as in the SHT group in case of SRT failure). From May 2004 to May 2011, 210 patients (105 in each arm) were registered, with the median follow-up being 5.5 yr. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary endpoint was time to treatment failure (TTF) of BCL. RESULTS AND LIMITATIONS TTF of BCL was significantly longer in the SRT ± SHT group (8.6 yr) than in the SHT group (5.6 yr; hazard ratio 0.56, 90% confidence interval [0.40-0.77]; one-sided p = 0.001). Thirty-two of 102 patients (31%) in the SRT ± SHT group did not have SRT treatment failure. However, clinical relapse-free survival and overall survival did not differ between the arms. The most frequent grade 3-4 adverse event was erectile dysfunction (83 patients [80%] in the SHT group vs. 76 [74%] in the SRT ± SHT group). Limitations include the short follow-up periods and surrogate endpoint setting to allow definitive conclusions. CONCLUSIONS Initial SRT prolongs TTF of BCL in patients with post-RP PSA failure, indicating that SRT ± SHT is more beneficial than SHT alone. PATIENT SUMMARY Patients who have prostate-specific antigen failure after radical prostatectomy benefit from salvage radiation therapy prior to salvage hormone therapy.
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Affiliation(s)
- Akira Yokomizo
- Department of Urology, Harasanshin Hospital, Fukuoka, Japan
| | - Masashi Wakabayashi
- Japan Clinical Oncology Group Data Centre/Operations Office, National Cancer Centre Hospital, Tokyo, Japan
| | - Takefumi Satoh
- Department of Urology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Katsuyoshi Hashine
- Department of Urology, National Hospital Organization Shikoku Cancer Centre, Ehime, Japan
| | - Takahiro Inoue
- Department of Urology, Kyoto University Hospital, Kyoto, Japan
| | | | - Shin Egawa
- Department of Urology, Jikei University Hospital, Tokyo, Japan
| | - Tomonori Habuchi
- Department of Urology, Akita University Graduate School of Medicine, Akita, Japan
| | | | - Osamu Ishizuka
- Department of Urology, Shinshu University School of Medicine, Nagano, Japan
| | - Nobuo Shinohara
- Department of Renal and Genitourinary Surgery, Hokkaido University Hospital, Hokkaido, Japan
| | - Mikio Sugimoto
- Department of Urology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Yasushi Yoshino
- Department of Urology, Nagoya University School of Medicine, Nagoya, Japan
| | - Keiji Nihei
- Division of Radiation Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Centre, Komagome Hospital, Bunkyo City, Japan
| | - Haruhiko Fukuda
- Japan Clinical Oncology Group Data Centre/Operations Office, National Cancer Centre Hospital, Tokyo, Japan
| | - Ken-Ichi Tobisu
- Tokyo Metropolitan Cancer and Infectious disease Centre, Komagome Hospital, Bunkyo City, Japan
| | - Yoshiyuki Kakehi
- Department of Urology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Seiji Naito
- Department of Urology, Harasanshin Hospital, Fukuoka, Japan.
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16
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Conceptual review of key themes in treating prostate cancer in older adults. J Geriatr Oncol 2019; 11:893-898. [PMID: 31704035 DOI: 10.1016/j.jgo.2019.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 08/06/2019] [Accepted: 10/03/2019] [Indexed: 11/22/2022]
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17
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Jeong JU, Nam TK, Song JY, Yoon MS, Ahn SJ, Chung WK, Cho IJ, Kim YH, Cho SH, Jung SI, Kwon DD. Prognostic significance of lymphovascular invasion in patients with prostate cancer treated with postoperative radiotherapy. Radiat Oncol J 2019; 37:215-223. [PMID: 31591870 PMCID: PMC6790794 DOI: 10.3857/roj.2019.00332] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 08/14/2019] [Indexed: 11/18/2022] Open
Abstract
Purpose To determine prognostic significance of lymphovascular invasion (LVI) in prostate cancer patients who underwent adjuvant or salvage postoperative radiotherapy (PORT) after radical prostatectomy (RP) Materials and Methods A total of 168 patients with prostate cancer received PORT after RP, with a follow-up of ≥12 months. Biochemical failure after PORT was defined as prostate-specific antigen (PSA) ≥0.2 ng/mL after PORT or initiation of androgen deprivation therapy (ADT) for increasing PSA levels regardless of the value. We analyzed the clinical outcomes including survivals, failure patterns, and prognostic factors affecting the outcomes. Results In total, 120 patients (71.4%) received salvage PORT after PSA levels were >0.2 ng/mL or owing to clinical failure. The 5-year biochemical failure-free survival (BCFFS), clinical failure-free survival (CFFS), distant metastasis-free survival (DMFS), overall survival, and cause-specific survival rates were 78.3%, 94.3%, 95.0%, 95.8%, and 97.3%, respectively, during a follow-up range of 12–157 months (median: 64 months) after PORT. On multivariate analysis, PSA level of ≤1.0 ng/mL at the time of receiving PORT predicted favorable BCFFS, CFFS, and DMFS. LVI predicted worse CFFS (p = 0.004) and DMFS (p = 0.015). Concurrent and/or adjuvant ADT resulted in favorable prognosis for BCFFS (p < 0.001) and CFFS (p = 0.017). Conclusion For patients with adverse pathologic findings, PORT should be initiated as early as possible after continence recovery after RP. Even after administering PORT, LVI was an unfavorable predictive factor, and further intensive adjuvant therapy should be considered for these patients.
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Affiliation(s)
- Jae-Uk Jeong
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Taek-Keun Nam
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Ju-Young Song
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Mee Sun Yoon
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Sung-Ja Ahn
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Woong-Ki Chung
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Ick Joon Cho
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Yong-Hyub Kim
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Shin Haeng Cho
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Seung Il Jung
- Department of Urology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Dong Deuk Kwon
- Department of Urology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
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Lee SU, Cho KH, Park W, Cho WK, Kim JS, Wee CW, Kim YS, Kim JH, Nam TK, Cho J, Jeong SM, Kim Y, Shim SJ, Choi Y, Kim JS. Clinical Outcomes of Postoperative Radiotherapy Following Radical Prostatectomy in Patients with Localized Prostate Cancer: A Multicenter Retrospective Study (KROG 18-01) of a Korean Population. Cancer Res Treat 2019; 52:167-180. [PMID: 31291715 PMCID: PMC6962467 DOI: 10.4143/crt.2019.126] [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: 03/26/2019] [Accepted: 06/21/2019] [Indexed: 11/21/2022] Open
Abstract
PURPOSE The purpose of this study was to investigate the clinical outcomes of postoperative radiotherapy (PORT) patients who underwent radical prostatectomy for localized prostate cancer. Materials and Methods Localized prostate cancer patients who received PORT after radical prostatectomy between 2001 and 2012 were identified retrospectively in a multi-institutional database. In total, 1,117 patients in 19 institutions were included. Biochemical failure after PORT was defined as prostate-specific antigen (PSA) ≥ nadir+2 after PORT or initiation of androgen deprivation therapy (ADT) for increasing PSA regardless of its value. RESULTS Ten-year biochemical failure-free survival, clinical failure-free survival, distant metastasisfree survival, overall survival (OS), and cause-specific survival were 60.5%, 76.2%, 84.4%, 91.1%, and 96.6%, respectively, at a median of 84 months after PORT. Pre-PORT PSA ≤ 0.5 ng/ml and Gleason's score ≤ 7 predicted favorable clinical outcomes, with 10-year OS rates of 92.5% and 94.1%, respectively. The 10-year OS rate was 82.7% for patients with a PSA > 1.0 ng/mL and 86.0% for patients with a Gleason score of 8-10. The addition of longterm ADT (≥ 12 months) to PORT improved OS, particularly in those with a Gleason score of 8-10 or ≥ T3b. CONCLUSION Clinical outcomes of PORT in a Korean prostate cancer population were very similar to those in Western countries. Lower Gleason score and serum PSA level at the time of PORT were significantly associated with favorable outcomes. Addition of long-term ADT (≥ 12 months) to PORT should be considered, particularly in unfavorable risk patients with Gleason scores of 8-10 or ≥ T3b.
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Affiliation(s)
- Sung Uk Lee
- The Proton Therapy Center, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Kwan Ho Cho
- The Proton Therapy Center, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Kyung Cho
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae-Sung Kim
- Department of Radiation Oncology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Chan Woo Wee
- Department of Radiation Oncology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Young Seok Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Ho Kim
- Department of Radiation Oncology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Taek-Keun Nam
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University College of Medicine, Hwasun, Korea
| | - Jaeho Cho
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Song Mi Jeong
- Department of Radiation Oncology, Ewha Womans University Medical Center, Ewha Womans University College of Medicine, Seoul, Korea
| | - Youngkyong Kim
- Department of Radiation Oncology, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Su Jung Shim
- Department of Radiation Oncology, Eulji Hospital, Eulji University School of Medicine, Seoul, Korea
| | - Youngmin Choi
- Department of Radiation Oncology, Dong-A University Hospital, Dong-A University School of Medicine, Busan, Korea
| | - Jun-Sang Kim
- Department of Radiation Oncology, Chungnam National University College of Medicine, Daejeon, Korea
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Van den Broeck T, van den Bergh RCN, Arfi N, Gross T, Moris L, Briers E, Cumberbatch M, De Santis M, Tilki D, Fanti S, Fossati N, Gillessen S, Grummet JP, Henry AM, Lardas M, Liew M, Rouvière O, Pecanka J, Mason MD, Schoots IG, van Der Kwast TH, van Der Poel HG, Wiegel T, Willemse PPM, Yuan Y, Lam TB, Cornford P, Mottet N. Prognostic Value of Biochemical Recurrence Following Treatment with Curative Intent for Prostate Cancer: A Systematic Review. Eur Urol 2019; 75:967-987. [PMID: 30342843 DOI: 10.1016/j.eururo.2018.10.011] [Citation(s) in RCA: 257] [Impact Index Per Article: 51.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 10/03/2018] [Indexed: 11/17/2022]
Abstract
CONTEXT In men with prostate cancer (PCa) treated with curative intent, controversy exists regarding the impact of biochemical recurrence (BCR) on oncological outcomes. OBJECTIVE To perform a systematic review of the existing literature on BCR after treatment with curative intent for nonmetastatic PCa. Objective 1 is to investigate whether oncological outcomes differ between patients with or without BCR. Objective 2 is to study which clinical factors and tumor features in patients with BCR have an independent prognostic impact on oncological outcomes. EVIDENCE ACQUISITION Medline, Medline In-Process, Embase, and the Cochrane Central Register of Controlled Trials were searched. For objective 1, prospective and retrospective studies comparing survival outcomes of patients with or without BCR following radical prostatectomy (RP) or radical radiotherapy (RT) were included. For objective 2, all studies with at least 100 participants and reporting on prognostic patient and tumor characteristics in patients with BCR were included. Risk-of-bias and confounding assessments were performed according to the Quality in Prognosis Studies tool. Both a narrative synthesis and a meta-analysis were undertaken. EVIDENCE SYNTHESIS Overall, 77 studies were included for analysis, of which 14 addressed objective 1, recruiting 20 406 patients. Objective 2 was addressed by 71 studies with 29 057, 11 301, and 4272 patients undergoing RP, RT, and a mixed population (mix of patients undergoing RP or RT as primary treatment), respectively. There was a low risk of bias for study participation, confounders, and statistical analysis. For most studies, attrition bias, and prognostic and outcome measurements were not clearly reported. BCR was associated with worse survival rates, mainly in patients with short prostate-specific antigen doubling time (PSA-DT) and a high final Gleason score after RP, or a short interval to biochemical failure (IBF) after RT and a high biopsy Gleason score. CONCLUSIONS BCR has an impact on survival, but this effect appears to be limited to a subgroup of patients with specific clinical risk factors. Short PSA-DT and a high final Gleason score after RP, and a short IBF after RT and a high biopsy Gleason score are the main factors that have a negative impact on survival. These factors may form the basis of new BCR risk stratification (European Association of Urology BCR Risk Groups), which needs to be validated formally. PATIENT SUMMARY This review looks at the risk of death in men who shows rising prostate-specific antigen (PSA) in the blood test performed after curative surgery or radiotherapy. For many men, rising PSA does not mean that they are at a high risk of death from prostate cancer in the longer term. Men with PSA that rises shortly after they were treated with radiotherapy or rapidly rising PSA after surgery and a high tumor grade for both treatment modalities are at the highest risk of death. These factors may form the basis of new risk stratification (European Association of Urology biochemical recurrence Risk Groups), which needs to be validated formally.
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Affiliation(s)
- Thomas Van den Broeck
- Department of Urology, University Hospitals Leuven, Leuven, Belgium; Laboratory of Molecular Endocrinology, KU Leuven, Leuven, Belgium.
| | | | - Nicolas Arfi
- Department of Urology, Hospital Saint Luc Saint Joseph, Lyon, France
| | - Tobias Gross
- Department of Urology, University of Bern, Inselspital, Bern, Switzerland
| | - Lisa Moris
- Department of Urology, University Hospitals Leuven, Leuven, Belgium; Laboratory of Molecular Endocrinology, KU Leuven, Leuven, Belgium
| | | | | | - Maria De Santis
- Charite Universitätsmedizin, Berlin, Germany; Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Stefano Fanti
- Nuclear Medicine Division, Policlinico S. Orsola, University of Bologna, Italy
| | - Nicola Fossati
- Unit of Urology/Division of Oncology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Università Vita-Salute San Raffaele, Milan, Italy
| | - Silke Gillessen
- Division of Cancer Sciences, University of Manchester and The Christie, Manchester, UK; Department of Oncology and Haematology, Cantonal Hospital St Gallen, St Gallen, Switzerland; University of Bern, Bern, Switzerland
| | - Jeremy P Grummet
- Department of Surgery, Central Clinical School, Monash University, Caulfield North, Victoria, Australia
| | - Ann M Henry
- Leeds Cancer Centre, St. James's University Hospital and University of Leeds, Leeds, UK
| | | | - Matthew Liew
- Department of Urology, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Olivier Rouvière
- Hospices Civils de Lyon, Radiology Department, Edouard Herriot Hospital, Lyon, France
| | - Jakub Pecanka
- Pecanka Consulting Services, Prague, Czech Republic; Department of Biomedical Data Sciences, University Medical Center, Leiden, The Netherlands
| | - Malcolm D Mason
- Division of Cancer & Genetics, School of Medicine Cardiff University, Velindre Cancer Centre, Cardiff, UK
| | - Ivo G Schoots
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Henk G van Der Poel
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Thomas Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany
| | | | - Yuhong Yuan
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Thomas B Lam
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK; Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Philip Cornford
- Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, UK
| | - Nicolas Mottet
- Department of Urology, University Hospital, St. Etienne, France
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Galla A, Maggio A, Delmastro E, Garibaldi E, Gabriele P, Bresciani S, Di Dia A, Stasi M, Gabriele D. Salvage radiation therapy after radical prostatectomy: survival analysis. MINERVA UROL NEFROL 2019; 71:240-248. [DOI: 10.23736/s0393-2249.18.03124-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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21
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Elective pelvic irradiation in prostate cancer patients with biochemical failure following radical prostatectomy: A propensity score matching analysis. PLoS One 2019; 14:e0215057. [PMID: 30973905 PMCID: PMC6459518 DOI: 10.1371/journal.pone.0215057] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 03/26/2019] [Indexed: 11/19/2022] Open
Abstract
Purpose To investigate whether whole pelvic radiotherapy (WPRT) improves biochemical relapse-free survival (bRFS) vs. prostate bed radiotherapy (PBRT) in prostate cancer patients receiving salvage radiotherapy (SRT) after radical prostatectomy. Methods Data from patients with prostate cancer who underwent SRT for biochemical recurrence between 2005 and 2012 in two academic institutions were retrospectively reviewed. Patients treated with WPRT in one hospital were compared with patients treated with PBRT in the other. Propensity scoring was performed to balance the characteristics of the different treatment groups, and bRFS was compared. Results Data from a total of 191 patients were included in the analysis (WPRT, n = 108; PBRT, n = 83). The median follow-up period was 66 months. Prior to matching, patients who received WPRT had higher pathologic Gleason scores as well as a higher incidence of pre-SRT PSA levels >0.5 ng/mL and lower rates of concurrent androgen-deprivation therapy. Propensity score matching balanced these characteristics and generated a cohort comprising 56 patients from each group. In the matched cohort, the 5 year bRFS of the WPRT group was significantly higher than that of the PBRT group (65.9 vs. 42.2%, p = 0.017). Multivariate analysis revealed that WPRT was an independent prognostic factor for bRFS (hazard ratio: 0.45, 95% confidence interval: 0.26–0.75, p = 0.002). This benefit of WPRT on bRFS was maintained in subgroup analyses, especially in patients with preoperative PSA level ≤20 ng/mL or pre-SRT PSA level ≥0.4 ng/mL. Conclusions These data suggest that, following radical prostatectomy, elective WPRT during SRT may improve bRFS compared with PBRT in selected patients. Patients with preoperative PSA level ≤20 ng/mL or pre-SRT PSA level ≥0.4 ng/mL represent a potential subgroup who benefit most from receiving WPRT. Results of prospective randomized trials are awaited to confirm this finding.
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Bruni A, Ingrosso G, Trippa F, Di Staso M, Lanfranchi B, Rubino L, Parente S, Frassinelli L, Maranzano E, Santoni R, Sighinolfi MC, Lohr F, Mazzeo E. Macroscopic locoregional relapse from prostate cancer: which role for salvage radiotherapy? Clin Transl Oncol 2019; 21:1532-1537. [PMID: 30868389 DOI: 10.1007/s12094-019-02084-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 03/07/2019] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Salvage radiotherapy (SRT) after radical prostatectomy for prostate cancer (PCa) is recommended as soon as PSA rises above 0.20 ng/ml, but many patients (pts) still experience local macroscopic relapse. The aim of this multicentric retrospective analysis was to evaluate the role of SRT in pts with macroscopic relapse. MATERIALS AND METHODS From 2001 to 2016, 105 consecutive pts with macroscopic PCa relapse underwent SRT ± androgen deprivation therapy (ADT). Mean age was 72 years. At time of relapse, 29 pts had a PSA value < 1.0 ng/mL, 50 from 1.1 to 5, and 25 pts > 5. Before SRT, 23 pts had undergone 18F-choline PET and 15 pts pelvic MRI. Ninety-four pts had prostatic bed relapse only, and four nodal involvement. Fifty-one pts were previously submitted to first-line ADT, while 6 pts received ≥ 2 lines. RESULTS At a median follow-up of 52 months, 89 pts were alive, while 16 were dead. Total RT dose to macroscopic lesions was > 70 Gy in 58 pts, 66-70 Gy in 43, and < 66 Gy in 4 pts. In 72 pts, target volume encompassed only the prostatic bed with sequential boost to macroscopic site; 33 pts received prophylactic pelvic RT. Ten-year overall survival was 76.1%, while distant metastasis-free survival was 73.3%. No grade 4-5 toxicities were found. CONCLUSIONS SRT ± ADT for macroscopic relapse showed a favorable oncological outcome supporting its important role in this scenario. Data from this series suggest that SRT may either postpone ADT or improve results over ADT alone in appropriately selected pts.
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Affiliation(s)
- A Bruni
- Radiotherapy Unit, University Hospital of Modena, Via del Pozzo 71, 41100, Modena, Italy.
| | - G Ingrosso
- Radiotherapy Unit, "Tor Vergata" University General Hospital, Rome, Italy
| | - F Trippa
- Radiotherapy Unit, "Santa Maria" University Hospital, Terni, Italy
| | - M Di Staso
- Radiotherapy Unit, "Nuovo San Salvatore" Hospital, L'Aquila, Italy
| | - B Lanfranchi
- Radiotherapy Unit, University Hospital of Modena, Via del Pozzo 71, 41100, Modena, Italy
| | - L Rubino
- Radiotherapy Unit, University Hospital of Modena, Via del Pozzo 71, 41100, Modena, Italy
| | - S Parente
- Radiotherapy Unit, "Nuovo San Salvatore" Hospital, L'Aquila, Italy
| | - L Frassinelli
- Radiotherapy Unit, University Hospital of Modena, Via del Pozzo 71, 41100, Modena, Italy
| | - E Maranzano
- Radiotherapy Unit, "Santa Maria" University Hospital, Terni, Italy
| | - R Santoni
- Radiotherapy Unit, "Tor Vergata" University General Hospital, Rome, Italy
| | - M C Sighinolfi
- Urology Unit, University Hospital of Modena, Modena, Italy
| | - F Lohr
- Radiotherapy Unit, University Hospital of Modena, Via del Pozzo 71, 41100, Modena, Italy
| | - E Mazzeo
- Radiotherapy Unit, University Hospital of Modena, Via del Pozzo 71, 41100, Modena, Italy
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Matsumoto K, Niwa N, Hattori S, Takeda T, Morita S, Kosaka T, Mizuno R, Shinojima T, Kikuchi E, Asanuma H, Oya M. Establishment of the optimal follow-up schedule after radical prostatectomy. Urol Oncol 2018; 36:341.e9-341.e14. [DOI: 10.1016/j.urolonc.2018.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 03/19/2018] [Accepted: 04/05/2018] [Indexed: 10/17/2022]
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Yang DD, Mahal BA, Muralidhar V, Vastola ME, Boldbaatar N, Labe SA, Nezolosky MD, Orio PF, King MT, Martin NE, Mouw KW, Trinh QD, Nguyen PL. Pathologic Outcomes of Gleason 6 Favorable Intermediate-Risk Prostate Cancer Treated With Radical Prostatectomy: Implications for Active Surveillance. Clin Genitourin Cancer 2018; 16:226-234. [DOI: 10.1016/j.clgc.2017.10.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 10/21/2017] [Accepted: 10/30/2017] [Indexed: 10/18/2022]
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Parent EE, Schuster DM. Update on 18F-Fluciclovine PET for Prostate Cancer Imaging. J Nucl Med 2018; 59:733-739. [PMID: 29523631 PMCID: PMC6910635 DOI: 10.2967/jnumed.117.204032] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 02/08/2018] [Indexed: 01/22/2023] Open
Abstract
PET is a functional imaging method that can exploit various aspects of tumor biology to enable greater detection of prostate cancer than can be provided by morphologic imaging alone. Anti-1-amino-3-18F-flurocyclobutane-1-carboxylic acid (18F-fluciclovine) is a nonnaturally occurring amino acid PET radiotracer that was recently approved by the U.S. Food and Drug Administration for detection of suspected recurrent prostate cancer. The tumor-imaging features of this radiotracer mirror the upregulation of transmembrane amino acid transport that occurs in prostate cancer because of increased amino acid metabolism for energy and protein synthesis. This continuing medical education article provides an overview on 18F-fluciclovine PET diagnostic capabilities for primary and metastatic disease, including reviews of published comparisons to conventional imaging and other molecular imaging agents. Additionally, the imaging procedure and image interpretation are detailed, including physiologic and pathologic uptake patterns and pitfalls.
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Affiliation(s)
- Ephraim E Parent
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - David M Schuster
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
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26
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ACR Appropriateness Criteria ® Post-treatment Follow-up Prostate Cancer. J Am Coll Radiol 2018; 15:S132-S149. [DOI: 10.1016/j.jacr.2018.03.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 03/04/2018] [Indexed: 11/23/2022]
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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.
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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.
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Adjuvant Radiation Therapy for High-Risk Post-prostatectomy Patients. Prostate Cancer 2018. [DOI: 10.1007/978-3-319-78646-9_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
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Zumsteg ZS, Daskivich TJ, Sandler HM. Salvage Radiotherapy for Biochemically Recurrent Prostate Cancer After Prostatectomy. J Clin Oncol 2017; 34:3829-3833. [PMID: 27573664 DOI: 10.1200/jco.2016.69.2509] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice. A 67-year-old man had presented to his primary physician for routine health maintenance. A digital rectal examination was performed and revealed a suspicious nodule in the right lobe of the prostate without any extraprostatic extension. A serum prostate-specific antigen (PSA) test was 12.4 ng/mL. He had no previous PSA tests. Transrectal ultrasound-guided prostate biopsy showed Gleason 3 + 4 prostate adenocarcinoma in seven of 12 cores. Bone scan and computed tomography scan of the pelvis showed no evidence of metastatic disease, and the patient underwent a robotic-assisted radical prostatectomy with bilateral pelvic lymphadenectomy. Pathology revealed Gleason 3 + 4 adenocarcinoma bilaterally, with extracapsular extension, no seminal vesicle invasion, a 2-mm positive margin at the right mid gland, and 0 of 15 lymph nodes containing adenocarcinoma. Two months after surgery, he had mild stress urinary incontinence and PSA of < 0.1 ng/mL. Adjuvant radiotherapy was discussed, but he elected to have careful follow-up. His PSA was monitored every 6 months and gradually increased from < 0.1 ng/mL to 0.4 ng/mL over the next 3 years. He was asymptomatic. He was referred to discuss the role of salvage radiotherapy.
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Stish BJ, Pisansky TM, Harmsen WS, Davis BJ, Tzou KS, Choo R, Buskirk SJ. Improved Metastasis-Free and Survival Outcomes With Early Salvage Radiotherapy in Men With Detectable Prostate-Specific Antigen After Prostatectomy for Prostate Cancer. J Clin Oncol 2017; 34:3864-3871. [PMID: 27480153 DOI: 10.1200/jco.2016.68.3425] [Citation(s) in RCA: 161] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Purpose To describe outcomes of salvage radiotherapy (SRT) for men with detectable prostate-specific antigen (PSA) after radical prostatectomy for prostate cancer and identify associations with outcomes. Patients and Methods A total of 1,106 patients received SRT between January 1987 and July 2013, with median follow-up 8.9 years. Outcomes were estimated using Kaplan-Meier for overall survival (OS) and cumulative incidence for biochemical recurrence (BcR), distant metastases (DM), and cause-specific mortality (CSM). Variable associations with outcomes used Cox or Fine-Gray methods, as appropriate. Multiple variable analyses used backward selection with P < .05 for retention. Results In multiple variable analyses, pathologic tumor stage, Gleason score, and pre-SRT PSA were associated with BcR, DM, CSM, and OS; androgen suppression and SRT doses > 68 Gy were associated with BcR; and age was associated with OS. Each pre-SRT PSA doubling increased significantly the relative risk of BcR (hazard ratio [HR], 1.30; P < .001), DM (HR, 1.32; P < .001), CSM (HR, 1.40; P < .001), and all-cause mortality (HR, 1.12; P = .02). Using a pre-SRT PSA cutoff ≤ 0.5 versus > 0.5 ng/mL, 5-year and 10-year cumulative incidences for BcR were 42% versus 56% and 60% versus 68% ( P < .001), DM 7% versus 14% and 13% versus 25% ( P < .001), CSM 1% versus 4% and 6% versus 13% ( P < .001), and OS of 94% versus 92% and 83% versus 73% ( P > .05). Conclusion SRT outcomes are in part affected by factors associated with prostatectomy findings but may be positively affected by using SRT at lower PSA levels, including reductions in BcR, DM, CSM, and all-cause mortality. These findings argue against prolonged monitoring of detectable postprostatectomy PSA levels that delay initiation of SRT.
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Affiliation(s)
- Bradley J Stish
- Bradley J. Stish, Thomas M. Pisansky, William S. Harmsen, Brian J. Davis, and Richard Choo, Mayo Clinic, Rochester MN; and Katherine S. Tzou and Steven J. Buskirk, Mayo Clinic, Jacksonville FL
| | - Thomas M Pisansky
- Bradley J. Stish, Thomas M. Pisansky, William S. Harmsen, Brian J. Davis, and Richard Choo, Mayo Clinic, Rochester MN; and Katherine S. Tzou and Steven J. Buskirk, Mayo Clinic, Jacksonville FL
| | - William S Harmsen
- Bradley J. Stish, Thomas M. Pisansky, William S. Harmsen, Brian J. Davis, and Richard Choo, Mayo Clinic, Rochester MN; and Katherine S. Tzou and Steven J. Buskirk, Mayo Clinic, Jacksonville FL
| | - Brian J Davis
- Bradley J. Stish, Thomas M. Pisansky, William S. Harmsen, Brian J. Davis, and Richard Choo, Mayo Clinic, Rochester MN; and Katherine S. Tzou and Steven J. Buskirk, Mayo Clinic, Jacksonville FL
| | - Katherine S Tzou
- Bradley J. Stish, Thomas M. Pisansky, William S. Harmsen, Brian J. Davis, and Richard Choo, Mayo Clinic, Rochester MN; and Katherine S. Tzou and Steven J. Buskirk, Mayo Clinic, Jacksonville FL
| | - Richard Choo
- Bradley J. Stish, Thomas M. Pisansky, William S. Harmsen, Brian J. Davis, and Richard Choo, Mayo Clinic, Rochester MN; and Katherine S. Tzou and Steven J. Buskirk, Mayo Clinic, Jacksonville FL
| | - Steven J Buskirk
- Bradley J. Stish, Thomas M. Pisansky, William S. Harmsen, Brian J. Davis, and Richard Choo, Mayo Clinic, Rochester MN; and Katherine S. Tzou and Steven J. Buskirk, Mayo Clinic, Jacksonville FL
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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.
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Artibani W, Porcaro AB, De Marco V, Cerruto MA, Siracusano S. Management of Biochemical Recurrence after Primary Curative Treatment for Prostate Cancer: A Review. Urol Int 2017; 100:251-262. [PMID: 29161715 DOI: 10.1159/000481438] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 09/12/2017] [Indexed: 12/27/2022]
Abstract
How to manage patients with prostate cancer (PCa) with biochemical recurrence (BCR) following primary curative treatment is a controversial issue. Importantly, this prostate-specific antigen (PSA)-only recurrence is a surrogate neither of PCa-specific survival nor of overall survival. Physicians are therefore challenged with preventing or delaying the onset of clinical progression in those deemed at risk, while avoiding over-treating patients whose disease may never progress beyond PSA-only recurrence. Adjuvant therapy for radical prostatectomy (RP) or local radiotherapy (RT) has a role in certain at-risk patients, although it is not recommended in low-risk PCa owing to the significant side-effects associated with RT and androgen deprivation therapy (ADT). The recommendations for salvage therapy differ depending on whether BCR occurs after RP or primary RT, and in either case, definitive evidence regarding the best strategy is lacking. Options for treatment of BCR after RP are RT at least to the prostatic bed, complete or intermittent ADT, or observation; for BCR after RT, salvage RP, cryotherapy, complete or intermittent ADT, brachytherapy, high-intensity focused ultrasound (HIFU), or observation can be considered. Many patient- and cancer-specific factors need to be taken into account when deciding on the best strategy, and optimal management depends on the involvement of a multidisciplinary team, consultation with the patient themselves, and the adoption of an individualised approach. Improvements in imaging techniques may enable earlier detection of metastases, which will hopefully refine future management decisions.
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Rodin D, Drumm M, Clayman R, Buscariollo DL, Galland-Girodet S, Eidelman A, Feldman AS, Dahl DM, McGovern FJ, Olumi AF, Niemierko A, Shipley WU, Zietman AL, Efstathiou JA. Risk Factors for Disease Progression After Postprostatectomy Salvage Radiation: Long-term Results of a Single-institution Experience. Clin Genitourin Cancer 2017; 16:S1558-7673(17)30236-7. [PMID: 28864223 DOI: 10.1016/j.clgc.2017.07.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/25/2017] [Accepted: 07/27/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Salvage radiotherapy (SRT) has been successfully used for recurrent prostate cancer after radical prostatectomy; however, the optimal timing of SRT remains controversial. Our objective was to identify the risk factors for disease progression after SRT, with a focus on the pre-SRT prostate-specific antigen (PSA) levels in the modern era of PSA testing. PATIENTS AND METHODS We performed a retrospective review of 551 consecutive patients who had undergone postradical prostatectomy SRT for recurrent prostate cancer from 2000 to 2013. The exclusion criteria were hormonal therapy before or concurrent with SRT, adjuvant RT, distant metastases, and missing data. Disease progression was defined as a repeat PSA level of ≥ 0.2 ng/mL greater than the post-SRT nadir, a continued increase in the PSA level despite SRT, initiation of systemic therapy, local recurrence, nodal failure, and/or distant metastases. Univariate and multivariable Cox regression analysis were performed to identify the predictors of disease progression. Secondarily, PSA kinetics were evaluated in the model and compared using the Akaike information criterion. RESULTS Of the 551 patients, 307 underwent SRT, of whom 134 experienced subsequent disease progression. The median interval to recurrence was 6.03 years (95% confidence interval, 3.74-8.36 years). On multivariable analysis, Gleason score, T stage, positive surgical margins, and pre-SRT PSA level were associated with progression; PSA kinetics did not independently predict for progression. When the pre-SRT PSA level was stratified (≤ 0.30, 0.31-0.50, 0.51-1.00, and > 1 ng/mL), incremental elevations were associated with an increased risk of disease progression. CONCLUSION Multiple factors predict for progression after SRT. These risk factors could help identify those who would derive the greatest benefit from additional systemic treatment. The findings of the present study also support initiation of early SRT, irrespective of the PSA kinetics.
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Affiliation(s)
- Danielle Rodin
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Michael Drumm
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | | | | | - Alec Eidelman
- Tufts University School of Dental Medicine, Boston, MA
| | - Adam S Feldman
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Douglas M Dahl
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Francis J McGovern
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Aria F Olumi
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Andrzej Niemierko
- Division of Biostatistics, Massachusetts General Hospital, Boston, MA
| | - William U Shipley
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Anthony L Zietman
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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Tumati V, Jackson WC, Abugharib AE, Raj G, Roehrborn C, Lotan Y, Courtney K, Bagrodia A, Gahan JC, Zumsteg ZS, Folkert MR, Laine AM, Hannan R, Spratt DE, Desai NB. Natural history of ‘second’ biochemical failure after salvage radiation therapy for prostate cancer: a multi-institution study. BJU Int 2017; 121:365-372. [DOI: 10.1111/bju.13926] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Vasu Tumati
- Department of Radiation Oncology; University of Texas Southwestern Medical Center; Dallas TX USA
| | - William C. Jackson
- Department of Radiation Oncology; University of Michigan; Ann Arbor MI USA
| | - Ahmed E. Abugharib
- Department of Radiation Oncology; University of Michigan; Ann Arbor MI USA
| | - Ganesh Raj
- Department of Urology; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Claus Roehrborn
- Department of Urology; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Yair Lotan
- Department of Urology; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Kevin Courtney
- Department of Internal Medicine; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Aditya Bagrodia
- Department of Urology; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Jeffrey C. Gahan
- Department of Urology; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Zachary S. Zumsteg
- Department of Radiation Oncology Cedars-Sinai Medical Center; Los Angeles CA USA
| | - Michael R. Folkert
- Department of Radiation Oncology; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Aaron M. Laine
- Department of Radiation Oncology; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Raquibul Hannan
- Department of Radiation Oncology; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Daniel E. Spratt
- Department of Radiation Oncology; University of Michigan; Ann Arbor MI USA
| | - Neil B. Desai
- Department of Radiation Oncology; University of Texas Southwestern Medical Center; Dallas TX USA
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Alves de Inda M, van Strijp D, den Biezen-Timmermans E, van Brussel A, Wrobel J, van Zon H, Vos P, Baillie GS, Tennstedt P, Schlomm T, Houslay MD, Bangma C, Hoffmann R. Validation of Cyclic Adenosine Monophosphate Phosphodiesterase-4D7 for its Independent Contribution to Risk Stratification in a Prostate Cancer Patient Cohort with Longitudinal Biological Outcomes. Eur Urol Focus 2017; 4:376-384. [PMID: 28753810 DOI: 10.1016/j.euf.2017.05.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 05/05/2017] [Accepted: 05/23/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND The clinical metrics used to date to assess the progression risk of newly diagnosed prostate cancer patients only partly represent the true biological aggressiveness of the underlying disease. OBJECTIVE Validation of the prognostic biomarker phosphodiesterase-4D7 (PDE4D7) in predicting longitudinal biological outcomes in a historical surgery cohort to improve postsurgical risk stratification. DESIGN, PATIENTS, AND METHODS RNA was extracted from biopsy punches of resected tumors from 550 patients. PDE4D7 was quantified using one-step quantitative reverse transcription-polymerase chain reaction. PDE4D7 scores were calculated by normalization of PDE4D7 to reference genes. Multivariate analyses were adjusted for clinical prognostic variables. Outcomes tested were: prostate-specific antigen relapse, start of salvage treatment, progression to metastases, overall mortality, and prostate cancer-specific mortality. The PDE4D7 score was combined with the clinical risk model Cancer of the Prostate Risk Assessment Postsurgical Score (CAPRA-S) using multivariate regression modeling; the combined score was tested in post-treatment progression free survival prediction. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Correlations with outcomes were analyzed using multivariate Cox regression and logistic regression statistics. RESULTS AND LIMITATIONS The PDE4D7 score was significantly associated with time-to-prostate specific antigen failure after prostatectomy (hazard ratio [HR]: 0.53, 95% confidence interval [CI]: 0.41-0.67 for each unit increase, p<0.0001). After adjustment for postsurgical prognostic variables the HR was 0.56 (95% CI: 0.43-0.73, p<0.0001). The PDE4D7 score remained significant after adjusting the multi-variate analysis for the CAPRA-S model categories (HR=0.54, 95% CI=0.42-0.69, p<0.0001). Combination of the PDE4D7 score with the CAPRA-S demonstrated a significant incremental value of 4-6% in 2-yr (p=0.004) or 5-yr (p=0.003) prediction of progression free survival after surgery. The combined model of PDE4D7 and CAPRA-S improves patient selection with very high risk of fast disease relapse after primary intervention. CONCLUSIONS The PDE4D7 score has the potential to provide independent risk information and to restratify patients with clinical intermediate- to high-risk characteristics to a very low-risk profile. PATIENT SUMMARY In this report, we studied the potential of a novel biomarker to predict outcomes of a cohort of prostate cancer patients who underwent surgery more than 10 yr ago. We found that a gene called phosphodiesterase-4D7 added extra information to the available clinical data. We conclude that the measurement of this gene in tumor tissue may contribute to more effective treatment decisions.
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Affiliation(s)
| | - Dianne van Strijp
- Philips Research Europe, High Tech Campus, Eindhoven, The Netherlands
| | | | - Anne van Brussel
- Philips Research Europe, High Tech Campus, Eindhoven, The Netherlands
| | - Janneke Wrobel
- Philips Research Europe, High Tech Campus, Eindhoven, The Netherlands
| | - Hans van Zon
- Philips Research Europe, High Tech Campus, Eindhoven, The Netherlands
| | - Pieter Vos
- Philips Research Europe, High Tech Campus, Eindhoven, The Netherlands
| | - George S Baillie
- Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, Scotland, UK
| | - Pierre Tennstedt
- Martini-Klinik Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thorsten Schlomm
- Martini-Klinik Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Miles D Houslay
- Institute of Pharmaceutical Science, King's College London, London, UK; Mironid Ltd, BioCity Scotland, Newhouse, Scotland, UK
| | - Chris Bangma
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ralf Hoffmann
- Philips Research Europe, High Tech Campus, Eindhoven, The Netherlands; Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, Scotland, UK.
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Yang DD, Muralidhar V, Mahal BA, Nezolosky MD, Labe SA, Vastola ME, Boldbaatar N, King MT, Martin NE, Orio PF, Choueiri TK, Trinh QD, Den RB, Spratt DE, Hoffman KE, Feng FY, Nguyen PL. Low rates of androgen deprivation therapy use with salvage radiation therapy in patients with prostate cancer after radical prostatectomy. Urol Oncol 2017; 35:542.e25-542.e32. [PMID: 28533151 DOI: 10.1016/j.urolonc.2017.04.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 04/12/2017] [Accepted: 04/24/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The RTOG 9601 and GETUG-AFU 16 randomized controlled trials demonstrated that the addition of androgen deprivation therapy (ADT) to salvage radiation therapy (SRT) improves progression-free and, for RTOG 9601, overall survival. We examined national trends in the use of ADT with SRT. MATERIALS AND METHODS Of the 484,009 patients in the National Cancer Database from 2004 to 2012 with localized or locally advanced prostate cancer treated with radical prostatectomy (RP), 4,200 men received SRT (≥6mo after surgery). We used Pearson's chi-squared test to evaluate changes in ADT use, and multiple logistic regression to examine predictors of ADT use. RESULTS Overall, 32.1% of SRT patients received ADT, which increased after initial results of RTOG 9601 showed an improvement in metastasis-free survival in 2010 (28.5% in 2008/2009 vs. 34.5% in 2011/2012, P = 0.006). Predictors of ADT use include presurgery prostate-specific antigen>20ng/ml vs.<10ng/ml (adjusted odds ratio [AOR] = 1.34, P = 0.002; 36.7% vs. 29.6%); positive vs. negative margins (AOR = 1.29, P = 0.001; 34.9% vs. 27.8%); Gleason 3+4 (AOR = 1.53; 21.3%), Gleason 4+3 (AOR = 2.40; 32.0%), or Gleason 8 to 10 (AOR = 4.49; 49.2%) vs. Gleason 2 to 6 (P≤0.005 for all; 13.2%); and pathologic T3a (AOR = 1.46; 30.9%), T3b (AOR = 2.50; 47.6%), or T4 (AOR = 4.14; 60.9%) vs. T2 (P<0.001 for all; 19.1%). Starting SRT 12 to 23.9 months (AOR = 0.69; 23.2%) or≥24 months (AOR = 0.25; 8.0%) after RP was associated with decreased odds of ADT use vs. starting SRT 6 to 8.9 months after RP (P≤0.002 for both; 35.0%). CONCLUSION Although less than one-third of SRT patients from the study era received ADT, there is evidence that physicians and patients have begun slowly adopting this practice with the 2010 reporting of a decrease in the cumulative incidence of metastases with the addition of ADT to SRT. Given the newly reported survival benefit of RTOG 9601, additional work will be necessary to identify which patients benefit the most from the use of ADT with SRT to individualize treatment.
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Affiliation(s)
| | | | - Brandon A Mahal
- Harvard Medical School, Boston, MA; Harvard Radiation Oncology Program, Boston, MA
| | - Michelle D Nezolosky
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA
| | - Shelby A Labe
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA
| | - Marie E Vastola
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA
| | - Ninjin Boldbaatar
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA
| | - Martin T King
- Harvard Medical School, Boston, MA; Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA
| | - Neil E Martin
- Harvard Medical School, Boston, MA; Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA
| | - Peter F Orio
- Harvard Medical School, Boston, MA; Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA
| | - Tni K Choueiri
- Harvard Medical School, Boston, MA; Department of Medical Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA
| | - Quoc-Dien Trinh
- Harvard Medical School, Boston, MA; Division of Urological Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
| | - Robert B Den
- Department of Radiation Oncology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Karen E Hoffman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Felix Y Feng
- Department of Medicine, Radiation Oncology, and Urology, Helen Diller Family Comprehensive Cancer Center, University of California at San Francisco, San Francisco, CA
| | - Paul L Nguyen
- Harvard Medical School, Boston, MA; Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA.
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Budäus L, Schiffmann J, Graefen M, Huland H, Tennstedt P, Siegmann A, Böhmer D, Budach V, Bartkowiak D, Wiegel T. Defining biochemical recurrence after radical prostatectomy and timing of early salvage radiotherapy : Informing the debate. Strahlenther Onkol 2017; 193:692-699. [PMID: 28470414 DOI: 10.1007/s00066-017-1140-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 04/07/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND The optimal prostate-specific antigen (PSA) level after radical prostatectomy (RP) for defining biochemical recurrence and initiating salvage radiation therapy (SRT) is still debatable. Whereas adjuvant or extremely early SRT irrespective of PSA progression might be overtreatment for some patients, SRT at PSA >0.2 ng/ml might be undertreatment for others. The current study addresses the optimal timing of radiation therapy after RP. PATIENTS AND METHODS Cohort 1 comprised 293 men with PSA 0.1-0.19 ng/ml after RP. Cohort 2 comprised 198 men with SRT. PSA progression and metastases were assessed in cohort 1. In cohort 2, we compared freedom from progression according to pre-SRT PSA (0.03-0.19 vs. 0.2-0.499 ng/ml). Multivariable Cox regression analyses predicted progression after SRT. RESULTS In cohort 1, 281 (95.9%) men had further PSA progression ≥0.2 ng/ml and 27 (9.2%) men developed metastases within a median follow-up of 74.3 months. In cohort 2, we recorded improved freedom from progression according to lower pre-SRT PSA (0.03-0.19 vs. 0.2-0.499 ng/ml: 69 vs. 53%; log-rank p = 0.051). Patients with higher pre-SRT PSA ≥0.2 ng/ml were at a higher risk of progression after SRT (hazard ratio: 1.8; p < 0.05). CONCLUSION The vast majority of patients with PSA ≥0.1 ng/ml after RP will progress to PSA ≥0.2 ng/ml. Additionally, early administration of SRT at post-RP PSA level <0.2 ng/ml might improve freedom from progression. Consequently, we suggest a PSA threshold of 0.1 ng/ml to define biochemical recurrence after RP.
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Affiliation(s)
- Lars Budäus
- Martini-Clinic, Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jonas Schiffmann
- Martini-Clinic, Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Markus Graefen
- Martini-Clinic, Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hartwig Huland
- Martini-Clinic, Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Pierre Tennstedt
- Martini-Clinic, Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alessandra Siegmann
- Department of Radiation Oncology, Charité University Hospital, Berlin, Germany
| | - Dirk Böhmer
- Department of Radiation Oncology, Charité University Hospital, Berlin, Germany
| | - Volker Budach
- Department of Radiation Oncology, Charité University Hospital, Berlin, Germany
| | - Detlef Bartkowiak
- Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany
| | - Thomas Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany
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Access to high-volume surgeons and the opportunity cost of performing radical prostatectomy by low-volume providers. Urol Oncol 2017; 35:459.e15-459.e24. [PMID: 28284890 DOI: 10.1016/j.urolonc.2017.01.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 01/15/2017] [Accepted: 01/30/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Evidence suggests that redirecting surgeries to high-volume providers may be associated with better outcomes and significant societal savings. Whether such referrals are feasible remains unanswered. METHODS Medicare Provider Utilization and Payment Data, SEER 18, and US Incidence data were used to determine the geographic distribution and radical prostatectomy volume for providers. Access was defined as availability of a high-volume provider within driving distance of 100 miles. The opportunity cost was defined as the value of benefits achievable by performing the surgery by a high-volume provider that was forgone by not making a referral. The savings per referral were derived from a published Markov model for radical prostatectomy. RESULTS A total of 14% of providers performed>27% of the radical prostatectomies with>30 cases per year and were designated high-volume providers. Providers with below-median volume (≤16 prostatectomies per year) performed>32% of radical prostatectomies. At least 47% of these were within a 100-mile driving distance (median = 22 miles), and therefore had access to a high-volume provider (>30 prostatectomies per year). This translated into a discounted savings of more than $24 million per year, representing the opportunity cost of not making a referral. The average volume for high- and low-volume providers was 55 and 13, respectively, resulting in an annual experience gap of 43 and a cumulative gap of 125 surgeries over 3 years. In 2014, the number of surgeons performing radical prostatectomy decreased by 5% while the number of high- and low-volume providers decreased by 25% and 11% showing a faster decline in the number of high-volume providers compared with low-volume surgeons. CONCLUSIONS About half of prostatectomies performed by surgeons with below-median annual volume were within a 100-mile driving distance (median of 22 miles) of a high-volume surgeon. Such a referral may result in minimal additional costs and substantially improved outcomes.
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Gandaglia G, Briganti A, Clarke N, Karnes RJ, Graefen M, Ost P, Zietman AL, Roach M. Adjuvant and Salvage Radiotherapy after Radical Prostatectomy in Prostate Cancer Patients. Eur Urol 2017; 72:689-709. [PMID: 28189428 DOI: 10.1016/j.eururo.2017.01.039] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 01/20/2017] [Indexed: 01/17/2023]
Abstract
CONTEXT Prostate cancer (PCa) patients found to have adverse pathologic features following radical prostatectomy (RP) are less likely to be cured with surgery alone. OBJECTIVE To analyze the role of postoperative radiotherapy (RT) in patients with aggressive PCa. EVIDENCE ACQUISITION We performed a systematic literature review of the Medline and EMBASE databases. The search strategy included the terms radical prostatectomy, adjuvant radiotherapy, and salvage radiotherapy, alone or in combination. We limited our search to studies published between January 2009 and August 2016. EVIDENCE SYNTHESIS Three randomized trials demonstrated that immediate RT after RP reduces the risk of recurrence in patients with aggressive PCa. However, immediate postoperative RT is associated with an increased risk of acute and late side effects ranging from 15% to 35% and 2% to 8%, respectively. Retrospective studies support the oncologic efficacy of initial observation followed by salvage RT administered at the first sign of recurrence; however, the impact of this delay on long-term control remains uncertain. Hopefully, ongoing randomized trials will shed light on the role of adjuvant RT versus observation±salvage RT in individuals with adverse features at RP. Accurate patient selection based on clinical characteristics and molecular profile is crucial. Dose escalation, whole-pelvis RT, novel techniques, and the use of hormonal therapy might improve the outcomes of postoperative RT. CONCLUSIONS Immediate RT reduces the risk of recurrence after RP in patients with aggressive disease. However, this approach is associated with an increase in the incidence of short- and long-term side effects. Observation followed by salvage RT administered at the first sign of recurrence might be associated with durable cancer control, but prospective randomized comparison with adjuvant RT is still awaited. Dose escalation, refinements in the technique, and the concomitant use of hormonal therapies might improve outcomes of patients undergoing postoperative RT. PATIENT SUMMARY Postoperative radiotherapy has an impact on oncologic outcomes in patients with aggressive disease characteristics. Salvage radiotherapy administered at the first sign of recurrence might be associated with durable cancer control in selected patients but might compromise cure in others.
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Affiliation(s)
- Giorgio Gandaglia
- Unit of Urology/Department of Oncology, URI, IRCCS San Raffaele Hospital, Milan, Italy.
| | - Alberto Briganti
- Unit of Urology/Department of Oncology, URI, IRCCS San Raffaele Hospital, Milan, Italy
| | - Noel Clarke
- Department of Urology, The Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
| | | | - Markus Graefen
- Martini-Clinic, Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Piet Ost
- Department of Radiation Oncology and Experimental Cancer Research, Ghent University Hospital, Ghent, Belgium
| | | | - Mack Roach
- Department of Radiation Oncology, University of California at San Francisco, San Francisco, CA, USA
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Narayan V, Vapiwala N, Mick R, Subramanian P, Christodouleas JP, Bekelman JE, Deville C, Rajendran R, Haas NB. Phase 1 Trial of Everolimus and Radiation Therapy for Salvage Treatment of Biochemical Recurrence in Prostate Cancer Patients Following Prostatectomy. Int J Radiat Oncol Biol Phys 2017; 97:355-361. [DOI: 10.1016/j.ijrobp.2016.10.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 09/28/2016] [Accepted: 10/12/2016] [Indexed: 12/15/2022]
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Change in Salvage Radiotherapy Management Based on Guidance With FACBC (Fluciclovine) PET/CT in Postprostatectomy Recurrent Prostate Cancer. Clin Nucl Med 2017; 42:e22-e28. [PMID: 27749412 DOI: 10.1097/rlu.0000000000001379] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE We explored the influence of FACBC (fluciclovine) PET/CT on the decision to offer radiotherapy and radiotherapy treatment field recommendations in postprostatectomy patients with recurrent prostate cancer. PATIENTS AND METHODS After obtaining institutional review board approval and informed consent, 87 patients with detectable prostate-specific antigen (PSA) levels were recruited into a prospective clinical trial. After an initial provider-determined radiotherapy plan based on conventional imaging, 44 of 87 patients were randomized to additionally undergo fluciclovine PET/CT. Pre- and post-fluciclovine radiotherapy decisions were compared and changes were noted. Statistical significance of these decision changes was determined. RESULTS Two of 44 patients in the experimental arm dropped out before fluciclovine scanning. Thirty-four (81.0%) of 42 had positive results on fluciclovine. Overall radiotherapy decision was changed in 17 (40.5%) of 42. Mean PSA, original Gleason score, and prostatectomy-PET interval did not differ significantly between patients with and without radiotherapy decision changes. Two (4.8%) of 42 had the decision for radiotherapy withdrawn due to positive extrapelvic findings. Radiotherapy field decision was changed in 15 (35.7%) of 42. Eleven (73.3%) of 15 had fields changed from prostate bed only to both prostate bed and pelvis, while 4 (26.7%) of 15 had fields changed from both prostate bed and pelvis to prostate bed only. Changes in overall radiotherapy decision and field were statistically significant (P < 0.0001). However, the change in the decision to offer radiotherapy or not was not statistically significant (P = 0.15). CONCLUSIONS Fluciclovine PET/CT significantly changed radiotherapy management decisions in postprostatectomy patients with recurrent prostate cancer. Further work in determining differences in PSA-free survival is ongoing.
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Rutenberg MS, Meister M, Amin PP, Hussain A, Naslund MJ, Kwok Y. Salvage external beam radiotherapy for locally recurrent prostate cancer after definitive brachytherapy. Brachytherapy 2016; 15:722-729. [DOI: 10.1016/j.brachy.2016.08.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 07/29/2016] [Accepted: 08/05/2016] [Indexed: 11/30/2022]
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Baumann R, Dunst J. [Begin salvage radiotherapy early after diagnosis of PSA recurrence]. Strahlenther Onkol 2016; 192:954-955. [PMID: 27785517 DOI: 10.1007/s00066-016-1059-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- René Baumann
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Feldstr. 21, 24105, Kiel, Deutschland.
| | - Jürgen Dunst
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Feldstr. 21, 24105, Kiel, Deutschland
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Moghanaki D, Turkbey B, Vapiwala N, Ehdaie B, Frank SJ, McLaughlin PW, Harisinghani M. Advances in Prostate Cancer Magnetic Resonance Imaging and Positron Emission Tomography-Computed Tomography for Staging and Radiotherapy Treatment Planning. Semin Radiat Oncol 2016; 27:21-33. [PMID: 27986208 DOI: 10.1016/j.semradonc.2016.08.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Conventional prostate cancer staging strategies have limited accuracy to define the location, grade, and burden of disease. Evaluations have historically relied upon prostate-specific antigen levels, digital rectal examinations, random systematic biopsies, computed tomography, pelvic lymphadenectomy, or 99mtechnetium methylene diphosphonate bone scans. Today, risk-stratification tools incorporate these data in a weighted format to guide management. However, the limitations and potential consequences of their uncertainties are well known. Inaccurate information may contribute to understaging and undertreatment, or overstaging and overtreatment. Meanwhile, advances in multiparametric magnetic resonance imaging (MRI), whole-body MRI, lymphotropic nanoparticle-enhanced MRI, and positron emission tomography are now available to improve the accuracy of risk stratification to facilitate more informed medical decisions. They also guide radiation oncologists to develop more accurate treatment plans. This review provides a primer to incorporate these advances into routine clinical workflow.
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Affiliation(s)
- Drew Moghanaki
- Radiation Oncology Service, Hunter Holmes McGuire VA Medical Center, Richmond, VA; Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA.
| | - Baris Turkbey
- Molecular Imaging Program, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Neha Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Behfar Ehdaie
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Steven J Frank
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Mukesh Harisinghani
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Long-term Impact of Adjuvant Versus Early Salvage Radiation Therapy in pT3N0 Prostate Cancer Patients Treated with Radical Prostatectomy: Results from a Multi-institutional Series. Eur Urol 2016; 71:886-893. [PMID: 27484843 DOI: 10.1016/j.eururo.2016.07.028] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 07/20/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Three prospective randomised trials reported discordant findings regarding the impact of adjuvant radiation therapy (aRT) versus observation for metastasis-free survival (MFS) and overall survival (OS) among patients with pT3N0 prostate cancer treated with radical prostatectomy (RP). None of these trials systematically included patients who underwent early salvage radiation therapy (esRT). OBJECTIVE To test the hypothesis that aRT was associated with better cancer control and survival compared with observation followed by esRT. DESIGN, SETTING, AND PARTICIPANTS Using a multi-institutional cohort from seven tertiary referral centres, we retrospectively identified 510 pT3pN0 patients with undetectable prostate-specific antigen (PSA) after RP between 1996 and 2009. Patients were stratified into two groups: aRT (group 1) versus observation followed by esRT in case of PSA relapse (group 2). Specifically, esRT was administered at a PSA level ≤0.5ng/ml. INTERVENTION We compared aRT versus observation followed by esRT. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The evaluated outcomes were MFS and OS. Multivariable Cox regression analyses tested the association between groups (aRT vs observation followed by esRT) and oncologic outcomes. Covariates consisted of pathologic stage (pT3a vs pT3b or higher), pathologic Gleason score (≤6, 7, or ≥8), surgical margin status (negative vs positive), and year of surgery. An interaction with groups and baseline patient risk was tested for the hypothesis that the impact of aRT versus observation followed by esRT was different by pathologic characteristics. The nonparametric curve fitting method was used to explore graphically the relationship between MFS and OS at 8 yr and baseline patient risk (derived from the multivariable analysis). RESULTS AND LIMITATIONS Overall, 243 patients (48%) underwent aRT, and 267 (52%) underwent initial observation. Within the latter group, 141 patients experienced PSA relapse and received esRT. Median follow-up after RP was 94 mo (interquartile range [IQR]: 53-126) and 92 mo (IQR: 70-136), respectively (p=0.2). MFS (92% vs 91%; p=0.9) and OS (89% vs 92%; p=0.9) at 8 yr after surgery were not significantly different between the two groups. These results were confirmed in multivariable analysis, in which observation followed by esRT was not associated with a significantly higher risk of distant metastasis (hazard ratio [HR]: 1.35; p=0.4) and overall mortality (HR: 1.39; p=0.4) compared with aRT. Using the nonparametric curve fitting method, a comparable proportion of MFS and OS at 8 yr among groups was observed regardless of pathologic cancer features (p=0.9 and p=0.7, respectively). Limitations consisted of the retrospective nature of the study and the relatively small size of the patient population. CONCLUSIONS At long-term follow-up, no significant differences between aRT and esRT were observed for MFS and OS. Our study, although based on retrospective data, suggests that esRT does not compromise cancer control and potentially reduces overtreatment associated with aRT. PATIENT SUMMARY At long-term follow-up, no significant differences in terms of distant metastasis and mortality were observed between immediate postoperative adjuvant radiation therapy (aRT) and initial observation followed by early salvage radiation therapy (esRT) in case of prostate-specific antigen relapse. Our study suggests that esRT does not compromise cancer control and potentially reduces overtreatment associated with aRT.
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Morlacco A, Karnes RJ. Early salvage radiation therapy post-prostatectomy: key considerations. Future Oncol 2016; 12:2579-2587. [PMID: 27387852 DOI: 10.2217/fon-2016-0208] [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: 11/21/2022] Open
Abstract
Post-prostatectomy radiotherapy (RT) is commonly employed to maximize oncologic outcomes in patients with pathologic adverse features (adjuvant RT]) or to treat men with prostate-specific antigen or local recurrence after initial observation (salvage RT [SRT]). Randomized controlled trials have been unable to compare adjuvant RT versus SRT; however, there is growing retrospective evidence that observation and early SRT (eSRT) may be a suitable. The issue of patient selection is crucial; several clinical tools and some newer biomarker-based tools might help in this process. Moreover, the optimal prostate-specific antigen threshold for eSRT, the RT dose, the irradiation field and the use of hormonal therapy are still open questions. In this article, we review the current literature on eSRT and provide some insights on what's happening for the future.
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Management of Postprostatectomy Biochemical Relapse With Salvage Radiotherapy: Results of an International Survey. Am J Clin Oncol 2016; 39:64-8. [PMID: 24390275 DOI: 10.1097/coc.0000000000000020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The management of patients with postprostatectomy salvage radiotherapy (SRT) presents radiation oncologists (ROs) with multiple treatment decisions that may impact outcomes. As the evidence addressing these issues is limited to retrospective data, it was hypothesized that widely disparate treatment paradigms exist. METHODS A 21-question survey was sent through SurveyMonkey to members of the American Society of Radiation Oncology. RESULTS A total of 999 ROs responded. Threshold rPSA values to initiate SRT ranged from 0.1 to 1 ng/mL. The highest dose prescribed by ROs ranged from <60 to >70.2 Gy. Elective lymph node irradiation was offered by 74%, and the majority (64%) referenced the Roach formula, Kattan nomogram, or D'Amico risk stratification to decide when it was appropriate. There was variability in pelvic field design with a preference to place the superior field border at either the upper, middle, or lower sacroiliac joint by 57.6%, 28.8%, and 13.6% of respondents, respectively. Adjuvant androgen deprivation therapy (ADT) was offered by 74%. CONCLUSIONS Disparate treatment paradigms exist for SRT that may impact patient outcomes. Variability includes patient selection, treatment design, and recommendations for ADT. Many reference formulas to predict the benefit of pelvic lymph node irradiation that are not yet validated in the postprostatectomy setting. These data make it clear that well-designed, prospective clinical trials are needed to better evaluate the role of larger treatment fields, dose escalation, and ADT for the thousands of patients who are treated with postprostatectomy SRT each year.
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Utilization of a Genomic Classifier for Prediction of Metastasis Following Salvage Radiation Therapy after Radical Prostatectomy. Eur Urol 2016; 70:588-596. [PMID: 26806658 DOI: 10.1016/j.eururo.2016.01.008] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 01/05/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Despite salvage radiation therapy (SRT) for recurrent prostate cancer (PCa) after radical prostatectomy (RP), some patients still progress to metastases. Identifying these men would allow them to undergo systemic therapy including testing novel therapies to reduce metastases risk. OBJECTIVE To test whether the genomic classifier (GC) predicts development of metastatic disease. DESIGN, SETTING, AND PARTICIPANTS Retrospective multi-center and multi-ethnic cohort study from two academic centers and one Veterans Affairs Medical Center in the United States involving 170 men receiving SRT for recurrent PCa post-RP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Time from SRT to development of metastatic disease tested using Cox regression, survival c-index, and decision curve analysis. Performance of GC was compared to the Cancer of the Prostate Risk Assessment Score and Briganti risk models based on these metrics. RESULTS AND LIMITATIONS With a median 5.7 yr follow-up after SRT, 20 patients (12%) developed metastases. On multivariable analysis, for each 0.1 unit increase in GC (scaled from 0 to 1), the hazard ratio for metastasis was 1.58 (95% confidence interval 1.16-2.17; p=0.002). Adjusting for androgen deprivation therapy did not materially change the results. The c-index for GC was 0.85 (95% confidence interval 0.73-0.88) versus 0.63-0.65 for published clinico-pathologic risk models. The 5-yr cumulative incidence of metastasis post-SRT in patients with low, intermediate, and high GC scores was 2.7%, 8.4%, and 33.1%, respectively (p<0.001). CONCLUSIONS While validation in larger, prospectively collected cohorts is required, these data suggest GC is a strong predictor of metastases among men receiving SRT for recurrent PCa post-RP, accurately identifying men who are excellent candidates for systemic therapy due to their very high-risk of metastases. PATIENT SUMMARY Genomic classifier and two clinico-pathologic risk models were evaluated on their ability to predict metastases among men receiving salvage radiation therapy for recurrent prostate cancer. Genomic classifier was able to identify candidates for further therapies due to their very high-risk of metastases.
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A phase 2 multimodality trial of docetaxel/prednisone with sunitinib followed by salvage radiation therapy in men with PSA recurrent prostate cancer after radical prostatectomy. Prostate Cancer Prostatic Dis 2016; 19:100-6. [PMID: 26754260 DOI: 10.1038/pcan.2015.59] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 10/21/2015] [Accepted: 11/17/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND In men with high Gleason PC and rapid PSA progression after surgery, failure rates remain unacceptably high despite salvage radiation. We explored a novel multimodality approach of docetaxel with anti-angiogenic therapy before salvage radiotherapy (RT). METHODS This was a phase 2 single-arm prospective open-label trial with historic controls. Eligible men had a rising PSA of 0.1-3.0 ng ml(-1) within 4 years of radical prostatectomy, no metastases except resected nodal disease, no prior androgen-deprivation therapy (ADT) and Gleason 7-10. Men received four cycles of docetaxel 70 mg m(-2) every 3 weeks with low dose prednisone and sunitinib 37.5 mg daily for 14/21 days each cycle, with no ADT. Salvage prostate bed RT (66 Gy) started at day 100. The primary end point was progression-free survival (PFS) rate at 24 months. Safety data, quality of life (QOL) and dose-limiting toxicities (DLTs) were measured over time. RESULTS Thirty-four men accrued in this multi-institutional clinical trial: 24% of men were node positive, 47% were Gleason 8-10, median PSA at entry was 0.54. The trial was terminated prematurely owing to excess DLTs (nine) including grade 3 hand-foot syndrome (n=4), neutropenic fever (n=2), AST increase (n=1), fatigue (n=1) and vomiting with diarrhea (n=1). PFS rate at 24 months was 51% (95% CI: 33, 67%) with a median PFS of 26.2 months (95% CI: 12.5, -). Six men (17.6%) had an undetectable PSA at 2 years. CONCLUSIONS Sunitinib and docetaxel/prednisone followed by salvage RT resulted in excess pre-specified DLTs. Although nearly half of the men experienced durable disease control, efficacy was not greater than expected with radiation alone. The use of the intermediate end point of PFS in this salvage setting permitted an early decision on further development of this combination.
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