PSA outcomes in patients with adenocarcinoma of the prostate with presenting PSA > 20 ng/ml.

Abstract

241 Background: Optimal treatment of prostate cancer with presenting PSA >20 ng/mL is debated within and between specialties, as reflected by variable PSA outcomes reported. We present our clinical outcomes in irradiated patients for this population. Methods: With IRB approval, we analyzed patient, disease, treatment, and PSA data of 149 patients with presenting PSA > 20 ng/mL radiated with curative intent 1997-2012 by a single physician (DS) at Beth Israel Medical Center (New York City). External beam radiation therapy (EBRT) was delivered first to prostate, seminal vesicles (SV) and draining pelvic lymph nodes to 45 Gy, then 5.4 Gy cone down, then a boost with either brachytherapy (BT) or 30.6 Gy conformal EBRT. BT was withheld in large volume of SV invasion by either DRE or by MRI. Hormonal therapy (HT) consisted of LHRH agonist +/- antiandrogen therapy. PSA was checked every 6 mos. Biochemical Failure (BF) was defined as post-treatment PSA nadir + 2 ng/mL. Results: 41% of patients were African American, 27% Hispanic, 21% Caucasian, and 6% Asian. The median patient age, Gleason score (GS), PSA, and T stage were 68 yrs (range 42-87), 30 ng/mL (range 20–280), 7 (range 5-10) and stage II (8% Tx, 29% T1, 32% T2, 22% T3a/b, 8% T3c). Combined EBRT and BT (CMT) were used in 70% (N=104); EBRT alone in 28% (N=42); BT alone in 2% (N=3). HT was given to 87% (N=129), (median duration 25 mos). Of CMT patients, 77% (N=81) had I-125 permanent seed implant, 22% (N=23) had Pd-103 implant, and 1% (N=1) had HDR temporary Ir-192 implant. With a minimum follow-up (FU) 2 years and median FU 4.9 years (range 2.0-14.1), overall BF was 18% (N=27), and median time to failure was 4 yrs (range 0.4–9.3). Of failures, median age was 64 (range 48-83), and 40% were African American; median pre-treatment PSA was 40 ng/mL (range 20–238), median stage was 3. BF occurred in 17/104 (16.3%) CMT patients (13/17 I-125 and 3/17 Pd-103), 9/42 (21.4%) EBRT patients, and 1/3 (33%) BT alone patients (1/1 I-125). All patients who failed received HT. Conclusions: Excellent overall biochemical outcomes in patients with presenting PSA > 20 ng/ml are reported, with only approximately 18% experiencing BF at a median FU of 4.9 years. Of all treatments analyzed, CMT yielded superior biochemical control.