Abstract

PurposeThis analysis compares salvage lymph node dissection (SLND) to salvage lymph node radiotherapy (SLNRT) of 68Ga-PSMA PET-positive nodal recurrences after radical prostatectomy (RPE).MethodsA total of 67 SLNRT and 33 SLND consecutive patients with pelvic and/or para-aortic nodal recurrences after RPE were retrospectively analyzed. Biochemical recurrence-free survival rates (bRFS; PSA <0.2 ng/mL) were calculated according to Kaplan–Meier and survival curves were compared using the log rank test. For multivariable analysis, binary logistic regression analysis was performed (p < 0.05).ResultsMedian follow-up was 17 months (range, 6–53 months) in SLND patients and 31 months (range, 3–56 months) in SLNRT patients (p = 0.027). SLNRT patients had significantly more tumours of pT3 and pT4 category (82% vs. 67%; p = 0.006), pathologically involved lymph nodes (45% vs. 27%; p = 0.001) and positive surgical margins (54% vs. 12%; p = 0.001) at time of RPE than SLND patients. PSA persistence after RPE was significantly more frequently observed in the SLNRT cohort (73% vs. 27%; p = 0.001). There was no significant difference in the distribution of PET-positive lymph nodes. Median PSA before SLND was higher than before SLNRT (3.07 ng/ml vs. 1.3 ng/ml; p = 0.393). The 2‑year bRFS was significantly higher in the SLNRT vs. the SLND cohort (92% vs. 30%; p = 0.001) with lower rates of distant metastases (21% vs. 52%; p = 0.002) and secondary treatments (5% vs. 39%; p = 0.011) irrespective of ongoing androgen deprivation therapy at last contact. In multivariable analysis, SLNRT was significantly associated with prolonged bRFS (regression coefficient 1.436, hazard ratio 4.204, 95% CI 1.789–9.878; p = 0.001).ConclusionBased on this retrospective study SLNRT might be the preferred treatment option for patients with nodal recurrence after previous RPE.

Highlights

  • Up to 30% of patients with high-risk prostate cancer (PCa) relapse after radical prostatectomy (RPE) with the majority of patients having lymph node recurrences [1–3]

  • This is strikingly comparable to outcome data achieved by salvage lymph node dissection (SLND), one has to reconsider that the majority of patients in the reported studies were staged at best with choline positron emission tomography/computer tomography (PET/CT) underestimating the true extent of nodal recurrence

  • There were significantly more patients in the salvage lymph node radiotherapy (SLNRT) cohort with evidence of pathologically involved lymph nodes (45% vs. 27%; p = 0.001) and positive surgical margins (54% vs. 12%; p = 0.001) at time of RPE

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Summary

Introduction

Up to 30% of patients with high-risk prostate cancer (PCa) relapse after radical prostatectomy (RPE) with the majority of patients having lymph node recurrences [1–3]. In a recent systematic review on SLND, wide ranges of 2- and 5-year biochemical recurrence-free survival rates (bRFS) between 23 to 64% and 6 to 31%, respectively, have been described. In patients treated with ENRT 3-year progression-free survival ranged from 61.8 to 75% [6], whereas in patients with SBRT to PET-positive lymph nodes 3-year progression-free survival ranged between 26 and 33% [5]. This is strikingly comparable to outcome data achieved by SLND, one has to reconsider that the majority of patients in the reported studies were staged at best with choline positron emission tomography/computer tomography (PET/CT) underestimating the true extent of nodal recurrence

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