Radical prostatectomy for high-risk prostate cancer

Role of Lutetium Radioligand Therapy in Prostate Cancer

Theranostics utilize ligands that chelate radionuclides and selectively bind with cancer-specific membrane antigens. In the case of prostate cancer (PCa), the state-of-the-art lutetium-177-PSMA combines the radioactive β-emitter 177Lu with Vipivotide Tetraxetan, a prostate-specific membrane antigen (PSMA)-binding ligand. Several studies have been conducted, and the therapy is not without adverse effects (e.g., xerostomia, nausea, and fatigue); however, few events are reported as severe. The available evidence supports the use of 177Lu-PSMA in selected metastatic castration-resistant prostate cancer patients, and the treatment is considered a standard of care in several clinical scenarios. Emerging research shows promising results in the setting of hormone-sensitive prostate cancer; however, evidence from high-quality controlled trials is still missing. In this review, we discuss the available evidence for the application of 177Lu-PSMA in the management of PCa patients.

Neoadjuvant 177Lu-PSMA-I&T Radionuclide Treatment in Patients with High-risk Prostate Cancer Before Radical Prostatectomy: A Single-arm Phase 1 Trial

BACKGROUND

High-risk localized prostate cancer (HRLPC) has a substantial risk of disease progression despite local treatment. Neoadjuvant systemic therapy before definitive local therapy may improve oncological outcomes by targeting the primary tumor and micrometastatic disease.

OBJECTIVE

To evaluate whether a lutetium-177 prostate-specific membrane antigen radioligand (LuPSMA) can be safely administered to patients with HRLPC before robot-assisted radical prostatectomy (RARP) and to describe immediate oncological outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This was an open-label, single-arm clinical trial. Patients with HRLPC and elevated radioligand uptake on PSMA positron emission tomography/computed tomography were enrolled. Two or three LuPSMA radioligand doses (7.4 GBq) were given at 2-wk intervals. RARP with lymph node dissection was performed 4 wk after the last LuPSMA dose.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The rate of surgical complications, operative parameters, changes in functional and quality-of-life measures, and immediate oncological outcomes (histological findings and biochemical response) were measured. Data were analyzed descriptively.

RESULTS AND LIMITATIONS

Fourteen patients participated (median age 67 yr). Prostate-specific antigen decreased by 17% (interquartile range [IQR] 9-50%) after two LuPSMA doses and 34% (IQR 11-60%) after three doses. Thirteen patients underwent RARP with no identifiable anatomical changes or intraoperative complications. Four patients (30%) had postoperative complications (pneumonia, pulmonary embolism, urinary leak with urinary tract infection). At 3 mo postoperatively, 12 patients (92%) required one pad or less. Final whole-mount pathology showed positive surgical margins (PSMs) in seven patients (53%) and downgrading to International Society of Urological Pathology grade group 3 in three patients (23%). Treatment-related effects included a clear vacuolated cytoplasm and pyknotic nuclei.

CONCLUSIONS

LuPSMA followed by RARP appears to be surgically safe. While oncological outcomes are pending, continence recovery seems to be unaffected by LuPSMA treatment.

PATIENT SUMMARY

We evaluated outcomes for patients with aggressive localized prostate cancer who received treatment with a radioactive agent before surgical removal of their prostate. This approach appears to be safe and feasible, but its therapeutic efficacy is still unknown.

Comparative effectiveness of treatments for high-risk prostate cancer patients

BACKGROUND

To determine the comparative effectiveness of primary radical prostatectomy (RP) compared to external bean radiation therapy (EBRT) with androgen deprivation therapy (ADT), or EBRT plus brachytherapy (BT) with or without ADT among Medicare fee-for-service beneficiaries with high-risk prostate cancer, for 10-year, mortality (overall and prostate cancer-specific), complications, health service use, and cost.

METHODS

This population-based cohort study used Surveillance, Epidemiology, and End Results - Medicare data. Eligible patients were men aged 66 or older and diagnosed with high-risk prostate cancer between 1996 and 2003. Outcomes evaluated were 10-year overall mortality and prostate cancer-specific mortality, complications, health service use, and cost. We used Cox regression, Poisson regression, and Generalized Linear Model (GLM) log-link models to assess the outcomes.

MAIN FINDINGS

The 10-year overall mortality of EBRT + ADT was comparable to that of the RP group (hazard ratio [HR] = 1.09, confidence interval [CI] = 0.72-1.66). The EBRT + BT ± ADT group had overall survival advantage compared to RP (HR = 0.47, CI = 0.31-0.73). Compared to the RP group, EBRT + ADT group had higher 10-year prostate cancer-specific mortality (HR = 2.19, CI = 1.92-5.21). Both EBRT + ADT and EBRT + BT ± ADT were associated with higher 10-year cost (odds ratio = 1.72, CI = 1.35-2.20; and odds ratio = 1.63, CI = 1.29-2.04), compared to RP group. Complications and health service use varied across 3 treatment groups and across phases of care.

PRINCIPAL CONCLUSIONS

Our results also demonstrate long-term overall survival benefits for EBRT + BT ± ADT, and greater bowel and bladder side effects over a decade, compared to RP. The RP group had advantage for long-term prostate-cancer specific mortality, compared to EBRT + ADT group. Thus, RP can provide superior cancer control with clear cost advantage for older men with high-risk disease. In terms of value proposition, our results support RP as preferred treatment option, compared to EBRT + ADT and EBRT + BT ± ADT for high-risk prostate cancer patients.

Predictive factors for short-term biochemical recurrence-free survival after robot-assisted laparoscopic radical prostatectomy in high-risk prostate cancer patients

BACKGROUND

We aimed to assess the short-term oncological outcomes of robot-assisted laparoscopic radical prostatectomy to determine the predictive factors associated with biochemical recurrence in high-risk prostate cancer patients.

METHODS

A total of 331 patients with localized prostate cancer underwent robot-assisted laparoscopic radical prostatectomy. Of them, 113 patients were diagnosed with high-risk prostate cancer according to the D'Amico risk group classification. We evaluated the association between pre- or postoperative predictive factors and biochemical recurrence using Cox regression analysis.

RESULTS

The 2-year biochemical recurrence-free survival rate was 65.0% in the high-risk group. On univariate analyses, PSA level > 20 ng/mL, Gleason pattern 5 component on biopsy, pathological stage T3 or higher, perineural invasion, and positive surgical margin were predictive factors for biochemical recurrence. On multivariate analysis, PSA level > 20 ng/mL, Gleason pattern 5 component on biopsy, perineural invasion, and positive surgical margin were identified as independent predictive factors. The 2-year biochemical recurrence-free survival rate was 36.5% for patients with PSA level > 20 ng/mL and/or Gleason pattern 5 component on biopsy.

CONCLUSIONS

PSA level > 20 ng/mL and/or presence of the Gleason pattern 5 component on biopsy are predictive factors for early biochemical recurrence after robot-assisted laparoscopic radical prostatectomy in high-risk prostate cancer patients. We considered that these patients require a combined modality therapy to improve their prognosis.

Prostate stem cell antigen mRNA in blood is a predictor of survival after radical prostatectomy in patients with high-risk prostate cancer

Objectives

To investigate whether the preoperative detection of prostate stem cell antigen (PSCA) mRNA in blood has predictive value for biochemical recurrence, overall survival, and cancer-specific survival after radical prostatectomy in patients with high-risk prostate cancer.

Results

Median age was 67 years (interquartile range: 63-71), and median follow-up was 41 months (interquartile range: 25–65). PSCA mRNA was detected in 151 patients (51.1%). Biochemical recurrence was developed in 101 patients (34.2%), and all-cause mortality and prostate cancer-specific mortality occurred in 17 (5.7%) and 8 (2.7%) patients, respectively. Kaplan–Meier analysis revealed significant differences in biochemical recurrence, overall survival, and cancer-specific survival according to PSCA mRNA positivity. Cox regression hazards model analysis showed that PSCA mRNA positivity was an independent predictor of biochemical recurrence, overall survival, and cancer-specific survival.

Conclusions

PSCA mRNA in the peripheral blood was related to poor prognosis. Detection of PSCA mRNA by polymerase chain reaction in peripheral blood can be used to predict survival after radical prostatectomy in patients with high-risk prostate cancer. Future study with larger cohort and long-term follow-up is required to confirm this finding.

Materials and methods

A total of 295 patients with high-risk prostate cancer scheduled to undergo radical prostatectomy were prospectively enrolled from 2008 to 2016. Nested reverse transcription polymerase chain reaction was used to detect cells with PSCA mRNA in peripheral blood. The predicting ability of PSCA mRNA positivity for biochemical recurrence, overall survival, and cancer-specific survival after radical prostatectomy was evaluated.

Radical Prostatectomy for High-risk Localized or Node-Positive Prostate Cancer: Removing the Primary

PURPOSE OF REVIEW

We reviewed the literature to determine what role, if any, radical prostatectomy should play in the treatment of high-risk and/or node-positive prostate cancer.

RECENT FINDINGS

The AUA, NCCN, and EAU all include radical prostatectomy as a treatment option for high-risk prostate cancer based on evidence that has shown improvements in biochemical-free and disease-specific survival. Lymph node-positive patients may also derive benefit from radical prostatectomy with lymph node dissection, however, only retrospective studies with high risk of selection bias have been published to date. High-risk prostate cancer is a heterogeneous disease representing a wide range of disease characteristics. Radical surgery, historically avoided in such patients, may now be considered a valid treatment option for select cases. The adverse effects of surgery using modern techniques lead to similar quality of life outcomes as radiation therapy, and treatment of the primary tumor is likely beneficial when compared to ADT alone.

Pathological outcomes and biochemical recurrence-free survival after radical prostatectomy for high-risk prostate cancer in the Indian population

Introduction:

We analyzed the biochemical recurrence-free survival (BRFS) of patients with high-risk prostate cancer (HRCaP) as per the D’Amico classification undergoing radical prostatectomy (RP) at our center. We aimed to determine whether the number and type of risk factors (cT2c-T3b, prostate-specific antigen >20 ng/ml, Gleason score >7) are associated with biochemical recurrence (BCR) in HRCaP patients undergoing RP in the Indian population.

Methods:

Between 2006 and 2017, 192 patients underwent RP (open RP [ORP], laparoscopic RP [LRP], and robotic RP [RRP]) at our center, of which 109 had D’Amico HR disease. Preoperative, postoperative, and pathological outcome data were analyzed for patients with HR disease as per the D’Amico classification. Subgroups were formed to determine whether an increasing number of risk factors (1, 2, or 3) were associated with poorer oncological results and early BCR. The Kaplan–Meier method with log-rank test was used to test the difference in BRFS between the groups. Univariate and multivariate analyses were done to find significant variable against BCR.

Results:

According to the D’Amico criteria, 109 patients had HR, 63 patients had intermediate-risk, and 19 patients had low-risk disease. These 109 patients with HR disease were analyzed in our study (50 RRP, 33 ORP, and 26 LRP). A total of 59 (54.1%) patients had one HR factor (1HR), 44 (40%) had two HR factors (2HR), and 6 (5.5%) had three HR factors (3HR). The mean follow-up for our patient population was 21.5 ± 19 months (median 18 months; range, 0–108). Overall, the 2-year and 5-year BRFS was 45% and 35%, respectively (mean BRFS 46 ± 6 months). Two-year BRFS was 63%, 23%, and 22%, respectively, for 1HR, 2HR, and 3HR (logrank, P < 0.0001). The prognostic substratification based on the three risk factors was significantly predictive for adverse pathologic features and oncologic outcomes.

Conclusion:

Substratification based on the three well-defined criteria leads to a better identification of the more aggressive cancers and prediction of need for additional treatment modalities. Localized HRCaP includes a heterogeneous population of patients with variable oncological outcomes.

Analysis of outcome following robotic assisted radical prostatectomy for patients with high risk prostate cancer as per D'Amico classification

INTRODUCTION

Prognosis of prostate cancer depends on the risk stratification. D'Amico classification, the most commonly used risk stratification method is based on three factors, i.e., prostate specific antigen (PSA), Gleason grade and clinical stage. The impact of presence of multiple risk factors on prognosis after radical prostatectomy has not been studied in Indian patients. We analyzed the outcome of patients with high-risk disease undergoing robotic-assisted radical prostatectomy (RARP), as per D'Amico classification.

MATERIALS AND METHODS

Our study is a review of the data of all patients with high-risk prostate cancer who underwent RARP between July 2010 and January 2015. Preoperative, perioperative and outcome data were analyzed for patients with high-risk disease as per D'Amico classification.

RESULTS

Of 227 patients who underwent RARP, 90 (39.6%) were in the high-risk group. PSA > 20 ng/ml was the most common risk factor, present in 50 (55.6%) patients. All three risk factors were present in 3 patients, and single risk factor was present in 65 patients. Nine (10%) patients had lymphnode involvement, 18 (20%) had positive margin, and 38 (41.1%) had extraprostatic extension (EPE). Among these adverse outcomes, only EPE showed significant association with multiplicity of risk factors. At 12 months, 27.8% had biochemical recurrence (BCR). 92% of patients were continent at 12 months.

CONCLUSION

About 92% of patients with high-risk disease were continent at 12 months, whereas less than one-third of the patients had BCR. EPE was the only outcome associated with multiplicity of risk factors. Adjuvant treatment is not required in two-thirds of patients.

Role of robot-assisted radical prostatectomy in the management of high-risk prostate cancer

We aimed to evaluate the role of robot-assisted radical prostatectomy (RARP) in the management of high-risk prostate cancer (PCa), with a focus on oncological, functional and perioperative outcomes. Further, we also aimed to briefly describe our novel modification to conventional RARP that allows immediate organ retrieval and examination for intra-operative surgical margin assessment. A literature search of PubMed was performed for articles on the management of high-risk PCa. Papers written in English and concerning clinical outcomes following RARP for locally advanced and high-risk PCa were selected. Outcomes data from our own center were also included. A total of 10 contemporary series were evaluated. Biopsy Gleason score ≥ 8 was the most common cause for classification of patients into the high-risk PCa group. Biochemical failure rate, in the few series that looked at long-term follow-up, varied from 9% to 26% at 1 year. The positive surgical margin rate varied from 12% to 53.3%. Urinary continence rates varied from 78% to 92% at 1 year. The overall complication rates varied from 2.4% to 30%, with anastomotic leak and lymphocele being the most common complications. Long-term data on oncological control following RARP in high-risk patients is lacking. Short-term oncological outcomes and functional outcomes are equivalent to open radical prostatectomy (RP). Safety outcomes are better in patients undergoing RARP when compared with open RP. Improved tools for predicting the presence of organ-confined disease (OCD) are available. High-risk patients with OCD would be ideal candidates for RARP and would benefit most from surgery alone.

Outcomes of Gleason Score ≤ 8 among high risk prostate cancer treated with 125I low dose rate brachytherapy based multimodal therapy

PURPOSE

To investigate the role of low dose rate (LDR) brachytherapy-based multimodal therapy in high-risk prostate cancer (PCa) and analyze its optimal indications.

MATERIALS AND METHODS

We reviewed the records of 50 high-risk PCa patients [clinical stage ≥ T2c, prostate-specific antigen (PSA) >20 ng/mL, or biopsy Gleason score ≥ 8] who had undergone 125I LDR brachytherapy since April 2007. We excluded those with a follow-up period <3 years. Biochemical recurrence (BCR) followed the Phoenix definition. BCR-free survival rates were compared between the patients with Gleason score ≥ 9 and Gleason score ≤ 8.

RESULTS

The mean initial PSA was 22.1 ng/mL, and mean D90 was 244.3 Gy. During a median follow- up of 39.2 months, biochemical control was obtained in 72% (36/50) of the total patients; The estimated 3-year BCR-free survival was 92% for the patients with biopsy Gleason scores ≤ 8, and 40% for those with Gleason scores ≥ 9 (p<0.001). In Cox multivariate analysis, only Gleason score ≥ 9 was observed to be significantly associated with BCR (p=0.021). Acute and late grade ≥ 3 toxicities were observed in 20% (10/50) and 36% (18/50) patients, respectively.

CONCLUSION

Our results showed that 125I LDR brachytherapy-based multimodal therapy in high-risk PCa produced encouraging relatively long-term results among the Asian population, especially in patients with Gleason score ≤ 8. Despite small number of subjects, biopsy Gleason score ≥ 9 was a significant predictor of BCR among high risk PCa patients after brachytherapy.

Course of the type of patient who is candidate for radical prostatectomy over 2 decades (1989-2009)

OBJECTIVE

To know the changes experienced by the patient profile candidate for radical prostatectomy over the last 2 decades in our institution..

MATERIAL AND METHODS

We analyze retrospectively a series of 1.132 patients with prostate cancer stadium T1-T2, submitted to radical prostatectomy during the period 1989-2009. The series divides in five homogeneous groups as for the number of patients and arranged chronologically. There uses the free survival of biochemical progression (SLPB) as criterion principal forecast.

RESULTS

In spite of the changes in the diagnosis and treatment of the disease, from the point of view of the forecast (SLPB) we estimate two groups different from patients: the first 250 controlled ones and the rest. The point of chronological cut places in this series in 1.999. We find significant differences in the majority of the clinical-pathological variables as PSA's level to the diagnosis (P <0,001), percentage of palpable tumors (P <0,001), clinical stadium (P <0,001), Gleason in the prostate biopsy (P =0,004), groups at risk of D'Amico (P <0,001), pathological stage (P <0,001), and percentage of patients with lymph node (P <0,001). Nevertheless, there are not detected differences of statistical significance in the Gleason of the specimen of prostatectomy (P =0,06) and in the percentage of surgical margins (P =0,6).

CONCLUSIONS

This study analyzes a patients' wide proceeding sample from the whole Spanish geography and presents some important information that reflect the evolution that has suffered the cancer of prostate located, so much regarding the diagnosis as to the forecast, in our country in the last 20 years.

The role of robot-assisted radical prostatectomy and pelvic lymph node dissection in the management of high-risk prostate cancer: a systematic review

CONTEXT

The role of robot-assisted radical prostatectomy (RARP) for men with high-risk (HR) prostate cancer (PCa) has not been well studied.

OBJECTIVE

To evaluate the indications for surgical treatment, technical aspects such as nerve sparing (NS) and lymph node dissection (LND), and perioperative outcomes of men with HR PCa treated with RARP.

EVIDENCE ACQUISITION

A systematic expert review of the literature was performed in October 2012, searching the Medline, Web of Science, and Scopus databases. Studies with a precise HR definition, robotic focus, and reporting of perioperative and pathologic outcomes were included.

EVIDENCE SYNTHESIS

A total of 12 papers (1360 patients) evaluating RARP in HR PCa were retrieved. Most studies (67%) used the D'Amico classification for defining HR. Biopsy Gleason grade 8-10 was the most frequent HR identifier (61%). Length of follow-up ranged from 9.7 to 37.7 mo. Incidence of NS varied, although when performed did not appear to compromise oncologic outcomes. Extended LND (ELND) revealed positive nodes in up to a third of patients. The rate of symptomatic lymphocele after ELND was 3%. Overall mean operative time was 168 min, estimated blood loss was 189 ml, length of hospital stay was 3.2 d, and catheterization time was 7.8 d. The 12-mo continence rates using a no-pad definition ranged from 51% to 95% with potency recovery ranging from 52% to 60%. The rate of organ-confined disease was 35%, and the positive margin rate was 35%. Three-year biochemical recurrence-free survival ranged from 45% to 86%.

CONCLUSIONS

Although the use of RARP for HR PCa has been relatively limited, it appears safe and effective for select patients. Short-term results are similar to the literature on open radical prostatectomy. Variability exists for NS and the template of LND, although ELND improves staging and removes a higher number of metastatic nodes. Further study is required to assess long-term outcomes.

Comparative risk-adjusted mortality outcomes after primary surgery, radiotherapy, or androgen-deprivation therapy for localized prostate cancer

BACKGROUND

Because no adequate randomized trials have compared active treatment modalities for localized prostate cancer, the authors analyzed risk-adjusted, cancer-specific mortality outcomes among men who underwent radical prostatectomy, men who received external-beam radiation therapy, and men who received primary androgen-deprivation therapy.

METHODS

The Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) registry comprises men from 40 urologic practice sites who are followed prospectively under uniform protocols, regardless of treatment. In the current study, 7538 men with localized disease were analyzed. Prostate cancer risk was assessed using the Kattan preoperative nomogram and the Cancer of the Prostate Risk Assessment (CAPRA) score, both well validated instruments that are calculated from clinical data at the time of diagnosis. A parametric survival model was constructed to compare outcomes across treatments adjusting for risk and age.

RESULTS

In total, 266 men died of prostate cancer during follow-up. Adjusting for age and risk, the hazard ratio for cancer-specific mortality relative to prostatectomy was 2.21 (95% confidence interval [CI], 1.50-3.24) for radiation therapy and 3.22 (95% CI, 2.16-4.81) for androgen deprivation. Absolute differences between prostatectomy and radiation therapy were small for men at low risk but increased substantially for men at intermediate and high risk. These results were robust to a variety of different analytic techniques, including competing risks regression analysis, adjustment by CAPRA score rather than Kattan score, and examination of overall survival as the endpoint.

CONCLUSIONS

Prostatectomy for localized prostate cancer was associated with a significant and substantial reduction in mortality relative to radiation therapy and androgen-deprivation monotherapy. Although this was not a randomized study, given the multiple adjustments and sensitivity analyses, it is unlikely that unmeasured confounding would account for the large observed differences in survival.