Local Control and Long-Term Disease-Free Survival for Stage D1 (T2-T4N1-N2M0) Prostate Cancer After Radical Prostatectomy in the PSA Era

[When to introduce hormone therapy after total prostatectomy with positive lymph nodes? Study of the factors influencing the time of introduction of hormone therapy]

INTRODUCTION

Adjuvant hormone therapy is the standard treatment after total prostatectomy with positive lymph node. However, this treatment has side effects and at the time of the PSA era and extensive lymph node dissection, this principle is questioned. The aim of this study is to describe the oncological characteristics of patients that may explain the delay in introducing hormone therapy in patients with positive lymph node.

METHODS

Monocentric, retrospective study of 161 patients from November 1988 to February 2018 in a single French University Hospital, having undergone radical prostatectomy with positive lymph nodes on pathology. For each patient, preoperative data (age, clinical stage, biopsy results, d'Amico classification) and postoperative data (pathological results, number of lymph nodes removed, number of positive lympnodes, recurrence free survival, specific survival and overall survival) were collected. The date of introduction of hormone therapy was noted and survival without hormonal therapy was established according to the Kaplan Meier curve. The pre- and post-operative oncological factors that could influence hormone therapy introduction were investigated with Chi² and Student tests (statistically significant when P<0.05).

RESULTS

The mean number of lymph nodes removed was 12 [1-40]. The mean number of positive lymph nodes was 2.5 [1-24], the mean percentage of positive lymph nodes was 25% (2.5-100). After a mean follow-up of 95 months (3-354), 88 patients (54.6%) had no hormonal treatment. The average time to hormonal treatment was 40 months [0-310]. At 3 years, survival without hormone therapy was 52% and 51% at 5 years. Only the percentage of positive lymphnodes appeared to be a significant predictor of the introduction of hormone therapy. (29.32% vs. 21.99%, P=0.047). Hormone-free survival was significantly higher in patients with lymph node involvement less than 25% (P<0.0001) or with less than 2 positive lymph nodes (P=0.0294).

CONCLUSION

Lymph node invasion is a factor of poor prognosis after total prostatectomy and leads to introduce hormone therapy. Our study identified the percentage and number of positive lymph nodes as factors that identify patients who may be delayed in introducing this hormone therapy.

LEVEL OF PROOF

3.

Lymphadenectomy in Gleason 7 prostate cancer: Adherence to guidelines and effect on clinical outcomes

BACKGROUND

To examine usage trends, guideline adherence, and survival data for patients undergoing lymphadenectomy (LND) at the time of radical prostatectomy (RP) for Gleason 7 prostate cancer (PCa).

METHODS

The SEER database was queried for all patients with nonmetastatic biopsy Gleason 7 PCa from 2004 to 2013. Distribution and trends of LND were analyzed. The Memorial-Sloan Kettering Cancer Center nomogram was applied to stratify patients based on risk of nodal disease at time of RP (<5% risk or ≥5% risk). Analyses were performed to determine covariates associated with LND receipt at time of RP and cancer-specific mortality (CSM).

RESULTS

A total of 78,641 patients with either G34 or G43 PCa underwent RP (59,194 and 19,447, respectively). Of these patients, 61.2% of G34 and 73.5% of G43 patients underwent LND. During this 10-year period, the proportion of G43 patients undergoing LND remained relatively stable, whereas the proportion of G34 patients undergoing LND ranged between 55.9% and 67.9%. Regional differences were a predictor of LND receipt regardless of risk stratification, but did not translate to higher risk of CSM. Receipt of LND was not predictive of improved CSM in any of the cohorts analyzed.

CONCLUSIONS

The role of LND for Gleason 7 prostate adenocarcinoma is not yet standardized, as indicated by the variability of LND dissection rates. Receipt of LND did not improve CSM, and in G43 patients, it predicted higher CSM. As the effect of LND on CSM is uncertain, further evaluation of oncologic benefit in this patient population is warranted.

Inhibition of androgen receptor promotes CXC-chemokine receptor 7-mediated prostate cancer cell survival

The atypical C-X-C chemokine receptor 7 (CXCR7) has been implicated in supporting aggressive cancer phenotypes in several cancers including prostate cancer. However, the mechanisms driving overexpression of this receptor in cancer are poorly understood. This study investigates the role of androgen receptor (AR) in regulating CXCR7. Androgen deprivation or AR inhibition significantly increased CXCR7 expression in androgen-responsive prostate cancer cell lines, which was accompanied by enhanced epidermal growth factor receptor (EGFR)-mediated mitogenic signaling, promoting tumor cell survival through an androgen-independent signaling program. Using multiple approaches we demonstrate that AR directly binds to the CXCR7 promoter, suppressing transcription. Clustered regularly interspaced short palindromic repeats (CRISPR) directed Cas9 nuclease-mediated gene editing of CXCR7 revealed that prostate cancer cells depend on CXCR7 for proliferation, survival and clonogenic potential. Loss of CXCR7 expression by CRISPR-Cas9 gene editing resulted in a halt of cell proliferation, severely impaired EGFR signaling and the onset of cellular senescence. Characterization of a mutated CXCR7-expressing LNCaP cell clone showed altered intracellular signaling and reduced spheroid formation potential. Our results demonstrate that CXCR7 is a potential target for adjuvant therapy in combination with androgen deprivation therapy (ADT) to prevent androgen-independent tumor cell survival.

[Cytoreductive radical prostatectomy for prostate cancer with minimal osseous metastases: results of a first feasibility and case control study]

BACKGROUND

Androgen deprivation therapy (ADT) represents the standard treatment for patients with prostate cancer (PCA) and osseous metastases. We explored the role of cytoreductive radical prostatectomy in PCA with low volume skeletal metastases in terms of a feasibility study.

MATERIAL AND METHODS

A total of 23 patients with biopsy proven PCA, minimal osseous metastases (≤3 hot spots on bone scan), absence of visceral or extensive lymph node metastases and a decrease in prostate-specific antigen (PSA) to <1.0 ng/ml after neoadjuvant ADT were included in the feasibility study (group A). The control group (group B) consisted of 38 men with metastatic PCA who were treated by ADT alone. Surgery-related complications, time to castration resistance, symptom-free, cancer-specific and overall survival were analyzed using descriptive statistical analyses.

RESULTS

The mean age was 61 years (range 42-69 years) and 64 years (47-83) in groups A and B, respectively, with similar patient characteristics in terms of initial PSA level, biopsy Gleason score, clinical stage and extent of metastatic disease. The median follow-up was 34.5 months (7-75 months) and 47 months (28-96 months) in groups A and B, respectively. Median time to castration resistance was 40 months (9-65 months) and 29 months (16-59 months) in groups A and B, respectively (p=0.04). Patients in group A experienced significantly better clinical symptom-free (38.6 versus 26.5 months, p=0.032) and cancer-specific survival rates (95.6% versus 84.2%, p=0.043) whereas the overall survival was similar. In group A none of the men underwent palliative surgical procedures for locally progressing PCA compared to 29% in group B.

CONCLUSIONS

Cytoreductive radical prostatectomy is feasible in well-selected men with metastatic PCA who responded well to neoadjuvant ADT. These men have a long life expectancy and the risk of locally recurrent PCA and local complications are reduced. Cytoreductive radical prostatectomy might be a treatment option in the multimodal management of PCA with minimal osseous metastases.

[Radical cancer surgery of renal cell and prostate carcinoma with hematogenous metastasis: benefits]

The therapeutic role of cytoreductive surgery for urogenital malignancies is controversially discussed in the literature. The current article critically reflects the potential impact of cytoreductive surgery in patients with renal cell cancer and prostate cancer with locoregional lymph node or systemic metastases based on a review of the literature and personal experience.Even in the era of molecular targeted therapies in metastatic renal cell cancer, cytoreductive radical nephrectomy seems to exert survival benefit when compared to systemic therapy alone if (1) patients demonstrate a good ECOG performance status, (2) exhibit good or intermediate prognosis according to the Heng criteria, (3) cerebral metastases have been excluded, and (4) >90% of the total cancer volume can be eliminated. Preliminary clinical studies suggest that neoadjuvant systemic treatment might be associated with a significantly reduced 1-year mortality rate.For prostate cancer cytoreductive radical prostatectomy is one of the guideline-recommended treatment options for men with intrapelvic lymph node metastases resulting in survival benefit when compared to androgen deprivation as monotherapy. Cytoreductive radical prostatectomy should be performed (1) in the presence of limited intrapelvic lymph node metastasis without bulky disease, (2) if complete resectability of the primary cancer and its metastasis can be achieved by extended radical prostatectomy and extended pelvic lymphadenectomy, (3) if the patient is included in a multimodality approach, and (4) if the life expectancy is > 10 years.The role of cytoreductive radical prostatectomy in men with osseous metastases remains unclear due to the lack of large clinical trials. Despite the presence of the first promising studies, it is not justified to perform cytoreductive radical prostatectomy outside clinical trials. Preliminary results from small studies indicate that patients with minimal metastatic burden, PSA decrease < 1.0 ng/ml following neoadjuvant ADT for 6 months and complete resectability of the tumor exhibit the best prognosis to benefit from this new surgical approach.

Who dies from prostate cancer?

BACKGROUND

During the last 30 years, there has been a major shift in initial staging in prostate cancer (CaP) in Western countries, with the incidence of metastases at diagnosis decreasing from over 50% in the 1970s to currently less than 10%. Yet, CaP is still the second cause of cancer death in men. We used two monthly curated databases of patients with castration-resistant prostate cancer (CRPC) to describe the natural history of patients dying of CaP in the modern era.

METHODS

The outcome of 190 men with metastatic CRPC treated from 2008 to 2011 was studied. The characteristics of the patients who died from CaP (n = 113 patients, 61%) were analyzed.

RESULTS

All 113 patients who died of CaP were assessable for the presence of metastases at diagnosis. Sixty-three patients (56%) had detectable metastases at diagnosis: 67%, 11% and 43% had bone, visceral and lymph node metastases, respectively. The median time to CRPC was 16 months and median overall survival (OS) was 5.2 years.Among the patients with localized CaP at diagnosis (n = 50, 44%), 46% had T stage ⩾ 3 and 38% had a Gleason score ⩾ 8. Overall, 64% of patients were classified as having a high-risk CaP. Only 26% who died from CaP had a Gleason score ⩽ 6. Median OS was 8.8 years.

CONCLUSIONS

In the modern era, approximately half of the patients who die from CaP have metastases at diagnosis. The paradigm of progression from localized disease to metastasis and eventually death is only represented in the other half, although possible initial screening and staging errors ought to be taken into consideration. More efforts are needed to conduct trials in patients with newly diagnosed metastatic CaP.

Cytoreductive radical prostatectomy in patients with prostate cancer and low volume skeletal metastases: results of a feasibility and case-control study

PURPOSE

Androgen deprivation represents the standard treatment for prostate cancer with osseous metastases. We explored the role of cytoreductive radical prostatectomy in prostate cancer with low volume skeletal metastases in terms of a feasibility study.

MATERIALS AND METHODS

A total of 23 patients with biopsy proven prostate cancer, minimal osseous metastases (3 or fewer hot spots on bone scan), absence of visceral or extensive lymph node metastases and prostate specific antigen decrease to less than 1.0 ng/ml after neoadjuvant androgen deprivation therapy were included in the feasibility study (group 1). A total of 38 men with metastatic prostate cancer who were treated with androgen deprivation therapy without local therapy served as the control group (group 2). Surgery related complications, time to castration resistance, and symptom-free, cancer specific and overall survival were analyzed using descriptive statistical analysis.

RESULTS

Mean patient age was 61 (range 42 to 69) and 64 (range 47 to 83) years in groups 1 and 2, respectively, with similar patient characteristics in terms of initial prostate specific antigen, biopsy Gleason score, clinical stage and extent of metastatic disease. Median followup was 34.5 months (range 7 to 75) and 47 months (range 28 to 96) in groups 1 and 2, respectively. Median time to castration resistant prostate cancer was 40 months (range 9 to 65) and 29 months (range 16 to 59) in groups 1 and 2, respectively (p=0.04). Patients in group 1 experienced significantly better clinical progression-free survival (38.6 vs 26.5 months, p=0.032) and cancer specific survival rates (95.6% vs 84.2%, p=0.043), whereas overall survival was similar. Of the men in groups 1 and 2, 20% and 29%, respectively, underwent palliative surgical procedures for locally progressing prostate cancer.

CONCLUSIONS

Cytoreductive radical prostatectomy is feasible in well selected men with metastatic prostate cancer who respond well to neoadjuvant androgen deprivation therapy. These men have a long life expectancy, and cytoreductive radical prostatectomy reduces the risk of locally recurrent prostate cancer and local complications. Cytoreductive radical prostatectomy might be a treatment option in the multimodality management of prostate cancer with minimal osseous metastases.

Salvage therapy of small volume prostate cancer nodal failures: a review of the literature

New imaging modalities may be useful to identify prostate cancer patients with small volume, limited nodal relapse ("oligo-recurrent") potentially amenable to local treatments (radiotherapy, surgery) with the aim of long-term control of the disease, even in a condition traditionally considered prognostically unfavorable. This report reviews the new diagnostic tools and the main published data about the role of surgery and radiation therapy in this particular subgroup of patients.

Primary treatment of the prostate improves local palliation in men who ultimately develop castrate-resistant prostate cancer

OBJECTIVES

To determine whether local treatment of primary prostate cancer gives palliative benefit to men who later develop castrate-resistant prostate cancer (CRPC). Local treatments of primary prostate cancer are defined as radical retropubic prostatectomy (RRP) or external beam radiation therapy (EBRT).

PATIENTS AND METHODS

Patient records were reviewed in five different hospitals in Sydney, Australia, and 263 men with CRPC were identified. Eligible patients comprised men who had progressive disease during androgen deprivation therapy with castrate levels of testosterone. Clinical and pathological data were reviewed and evaluated using the chi-squared test and relative risk analysis to determine the relationship between previous local prostate treatment and complications secondary to local disease. The end-point was complications and morbidity attributed to cancer progression locally (i.e. from the prostate).

RESULTS

Primary treatment of the prostate by either RRP or EBRT significantly reduces the incidence of local complications compared to no primary treatment (32.6% vs 54.6%; P = 0.001). RRP showed a significantly lower level of local complications compared to EBRT (20.0% vs 46.7%; P = 0.007). The most common local complications were bladder outlet obstruction (35.0%) and ureteric obstruction (15.2%).

CONCLUSIONS

The present retrospective analysis supports the hypothesis that primary local prostatic treatment gives palliative benefit to men who later develop CRPC. RRP was associated with the lowest local complication rate experienced at the stage of metastatic disease.

Early versus deferred androgen suppression therapy for patients with lymph node-positive prostate cancer after local therapy with curative intent: a systematic review

Background

There is currently no consensus regarding the optimal timing for androgen suppression therapy in patients with prostate cancer that have undergone local therapy with curative intent but are proven to have node-positive disease without signs of distant metastases at the time of local therapy. The objective of this systematic review was to determine the benefits and harms of early (at the time of local therapy) versus deferred (at the time of clinical disease progression) androgen suppression therapy for patients with node-positive prostate cancer after local therapy.

Methods

The protocol was registered prospectively (CRD42011001221; http://www.crd.york.ac.uk/PROSPERO). We searched the MEDLINE, EMBASE, and CENTRAL databases, as well as reference lists, the abstracts of three major conferences, and three trial registers, to identify randomized controlled trials (search update 04/08/2012). Two authors independently screened the identified articles, assessed trial quality, and extracted data.

Results

Four studies including 398 patients were identified for inclusion. Early androgen suppression therapy lead to a significant decrease in overall mortality (HR 0.62, 95% CI 0.46-0.84), cancer-specific mortality (HR 0.34, 95% CI 0.18-0.64), and clinical progression at 3 or 9 years (RR 0.29, 95% CI 0.16-0.52 at 3 years and RR 0.49, 95% CI 0.36-0.67 at 9 years). One study showed an increase of adverse effects with early androgen suppression therapy. All trials had substantial methodological limitations.

Conclusions

The data available suggest an improvement in survival and delayed disease progression but increased adverse events for patients with node-positive prostate cancer after local therapy treated with early androgen suppression therapy versus deferred androgen suppression therapy. However, quality of data is low. Randomized controlled trials with blinding of outcome assessment, planned to determine the timing of androgen suppression therapy in node-positive prostate cancer using modern diagnostic imaging modalities, biochemical testing, and standardized follow-up schedules should be conducted to confirm these findings.

Lymph node-positive prostate cancer: current issues, emerging technology and impact on clinical outcome

Lymph node metastasis in patients with prostate cancer indicates a poorer prognosis compared with patients without lymph node metastasis; however, some patients with node-positive disease have long-term survival. Many studies have attempted to discern what characteristics of lymph node metastasis are prognostically significant. These characteristics include nodal tumor volume, number of positive lymph nodes, lymph node density, extranodal extension, lymphovascular invasion and tumor dedifferentiation. Favorable characteristics of regional lymph node involvement included a smaller tumor size and smaller tumor volume. However, the current staging system for prostate cancer does not provide different subclassifications for patients with node-positive prostate cancer. In recent years numerous advanced technologies for the detection of lymph node metastasis have been developed, including molecular imaging techniques and the CellSearch Circulating Tumor Cell System. With the increased detection of patients with prostate cancer, emergence of new technology to identify lymph node metastasis and the number of radical prostatectomies being performed on the rise, subclassifying patients with lymph node-positive disease is imperative. Subclassification would provide a better picture of patient prognosis and allow for a better understanding of targeted therapies to treat patients with lymph node metastasis.

Impact of adjuvant androgen-deprivation therapy on disease progression in patients with node-positive prostate cancer

Purpose

The survival benefits of adjuvant androgen-deprivation therapy (ADT) in prostate cancer and lymph node metastasis remain unclear. We assessed the role of ADT in disease progression after radical prostatectomy (RP).

Materials and Methods

Of 937 patients who underwent RP, we identified 40 (4.2%) who had lymph node metastasis. A total of 18 received adjuvant ADT (ADT group) and 22 were observed (observation group). Clinical progression-free survival (PFS), cancer- specific survival (CSS), and overall survival (OS) were compared in the 2 groups. Prognostic factors for clinical progression and biochemical recurrence (BCR) were analyzed.

Results

The 5-year PFS, CSS, and OS of the entire cohort were 75.0%, 85.0%, and 72.5%, respectively. In the ADT group, 6 patients (33.3%) showed clinical progression at a median 42.7 months. The 5-year PFS, CSS, and OS rates of this group were 72.2%, 83.3%, and 72.2%, respectively. In the observation group, 14 patients (63.6%) received salvage therapy owing to BCR. Nine patients (40.9%) with BCR in the observation group showed clinical progression at a median 43.4 months after RP. The 5-year PFS, CSS, and OS rates of this group were 77.2%, 86.4%, and 72.8%, respectively. In the observation group, the BCR rate was lower in patients with pT3a or less disease than in those with pT3b disease.

Conclusions

Adjuvant ADT in node-positive prostate cancer did not reduce or delay disease progression or improve survival. Because a substantial number of untreated patients with pT3a or less disease did not experience recurrence, administration of ADT should be initiated carefully. However, in patients with pT3b disease, adjuvant ADT and radiotherapy could be considered.

Persistent, biologically meaningful prostate cancer after 1 year of androgen ablation and docetaxel treatment

PURPOSE

Clinicians are increasingly willing to treat prostate cancer within the primary site in the presence of regional lymph node or even limited distant metastases. However, no formal study on the merits of this approach has been reported. We used a preoperative clinical discovery platform to prioritize pathways for assessment as therapeutic targets and to test the hypothesis that the primary site harbors potentially lethal tumors after aggressive treatment.

PATIENTS AND METHODS

Patients with locally advanced or lymph node-metastatic prostate cancer underwent 1 year of androgen ablation and three cycles of docetaxel therapy, followed by prostatectomy. All specimens were characterized for stage by accepted criteria. Expression of select molecular markers implicated in disease progression and therapy resistance was determined immunohistochemically and compared with that in 30 archived specimens from untreated patients with high-grade prostate cancer. Marker expression was divided into three groups: intracellular signaling pathways, stromal-epithelial interaction pathways, and angiogenesis.

RESULTS

Forty patients were enrolled, 30 (75%) of whom underwent prostatectomy and two (5%) who underwent cystoprostatectomy. Twenty-nine specimens contained sufficient residual tumor for inclusion in a tissue microarray. Immunohistochemical analysis showed increased epithelial and stromal expression of CYP17, SRD5A1, and Hedgehog pathway components, and modulations of the insulin-like growth factor I pathway.

CONCLUSION

A network of molecular pathways reportedly linked to prostate cancer progression is activated after 1 year of therapy; biomarker expression suggests that potentially lethal cancers persist in the primary tumor and may contribute to progression.

Use and assessment of PSA in prostate cancer

Since the introduction of prostate-specific antigen (PSA) screening in the late 1980s, more prostate cancers have been detected, and at an earlier stage. As a consequence, the majority of prostate cancers are now detected years before the emergence of clinically evident disease, which usually represents locally advanced or metastatic cancer. PSA screening has remained controversial, because many of the prostate cancers detected are low grade and slow growing. With this long natural history and a median survival without treatment that often approaches at least 15 to 20 years, many clinicians and researchers have questioned if prostate cancer screening and treatment actually improves survival, as many patients will die with prostate cancer rather than of prostate cancer. In this review, the authors discuss the rationale for prostate cancer screening and present the current guidelines for the use of PSA.

[Node-positive prostate cancer. Value of radical prostatectomy]

The current review article critically discusses the potential advantages and disadvantages of radical prostatectomy in patients with locally advanced lymph node-positive prostate cancer. It is the purpose of the manuscript to develop a therapeutic algorithm for management of these patients to achieve optimal oncological and functional results. Based on the data in the literature radical prostatectomy as part of a multimodality approach seems to be indicated in the following clinical scenario: limited intrapelvic lymph node metastasis without bulky disease; complete resectability of the primary cancer and metastases by extended radical prostatectomy and extended pelvic lymphadenectomy; inclusion of the patient in a multimodality approach; life expectancy > 10 years. In patients with extensive locally advanced PCA or large pelvic metastases, radical prostatectomy might be indicated to improve local cancer control and to prevent significant local and supravesical complications. In these cases, the indication for extensive surgery includes radical cystoprostatectomy and should be discussed in an interdisciplinary tumour board.

A review of high-risk prostate cancer and the role of neo-adjuvant and adjuvant therapies

High-risk, localized prostate cancer represents a complex and diverse disease with many available treatment modalities. Patients are often deemed high risk because they are at increased risk for biochemical failure after primary intervention. However, these "high-risk" men may not be at significant risk of dying from their cancer. In this review, an attempt will be made to better define high-risk patients and help identify men at increased risk for mortality, not simply biochemical failure, after a diagnosis of localized prostate cancer. A review of available monotherapies as well as previously successful multimodality treatments will also be presented. Finally, this review will provide a glimpse into the future direction of high-risk prostate cancer multimodal therapy by providing a synopsis several current randomized clinical trials using effective systemic adjuvant therapies following local treatment.