Node-positive Prostate Cancer Patients Research Articles

Evaluation of Treatment Outcomes of Prostate Cancer Patients With Lymph Node Metastasis Treated With Definitive Radiotherapy: Comparative Analysis of PSMA PET/CT and Conventional Imaging.

We investigated the impact of prostate-specific membrane antigen (PSMA) PET/CT compared with conventional imaging on treatment outcomes for node-positive prostate cancer (PCa) patients who underwent androgen deprivation therapy (ADT) and external radiotherapy (RT). A multicentric, retrospective study recruited patients with node-positive PCa patients who underwent conventional radiological evaluation or PSMA PET/CT and received ADT and RT at 3 hospitals from 2009 to 2021 were enrolled. Patients underwent prostate and pelvis RT, accompanied by a minimum of 6 months of ADT. The primary endpoints were progression-free survival (PFS) and PCa-specific survival (PCSS). Cox regression analyzed the association of survival with potential prognostic factors, whereas logistic regression identified the predictors of bone and lymph node metastasis. The median follow-up time was 64.0 months. The majority of patients (64.1%) underwent PSMA PET/CT for staging. The 5-year rates of PFS and PCSS were 63.7% and 83.7%, respectively. Disease progression was observed in 90 patients (36.3%). In multivariable analysis, ADT duration of less than 24 months and post-RT prostate-specific antigen (PSA) nadir were prognostic for PFS. Early clinical T stage and PSMA PET/CT predicted better PCSS. Patients staged with PSMA PET/CT had exhibited significantly higher 5-year PCSS rates than compared with those staged with conventional imaging (95.1% vs 76.9%; P = 0.01). Shorter ADT duration and higher PSA levels after RT independently predicted bone metastasis in multivariable logistic regression. Advanced T stage, shorter ADT duration, and higher PSA levels after neoadjuvant ADT predicted nonregional lymph node recurrence. ADT with pelvis RT is an effective treatment option for node-positive PCa patients. The PSMA PET/CT outperformed conventional imaging in PCSS, emphasizing the importance of precise clinical staging for patients undergoing definitive RT.

Pelvic lymph node mapping in prostate cancer: examining the impact of PSMA PET/CT on radiotherapy decision-making in patients with node-positive disease

IntroductionProstate Specific Membrane Antigen (PSMA) imaging with Positron Emission Tomography (PET) plays a crucial role in prostate cancer management. However, there is a lack of comprehensive data on how PSMA PET/CT (Computed Tomography) influences radiotherapeutic decisions, particularly in node-positive prostate cancer cases. This study aims to address this gap by evaluating two primary objectives: (1) Mapping the regional and non-regional lymph nodes (LNs) up to the aortic bifurcation and their distribution using conventional methods with CT compared to PSMA PET/CT, and (2) assessing the impact of PSMA PET/CT findings on radiotherapeutic decisions.MethodsA retrospective analysis of 95 node-positive prostate cancer patients who underwent both CT and PSMA PET/CT imaging prior to primary radiotherapy and androgen deprivation therapy (ADT) was conducted. The analysis focused on identifying LNs in various regions including the common iliac, external iliac, internal iliac, obturator, presacral, mesorectal, inguinal, and other stations. Treatment plans were reviewed for modifications based on PSMA PET/CT findings, and statistical analysis was performed to identify predictors for exclusive nodal positivity on PSMA PET/CT scans.ResultsPSMA PET/CT identified additional positive nodes in 48% of cases, resulting in a staging shift from N0 to N1 in 29% of patients. The most frequent metastatic LNs were located in the external iliac (76 LNs; 34%), internal iliac (43 LNs; 19%), and common iliac (35 LNs; 15%) stations. In patients with nodes only detected on PSMA PET the most common nodes were in the external iliac (27, 40%), internal iliac (13, 19%), obturator (11, 15%) stations. Within the subgroup of 28 patients exclusively demonstrating PSMA PET-detected nodes, changes in radiotherapy treatment fields were implemented in 5 cases (18%), and a dose boost was applied for 23 patients (83%). However, no discernible predictors for exclusive nodal positivity on PSMA PET/CT scans emerged from the analysis.DiscussionThe study underscores the pivotal role of PSMA PET/CT compared to CT alone in accurately staging node-positive prostate cancer and guiding personalized radiotherapy strategies. The routine integration of PSMA PET/CT into diagnostic protocols is advocated to optimize treatment precision and improve patient outcomes.

Relapse Rate in Node-positive Prostate Cancer Patients Treated with Radical Radiotherapy

Relapse Rate in Node-positive Prostate Cancer Patients Treated with Radical Radiotherapy

Characterization of Lymph Node Tumor Burden in Node-Positive Prostate Cancer Patients after Robotic-Assisted Radical Prostatectomy with Extended Pelvic Lymph Node Dissection.

Prostate cancer (PCa) nodal staging does not account for lymph node (LN) tumor burden. The LN anatomical compartment involved with the tumor or the quantified extent of extranodal extension (ENE) have not yet been studied in relation to biochemical recurrence-free survival (BRFS). Histopathological slides of 66 pN1 PCa patients who underwent extended pelvic lymph node dissection were reviewed. We recorded metrics to quantify LN tumor burden. We also characterized the LN anatomical compartments involved and quantified the extent of ENE. The median follow-up time was 38 months. The median number of total LNs obtained per patient was 30 (IQR 23-37). In the risk-adjusted cox regression model, the following variables were associated with BRFS: mean size of the largest LN deposit per patient (log2: adjusted hazard ratio (aHR) = 1.91, p < 0.001), the mean total span of all LN deposits per patient (2.07, p < 0.001), and the mean percent surface area of the LN involved with the tumor (1.58, p < 0.001). There was no significant BRFS association for the LN anatomical compartment or the quantified extent of ENE. LN tumor burden is associated with BRFS. The LN anatomical compartments and the quantified extent of ENE did not show significant association with BRFS.

PO-1481 Clinical outcomes of clinically node positive prostate cancer patients after definitive radiotherapy

PO-1481 Clinical outcomes of clinically node positive prostate cancer patients after definitive radiotherapy

OC-0421 Development and QA of IGRT procedures for node-positive prostate cancer patients in the PEARLS trial

OC-0421 Development and QA of IGRT procedures for node-positive prostate cancer patients in the PEARLS trial

PD15-01 SURVIVAL IN ADJUVANT VS SALVAGE RADIATION THERAPY IN PATHOLOGICAL NODE POSITIVE PROSTATE CANCER PATIENTS: A MULTICENTRIC STUDY

PD15-01 SURVIVAL IN ADJUVANT VS SALVAGE RADIATION THERAPY IN PATHOLOGICAL NODE POSITIVE PROSTATE CANCER PATIENTS: A MULTICENTRIC STUDY

Survival after radical prostatectomy vs. radiation therapy in clinical node positive prostate cancer patients: A multicentric study

Survival after radical prostatectomy vs. radiation therapy in clinical node positive prostate cancer patients: A multicentric study

SC1 - Oncological outcomes, patterns of recurrence and impact of competing causes of mortality in clinically node-positive prostate cancer patients treated with radical prostatectomy

SC1 - Oncological outcomes, patterns of recurrence and impact of competing causes of mortality in clinically node-positive prostate cancer patients treated with radical prostatectomy

Selecting lymph node-positive patients for adjuvant therapy after radical prostatectomy and extended pelvic lymphadenectomy: An outcome analysis of 100 node-positive patients managed without adjuvant therapy.

The aim of the study is to evaluate the effect of deferred androgen deprivation therapy on biochemical recurrence (BCR) and other survival parameters in node-positive prostate cancer patients after robot-assisted radical prostatectomy with bilateral extended pelvic lymph node dissection (RARP + EPLND). Of the 453 consecutive RARP procedures performed from 2011 to 2018, 100 patients with no prior use of androgen deprivation therapy were found to be lymph node (LN) positive and were observed, with initiation of salvage treatment at the time of BCR only. Patients were divided into 1 or 2 LNs (67)-and more than 2 LNs (33)-positive groups to assess survival outcomes. At a median follow-up of 21 months (1-70 months), the LN group (p < 0.000), preoperative prostate-specific antigen (PSA, p = 0.013), tumor volume (TV, p = 0.031), and LND (p = 0.004) were significantly associated with BCR. In multivariate analysis, only the LN group (p = 0.035) and PSA level (p = 0.026) were statistically significant. The estimated BCR-free survival rates in the 1/2 LN group were 37.6% (27%-52.2%), 26.5% (16.8%-41.7%), and 19.9% (9.6%-41.0%) at 1, 3, and 5 years, respectively, with a hazard of developing BCR of 0.462 (0.225-0.948) compared with the more than 2 LN-positive group. Estimated 5-year overall survival, cancer-specific, metastasis-free, and local recurrence-free survival rates were 88.4% (73.1%-100%), 89.5% (74%-100%), 65.1% (46.0%-92.1%), and 94.8% (87.2%-100.0%), respectively, for which none of the factors were significant. Based on cutoff values for PSA, TV, and LND of 30 ng/mL, 30%, and 10%, respectively, the 1/2 LN group was substratified, wherein the median BCR-free survival for the low- and intermediate-risk groups was 40 and 12 months, respectively. Nearly one fourth and one fifth of 1/2 node-positive patients were BCR-free at 3 and 5 years after RARP + EPLND. Further substratification using PSA, TV, and LN density may help in providing individualized care regarding the initiation of adjuvant therapy.

Risk Factors for Biochemical Recurrence After PSMA-PET-Guided Definitive Radiotherapy in Patients With De Novo Lymph Node-Positive Prostate Cancer.

IntroductionThe National Comprehensive Cancer Network recommends external beam radiotherapy (EBRT) combined with androgen deprivation therapy (ADT) as the preferred treatment option for newly diagnosed node-positive (cN1) prostate cancer (PCa) patients. However, implementation of positron emission tomography targeting prostate-specific membrane antigen (PSMA-PET) in the staging of primary PCa patients has a significant impact on RT treatment concepts. This study aims to evaluate outcomes and their respective risk factors on patients with PSMA-PET-based cN1 and/or cM1a PCa receiving primary RT and ADT.MethodsForty-eight patients with cN0 and/or cM1a PCa staged by [18F]PSMA-1007-PET (n = 19) or [68Ga]PSMA-11-PET (n = 29) were retrospectively included. All patients received EBRT to the pelvis ± boost to positive nodes, followed by boost to the prostate. The impact of different PET-derived characteristics such as maximum standard uptake value (SUVmax) and number of PET-positive lymph nodes on biochemical recurrence-free survival (BRFS) (Phoenix criteria) and metastasis-free survival (MFS) was determined using Kaplan–Meier and Cox proportional hazard regression analyses.ResultsMedian follow-up was 24 months. Median initial serum prostate-specific antigen was 20.2 ng/ml (IQR 10.2–54.2). Most patients had cT stage ≥ 3 (63%) and ISUP grade ≥ 3 (85%). Median dose to the prostate, elective nodes, and PET-positive nodes was 75 Gy, 45 Gy, and 55 Gy, respectively. Ninety percent of patients received ADT with a median duration of 9 months (IQR 6–18). In univariate analysis, cM1a stage (p = 0.03), number of >2 pelvic nodes (p = 0.01), number of >1 abdominal node (p = 0.02), and SUVmax values ≥ median (8.1 g/ml for 68Ga-PSMA-11 and 7.9 g/ml for 18F-PSMA-1007) extracted from lymph nodes were significantly associated with unfavorable BRFS, but classical clinicopathological features were not. Number of >2 pelvic nodes (n = 0.03), number of >1 abdominal node (p = 0.03), and SUVmax values ≥ median extracted from lymph nodes were associated with unfavorable MFS. In multivariate analysis, number of >2 pelvic lymph nodes was significantly associated with unfavorable BRFS (HR 5.2, p = 0.01) and SUVmax values ≥ median extracted from lymph nodes had unfavorable MFS (HR 6.3, p = 0.02).ConclusionMore than 2 PET-positive pelvic lymph nodes are associated with unfavorable BRFS, and high SUVmax values are associated with unfavorable MFS. Thus, the number of PET-positive lymph nodes and the SUVmax value might be relevant prognosticators to identify patients with favorable outcomes.

Nomograms for Metastasis-Free and Overall Survival for Pathologically Node Positive Prostate Cancer Patients Treated With or Without Radiation Therapy Plus Short-Term ADT.

We aimed to develop nomograms to predict the risk reduction for metastasis and death in pathologically node-positive (pN +) prostate cancer patients treated with or without radiation therapy (RT). From a prospectively gathered institutional database, we identified patients with pN+M0 prostate cancer after surgery. We evaluated several regression models of known or suspected clinical-pathologic covariates and selected the model with the highest Harrell's concordance-index (c-index) and clinical utility to prognosticate metastasis for inclusion in a nomogram. Covariates in the final, competing-risk adjusted, metastasis model included PSA nadir after surgery, pathologic T-stage, margin status, Gleason score (GS), number of positive lymph nodes, and use of postoperative radiotherapy combined with androgen deprivation therapy (RT+ADT). The overall survival model also included Charlson comorbidity score and age. 336 pN+men with a mean age of 64.9 years and a median follow-up of 4.1 years who had a radical prostatectomy were included in the analysis. 83 men were recommended RT+ADT, of whom 4% refused the ADT and received RT alone. C-index was 0.85 and 0.71 for the MFS and OS models, respectively. On multivariable analysis (MVA) adjusted for competing risks, RT+ADT significantly improved MFS (HR=0.70 P=< .01) with number of nodes positive, GS 8-10, PSA nadir > 1 ng/mL, and pT3b prognostic for metastasis. MVA for OS demonstrates RT+ADT improves survival (HR=0.40, P=.02), with GS8-10 and PSA nadir > 1.0 prognostic for death. We developed predictive nomograms for patients with pN+ prostate cancer following radical prostatectomy. These models can discretely quantify an individual's risk of metastasis or death with and without post-prostatectomy radiotherapy.

A0825 - Oncological outcomes, patterns of recurrence and impact of competing causes of mortality in clinically node-positive prostate cancer patients treated with radical prostatectomy

A0825 - Oncological outcomes, patterns of recurrence and impact of competing causes of mortality in clinically node-positive prostate cancer patients treated with radical prostatectomy

SC282 - PET/CT allows for a reliable assessment of the real nodal burden in clinically node-positive prostate cancer patients candidate for radical prostatectomy: results from a multi-institutional series

SC282 - PET/CT allows for a reliable assessment of the real nodal burden in clinically node-positive prostate cancer patients candidate for radical prostatectomy: results from a multi-institutional series

Clinical outcomes of salvage treatment in lymph node-positive prostate cancer patients after radical prostatectomy.

IntroductionThe optimal salvage treatment strategies for lymph node-positive (LNP) patients after radical surgery have not been clearly defined in prostate cancer with biochemical recurrence or persistence of elevated prostate-specific antigen (PSA). In this study, we compared the clinical outcomes of two different salvage treatments, androgen deprivation therapy (ADT) alone versus ADT with radiotherapy (RT). We also investigated prognostic factors that could support the use of ADT with RT in LNP prostate cancer.Materials and methodsWe retrospectively reviewed 94 LNP prostate cancer patients who underwent radical prostatectomy (RP) followed by salvage treatment between 2004 and 2018. Salvage treatments involved either ADT alone or ADT with RT according to the clinical judgment of the physician. We analyzed clinicopathological and treatment factors related to 2nd biochemical failure (2nd BCF), clinical progression (CP), and progression-free survival (PFS). The cumulative failure after salvage treatment was defined as including both 2nd BCF and CP.ResultsThe median duration of follow-up was 55 months (interquartile range, 35–97 months). Thirty-seven (39.4%) patients were treated with ADT alone, and 57 patients (60.6%) were treated with a combination of ADT with RT. During follow-up period, the incidence of failure after salvage treatment in the ADT alone group and the combined treatment group was 89.2% and 45.6%, respectively (HR, 22.4; 95% CI 5.43–92.1; P < 0.001). The combination of ADT with RT was associated with better 2nd BCF and PFS than ADT alone (P = 0.007 and P = 0.015, respectively). In multivariate analyses, number of positive LN ≥ 2 and PSA nadir ≥ 0.005 ng/ml after RP were associated with poor 2nd BCF, CP, and PFS after salvage treatment. Salvage by combined ADT plus RT showed better 2nd BCF and PFS than ADT alone. Specifically, patients with number of positive LN ≥ 2 or PSA nadir ≥ 0.005 ng/ml after RP showed better 2nd BCF (P = 0.004) or PFS (P = 0.011) when treated with ADT plus RT rather than ADT alone.ConclusionsIn patients with LNP prostate cancer, salvage ADT plus RT improved 2nd BCF and PFS compared to ADT alone. In particular, when the patients had more than two positive lymph nodes or PSA nadir ≥ 0.005 ng/ml after RP, ADT with RT seems to be a more beneficial salvage treatment resulting in better 2nd BCF and PFS.

PD05-09 PET/CT ALLOWS FOR A RELIABLE ASSESSMENT OF THE REAL NODAL BURDEN IN CLINICALLY NODE-POSITIVE PROSTATE CANCER PATIENTS CANDIDATE FOR RADICAL PROSTATECTOMY: RESULTS FROM A MULTI-INSTITUTIONAL SERIES

You have accessJournal of UrologyProstate Cancer: Advanced (including Drug Therapy) I (PD05)1 Sep 2021PD05-09 PET/CT ALLOWS FOR A RELIABLE ASSESSMENT OF THE REAL NODAL BURDEN IN CLINICALLY NODE-POSITIVE PROSTATE CANCER PATIENTS CANDIDATE FOR RADICAL PROSTATECTOMY: RESULTS FROM A MULTI-INSTITUTIONAL SERIES Giorgio Gandaglia, R. Jeffrey Karnes, Charlien Berghen, Wouter Everaerts, Gaëtan Devos, Steven Joniau, Daniele Robesti, Armando Stabile, Simone Scuderi, Francesco Barletta, Vito Cucchiara, Elio Mazzone, Giuseppe Rosiello, Andrea Salonia, Pierre I Karakiewicz, Hendrik Van Poppel, Francesco Montorsi, and Alberto Briganti Giorgio GandagliaGiorgio Gandaglia More articles by this author , R. Jeffrey KarnesR. Jeffrey Karnes More articles by this author , Charlien BerghenCharlien Berghen More articles by this author , Wouter EveraertsWouter Everaerts More articles by this author , Gaëtan DevosGaëtan Devos More articles by this author , Steven JoniauSteven Joniau More articles by this author , Daniele RobestiDaniele Robesti More articles by this author , Armando StabileArmando Stabile More articles by this author , Simone ScuderiSimone Scuderi More articles by this author , Francesco BarlettaFrancesco Barletta More articles by this author , Vito CucchiaraVito Cucchiara More articles by this author , Elio MazzoneElio Mazzone More articles by this author , Giuseppe RosielloGiuseppe Rosiello More articles by this author , Andrea SaloniaAndrea Salonia More articles by this author , Pierre I KarakiewiczPierre I Karakiewicz More articles by this author , Hendrik Van PoppelHendrik Van Poppel More articles by this author , Francesco MontorsiFrancesco Montorsi More articles by this author , and Alberto BrigantiAlberto Briganti More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001969.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: PET/CT scan might identify nodal metastases in prostate cancer (PCa) patients considered for radical prostatectomy (RP). No data addressed the performance characteristics and prognostic value of a positive PET/CT in the nodes for the identification of men more likely to recur METHODS: 346 patients treated with RP and an extended lymph node dissection (LND) with pelvic or retroperitoneal lymphadenopathies at cross-sectional abdominal imaging (n=283 81.8%) vs. choline or PSMA PET/CT (n=63 18.2%) were identified. Lowess analyses explored the non-linear relationship between the number of positive spots and pathologically positive nodes according to imaging (cross-sectional vs PET/CT). Kaplan-Meier analyses assessed time to biochemical recurrence (BCR) in the PET/CT cohort after stratifying patients according to the number of lymphadenopathies. The best cut-off for the number of lymphadenopathies at PET/CT predicting BCR was determined RESULTS: The rate of pN1 disease (74 vs 69%), the number of nodes removed (25 vs 24) and of positive nodes (2 vs 2) at LND did not differ (all P≥0.2). The site of lymphadenopathies was the pelvis only and the pelvis ± retroperitoneum in 84 vs. 88% and 16 vs 12% patients (p=0.3). Cross-sectional imaging was associated with underestimation of nodal burden when ≥2 lymphadenopathies were detected. PET/CT was characterized by excellent concordance with the number of positive nodes at RP. Median follow-up was 70 months and 183 patients experienced BCR. For PET/CT, the most-informative cut-off predicting BCR was 2 clinical lymphadenopathies. When patients selected based on PET/CT were stratified according to the number of positive spots (1 vs ≥2), the 3-year BCR-free survival rates were 48 vs. 21% (p=0.03). This was consistent to what observed when stratifying patients according to the number of positive nodes at final pathology (41 vs 23% p=0.04) CONCLUSIONS: While conventional imaging underestimates the nodal burden, PET/CT is characterized by excellent concordance with final pathology. This resulted in a more reliable prediction of BCR, where the presence of ≥2 positive spots at PET/CT might identify men more likely to experience early recurrence. Source of Funding: - © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e58-e59 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Giorgio Gandaglia More articles by this author R. Jeffrey Karnes More articles by this author Charlien Berghen More articles by this author Wouter Everaerts More articles by this author Gaëtan Devos More articles by this author Steven Joniau More articles by this author Daniele Robesti More articles by this author Armando Stabile More articles by this author Simone Scuderi More articles by this author Francesco Barletta More articles by this author Vito Cucchiara More articles by this author Elio Mazzone More articles by this author Giuseppe Rosiello More articles by this author Andrea Salonia More articles by this author Pierre I Karakiewicz More articles by this author Hendrik Van Poppel More articles by this author Francesco Montorsi More articles by this author Alberto Briganti More articles by this author Expand All Advertisement Loading ...

PO-1318 salvage treatment outcomes in lymph node-positive prostate cancer patients after surgery

PO-1318 salvage treatment outcomes in lymph node-positive prostate cancer patients after surgery

P0924 - PET/CT allows for a reliable assessment of the real nodal burden in clinically node-positive prostate cancer patients candidate for radical prostatectomy: Results from a multi-institutional series

P0924 - PET/CT allows for a reliable assessment of the real nodal burden in clinically node-positive prostate cancer patients candidate for radical prostatectomy: Results from a multi-institutional series

Phase I/II Study of Extreme Hypofractionated Stereotactic Body Radiation Therapy Boost to Prostate for Locally Advanced, Node-Positive and Oligometastatic Cancer.

Introduction: Stereotactic body radiation therapy (SBRT) is increasingly being utilized to deliver escalated radiation doses for improving outcomes in various malignancies. We analyzed our cohort of locally advanced, node-positive, and bone oligometastatic prostate cancer patients, that were treated with a combination of pelvic RT using conventional fractionation (CF) and SBRT boost to prostate using extreme hypofractionation (EH), along with hormone therapy (HT).Materials and Methods: Outcomes of 44 prospectively treated patients were analyzed. Volumetric modulated arc therapy (VMAT) was utilized to deliver a dose of 45 Gy to pelvic nodal region, 50 Gy to prostate, and 54-56 Gy to gross nodes in 25 fractions. EH boost 18 Gy in three fractions was delivered to the prostate using CyberKnife (Accuray, Sunnyvale, CA, USA) SBRT. Bone oligometastasis, if any, were treated to a dose of 16 Gy in two fractions, delivered on weekends. Serum prostate-specific antigen (PSA), multi-parametric magnetic resonance imaging (MRI) of pelvis, and prostate-specific membrane antigen-positron emission tomography (PSMA-PET) were used for response assessment during follow-up. HT was given as per standard guidelines.Results: There were 33 (75%) locally advanced, nine (20.5%) node-positive, and two (4.5%) oligometastatic cases. At a median follow-up of 63.5 months, the five-year progression-free survival (PFS) was 88.2%, biochemical PFS (bPFS) was 91.4% and overall survival (OS) was 96.9%. Grade III or greater acute genitourinary and gastrointestinal toxicity was 2.3% each, and late toxicity was 4.5% and 0%, respectively.Conclusion: Excellent five-year outcomes can be attained even for locally advanced, node-positive and bone oligometastatic prostate cancer, by means of dose-escalation using EH-SBRT boost to the prostate.

Adjuvant radiotherapy in node positive prostate cancer patients: a debate still on. when, for whom?

To evaluate the impact of adjuvant radiotherapy (aRT) in patients with prostate cancer (PCa) found to have pathological positive lymph nodes (pN1s) after radical prostatectomy (RP) and extended pelvic lymph node dissection (ePLND) with regard to distant recurrence-free survival (RFS), according to both main tumour pathological characteristics and number of positive lymph nodes. Biochemical RFS, local RFS, overall survival (OS) and acute and late toxicity were assessed as secondary endpoints. A retrospective cohort of 187 consecutive patients with pN1 PCa were treated with aRT at the IEO, European Institute of Oncology IRCCS, Milan, Italy. aRT on the tumour bed and pelvis was administered within 6months of RP. Androgen deprivation therapy was administered according to the guidelines. Univariate and multivariate Cox regression analyses predicting biochemical RFS, local RFS, distant RFS and OS rates were performed to assess whether the number of pN1s represented an independent prognostic factor. The Youden index was computed to find the optimal threshold for the number of pN1s able to discriminate between patients with or without biochemical and clinical relapse. At 5years, local RFS, distant RFS, biochemical RFS and OS were 68%, 71%, 56% and 94%, respectively. The median follow-up was 49months. The number of pN1s was significantly associated with biochemical RFS, local RFS and distant RFS. The best threshold for discriminating between patients with or without biochemical and clinical relapse was five pN1s. In multivariate analyses, the number of pN1s was confirmed to be an independent predictor of biochemical RFS, local RFS and distant RFS, but not of OS. Multivariate analyses also showed an increased risk of biochemical relapse for increasing values of initial prostate-specific antigen and for patients with tumour vascular invasion. Local and distant RFS were also inversely correlated with significantly reduced risk for International Society of Urological Pathology grade group <3 (group 1 or 2 compared to group 3). Our data confirmed the encouraging outcomes of patients with pN1 PCa treated with adjuvant treatments and the key role represented by the number of pN1s in predicting biochemical RFS, clinical RFS and distant RFS. Large prospective cohort studies and randomized clinical trials are needed to confirm these results and to identify the subgroup of patients with pN1 PCa who would most benefit from aRT.