Underwent Salvage Radical Prostatectomy Research Articles

Salvage Radical Prostatectomy after Primary Focal Ablative Therapy: A Systematic Review and Meta-Analysis.

Focal therapy (FT) has been gaining popularity as a treatment option for localized intermediate-risk prostate cancer (PCa) due to the associated lower morbidity compared to whole-gland treatment. However, there is an increased risk of local cancer recurrence requiring subsequent treatment in a small proportion of patients. To conduct a systematic review and meta-analysis to better describe and analyze patient postoperative, oncologic, and functional outcomes for those who underwent salvage radical prostatectomy (sRP) to manage their primary FT failure. A systematic review was completed using three databases (PubMed, Embase, and CINAHL) from October to December 2021 to identify data on outcomes in patients who received sRP for cancer recurrence after prior focal treatment. 12 articles (482 patients) were included. Median time to sRP was 24 months. Median follow-up time was 27 months. A meta-analysis revealed a postoperative complication rate of 15% (95% CI: 0.09, 0.24), with 4.6% meeting criteria for a major complication Clavien (CG) grade ≥3. Severe GU toxicity was seen in 3.6% of the patients, and no patients had severe GI toxicity. Positive surgical margins (PSM) were found in 27% (95% CI: 0.19, 0.37). Biochemical recurrence (BCR) after sRP occurred in 23% (95% CI: 0.17, 0.30), indicating a BCR-free probability of 77% at 2 years. Continence (pad-free) and potency (ability to have penetrative sex) were maintained in 67% (95% CI: 0.53, 0.78) and 37% (95% CI: 0.18, 0.62) at 12 months, respectively. Our evidence shows acceptable complication rates and oncologic outcomes; however, with suboptimal functional outcomes for patients undergoing sRP for recurrent PCa after prior FT. Inferior outcomes were observed for salvage treatment compared to primary radical prostatectomy (pRP). More high-quality studies are needed to better characterize outcomes after this sequence of PCa treatments. We looked at treatment outcomes and toxicity for men treated with sRP for prior FT failure. We conclude that these patients will have significant detriment to genitourinary function, with outcomes being worse than those for pRP patients.

Enrichment of “Cribriform” morphologies (intraductal and cribriform adenocarcinoma) and genomic alterations in radiorecurrent prostate cancer

AbstractLocally relapsed prostate cancer (PCa) after radiation therapy (RT) is associated with substantial morbidity and mortality. Morphological and molecular consequences that may contribute to RT resistance and local recurrence remain poorly understood. Locally recurrent PCa tissue from 53 patients with clinically localized PCa who failed with primary RT and subsequently underwent salvage radical prostatectomy (RP) was analyzed for tumor focality, clinicopathological, molecular, and genomic characteristics. Targeted next-generation sequencing with full exon coverage of 1,425 cancer-related genes was performed on 10 representative radiorecurrent PCas exhibiting no RT effect with matched adjacent benign prostate tissue. At RP, 37 (70%) of PCas had no RT effect with the following characteristics: grade group (GG) ≥ 3 (70%), unifocal tumor (75%), extraprostatic disease (78%), lymph node metastasis (8%), and “cribriform” morphologies (84%) [cribriform PCa (78%) or intraductal carcinoma (IDC-P) (61%)] at a median percentage of approximately 80% of tumor volume. In the setting of multifocal tumors (25%) at RP, the cribriform morphologies were restricted to index tumors. Of 32 patients with available pre-RT biopsy information, 16 had GG1 PCa, none had cribriform morphologies at baseline but 81% demonstrated cribriform morphologies at RP. Notable alterations detected in the sequenced tumors included: defects in DNA damage response and repair (DDR) genes (70%) (TP53, BRCA2, PALB2, ATR, POLQ), PTEN loss (50%), loss of 8p (80%), and gain of MYC (70%). The median tumor mutational burden was 4.18 mutations/Mb with a range of 2.16 to 31.86. Our findings suggest that most radiorecurrent PCas are enriched in cribriform morphologies with potentially targetable genomic alterations. Understanding this phenotypic and genotypic diversity of radiorecurrent PCa is critically important to facilitate optimal patient management.

A0969 - The role of lymph node dissection in patients undergoing salvage radical prostatectomy for radiation recurrent prostate cancer

A0969 - The role of lymph node dissection in patients undergoing salvage radical prostatectomy for radiation recurrent prostate cancer

MP15-10 THE ROLE OF LYMPH NODE DISSECTION IN PATIENTS UNDERGOING SALVAGE RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy I (MP15)1 Sep 2021MP15-10 THE ROLE OF LYMPH NODE DISSECTION IN PATIENTS UNDERGOING SALVAGE RADICAL PROSTATECTOMY Fahad Quhal, Pawel Rajwa, Keiichiro Mori, Ekaterina Laukhtina, Nico C. Grossmann, Abdulmajeed Aydh, Reza Sari Motlagh, Satoshi Katayama, Hadi Mostafai, Benjamin Pradere, Paolo Gontero, Romain Mathieu, Pierre I. Karakiewicz, Alberto Briganti, Axel Heidenreich, and Shahrokh Shariat Fahad QuhalFahad Quhal More articles by this author , Pawel RajwaPawel Rajwa More articles by this author , Keiichiro MoriKeiichiro Mori More articles by this author , Ekaterina LaukhtinaEkaterina Laukhtina More articles by this author , Nico C. GrossmannNico C. Grossmann More articles by this author , Abdulmajeed AydhAbdulmajeed Aydh More articles by this author , Reza Sari MotlaghReza Sari Motlagh More articles by this author , Satoshi KatayamaSatoshi Katayama More articles by this author , Hadi MostafaiHadi Mostafai More articles by this author , Benjamin PradereBenjamin Pradere More articles by this author , Paolo GonteroPaolo Gontero More articles by this author , Romain MathieuRomain Mathieu More articles by this author , Pierre I. KarakiewiczPierre I. Karakiewicz More articles by this author , Alberto BrigantiAlberto Briganti More articles by this author , Axel HeidenreichAxel Heidenreich More articles by this author , and Shahrokh ShariatShahrokh Shariat More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001996.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prostate cancer (PCa) recurrence after primary radiotherapy is increasingly encountered. Radical prostatectomy is a salvage local treatment with potentially durable disease control for these patients. Here, we sought to examine the effect of lymph node dissection on the outcomes of patients with radiation-recurrent PCa who underwent salvage radical prostatectomy (SRP). METHODS: A retrospective review of patients with radiation-recurrent PCa who underwent SRP at six referral centers from 2000 to 2016. Recurrence after radiotherapy was defined as a prostate specific antigen (PSA) increase of ≥2 ng/mL above the nadir. All patients underwent a pre-SRP biopsy. Biochemical recurrence (BCR) was defined as PSA value of ≥0.2 ng/mL after SRP. The effect of the number of removed lymph nodes (RLNs) and positive lymph nodes (PLNs) on BCR-free survival, metastases free survival, overall survival (OS) was tested in multivariate Cox regression analyses. RESULTS: Overall, 334 patients underwent SRP and pelvic lymph node dissection. The median age and PSA at surgery were 68 years, and 3.55 ng/mL, respectively. The median follow up duration was 22.9 months (IQR 4.6-33.2) Lymph node involvement( LNI) was associated with increased risk of BCR (HR 2.18, p<0.001), metastasis (HR 3.93, p<0.001) and overall mortality (HR 2.88, p=0.006). In a multivariate cox regression analysis, an increased number of RLNs significantly reduced the risk of BCR (HR 0.96, p=0.01). In patients with positive lymph nodes, a higher number of RLN and a lower number of PLNs were both associated with improved freedom from BCR (HR 0.89, p= 0.001 and HR 1.34, p=0.008, respectively).The number of RLNs was not significantly associated with MFS. However, patients with ≥two positive lymph nodes were at a significantly increased risk of developing metastasis (HR 3.72, p=0.017). Neither the number of RLNs nor the number of PLNs were significantly associated with OS. In logistic regression analysis, an increased number of RLNs was associated with a higher probability of finding positive lymph nodes. CONCLUSIONS: LNI increased the risk of BCR, metastasis and overall mortality in radiation-recurrent PCa patients undergoing SRP. The increased number of RLNs improved staging through a higher probability of detecting LNI. Furthermore, an increased number of RLNs during SRP reduced the risk of BCR, hinting at a possible therapeutic benefit. However, further research with standardized lymph node templates is needed to support this conclusion and develop a precise therapeutic adjuvant strategy based on the number of RLNs and the number of PLNs. Source of Funding: No funding © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e267-e268 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Fahad Quhal More articles by this author Pawel Rajwa More articles by this author Keiichiro Mori More articles by this author Ekaterina Laukhtina More articles by this author Nico C. Grossmann More articles by this author Abdulmajeed Aydh More articles by this author Reza Sari Motlagh More articles by this author Satoshi Katayama More articles by this author Hadi Mostafai More articles by this author Benjamin Pradere More articles by this author Paolo Gontero More articles by this author Romain Mathieu More articles by this author Pierre I. Karakiewicz More articles by this author Alberto Briganti More articles by this author Axel Heidenreich More articles by this author Shahrokh Shariat More articles by this author Expand All Advertisement Loading ...

The role of lymph node dissection in salvage radical prostatectomy for patients with radiation recurrent prostate cancer.

PurposeTo examine the effect of lymph node dissection on the outcomes of patients who underwent salvage radical prostatectomy (SRP).Material and MethodsWe retrospectively reviewed data from radiation‐recurrent patients with prostate cancer (PCa) who underwent SRP from 2000–2016. None of the patients had clinical lymph node involvement before SRP. The effect of the number of removed lymph nodes (RLNs) and the number of positive lymph nodes (PLNs) on biochemical recurrence (BCR)‐free survival, metastases free survival, and overall survival (OS) was tested in multivariable Cox regression analyses.ResultsAbout 334 patients underwent SRP and pelvic lymph node dissection (PLND). Lymph node involvement was associated with increased risk of BCR (p < .001), metastasis (p < .001), and overall mortality (p = .006). In a multivariable Cox regression analysis, an increased number of RLNs significantly lowered the risk of BCR (hazard ratio [HR] 0.96, p = .01). In patients with positive lymph nodes, a higher number of RLNs and a lower number of PLNs were associated with improved freedom from BCR (HR 0.89, p = .001 and HR 1.34, p = .008, respectively). At a median follow‐up of 23.9 months (interquartile range, 4.7–37.7), neither the number of RLNs nor the number of PLNs were associated with OS (p = .69 and p = .34, respectively).ConclusionPathologic lymph node involvement increased the risk of BCR, metastasis and overall mortality in radiation‐recurrent PCa patients undergoing SRP. The risk of BCR decreased steadily with a higher number of RLNs during SRP. Further research is needed to support this conclusion and develop a precise therapeutic adjuvant strategy based on the number of RLNs and PLNs.

Triggers and oncologic outcome of salvage radical prostatectomy, salvage radiotherapy and active surveillance after focal therapy of prostate cancer

PurposeDue to the tissue preserving approach of focal therapy (FT), local cancer relapse can occur. Uncertainty exists regarding triggers and outcome of salvage strategies.MethodsPatients with biopsy-proven prostate cancer (PCa) after FT for localized PCa from 2011 to 2020 at eight tertiary referral hospitals in Germany that underwent salvage radical prostatectomy (S-RP), salvage radiotherapy (S-RT) or active surveillance (AS) were reported. Prostate specific antigen (PSA) changes, suspicious lesions on mpMRI and histopathological findings on biopsy were analyzed. A multivariable regression model was created for adverse pathological findings (APF) at S-RP specimen. Kaplan–Meier curves were generated to determine oncological outcomes.ResultsA total of 90 men were included. Cancer relapse after FT was detected at a median of 12 months (IQR 9–16). Of 50 men initially under AS 13 received S-RP or S-RT. In total, 44 men underwent S-RP and 13 S-RT. At cancer relapse 17 men (38.6%) in the S-RP group [S-RT n = 4 (30.8%); AS n = 3 (6%)] had ISUP > 2. APF (pT ≥ 3, ISUP ≥ 3, pN + or R1) were observed in 23 men (52.3%). A higher ISUP on biopsy was associated with APF [p = 0.006 (HR 2.32, 97.5% CI 1.35–4.59)] on univariable analysis. Progression-free survival was 80.4% after S-RP and 100% after S-RT at 3 years. Secondary therapy-free survival was 41.7% at 3 years in men undergoing AS. Metastasis-free survival was 80% at 5 years for the whole cohort.ConclusionWith early detection of cancer relapse after FT S-RP and S-RT provide sufficient oncologic control at short to intermediate follow-up. After AS, a high secondary-therapy rate was observed.

P033 - The significance of De-Ritis ratio in patients with radiation-recurrent prostate cancer undergoing salvage radical prostatectomy

P033 - The significance of De-Ritis ratio in patients with radiation-recurrent prostate cancer undergoing salvage radical prostatectomy

Is the Toxicity of Salvage Prostatectomy Related to the Primary Prostate Cancer Therapy Received?

To compare the toxicity profile and oncological outcome of salvage radical prostatectomy following focal therapy versus salvage radical prostatectomy after radiation therapies (external beam radiation therapy or brachytherapy). Data concerning all men undergoing salvage radical prostatectomy for recurrent prostate cancer after either focal therapy, external beam radiation therapy or brachytherapy were retrospectively collected from 4 high volume surgical centers. The primary outcome measure of the study was toxicity of salvage radical prostatectomy characterized by any 30-day postoperative Clavien-Dindo complication rate, 12-month continence rate and 12-month potency rate. The secondary outcome was oncological outcome after salvage radical prostatectomy including positive margin rate and 12-month biochemical recurrence rate. Biochemical recurrence was estimated using Kaplan-Meier methods and significant differences were calculated using a log rank test. Median followup was 29.5 months. Between April 2007 and September 2018, 185 patients underwent salvage radical prostatectomy of whom 95 had salvage radical prostatectomy after focal therapy and 90 had salvage radical prostatectomy after radiation therapy (external beam radiation therapy or brachytherapy). Salvage radical prostatectomy after radiation therapy was associated with a significantly higher 30-day Clavien-Dindo I-IV complication rate (34% vs 5%, p <0.001). At 12 months following surgery, patients undergoing salvage radical prostatectomy after focal therapy had significantly better continence (83% pad-free vs 49%) while potency outcomes were similar (14% vs 11%). Men undergoing salvage radical prostatectomy after radiation therapy had a significantly higher stage and grade of disease together with a higher positive surgical margin rate (37% vs 13%, p=0.001). The 3-year biochemical recurrence after focal therapy was 35% compared to 32% after radiation therapy (p=0.76). In multivariable analysis, men undergoing salvage radical prostatectomy after focal therapy experienced a higher risk of biochemical recurrence (HR 0.36, 95% CI 0.16-0.82, p=0.02). This multicenter study demonstrates the toxicity of salvage radical prostatectomy in terms of perioperative complications and long-term urinary continence recovery is dependent on initial primary prostate cancer therapy received with men undergoing salvage radical prostatectomy after focal therapy experiencing lower postoperative complication rates and better urinary continence outcomes.

Biochemichal recurrence in prostate cancer after salvage surgery in correlation to the site of reccurrent disease.

306 Background: Due to improved diagnostic tools salvage surgery is getting more popular after failure of primary local treatment as radical prostatectomy or radiotherapy. We analyzed PSA progression free survival (PFS) after radical prostatectomy and or radiotherapy in accordance to the location of the recurrence and the performed salvage surgery. Methods: We retrospectively analyzed 274 patients with salvage surgeries. 142, 18, and 114 patients underwent salvage radical prostatectomy (SPRE, Group1), locoregional recurrences mainly in seminal vesical remnants (SVR, Group2) or salvage lymph node dissection (SLND, Group3). All patients were diagnosed either by Choline- or more lately PSMA-PET CT. All surgeries had been done open. In Group1 radical prostatectomy and lymph node dissection, in Group 2 the seminal vesicals and in Group3 an ipsilateral pelvic lymph node dissection had been performed due to imaging results. Results: Median age at time of surgery was 67(62-72)years. Median PSA was 3.1(1.45-5.45)ng/ml. Radiotherapy or hormone therapy before salvage surgery in Group 1,2,3 was done in 100%, 61,1%, 54,39% and 12,6%, 27,8%, 18,42% of the patients. Median progression free survival in Group 1, 2, 3 is 41(11.104), 29 (8-47) and 8 (2-21) months (p &lt; 0.001). PSA PFS in Group1/2 and Group 1/3 differed significantly with an HR of 1.85 (95%CI;1,0-3.44) and HR of 2.72 (95%CI; 1,84-4,04). Only age at time of surgery and interval from primary treatment to salvage procedure in months were significant predictors in an univariate Cox regression analysis. Conclusions: We demonstrate that the best biochemical control in salvage surgeries is achieved in patients with isolated recurrence in the prostate after radiotherapy. The effect of salvage surgery decreases with increasing distance of the site of recurrence to the prostate.

Radical prostatectomy after vascular-targeted photodynamic therapy (VTP) with TOOKAD® : feasibility, early and intermediate results

Introductionand objectives: vascular-targeted photodynamic therapy with TOOKAD® (VTP) is a new therapeutic option for localized prostate cancer (PCa) management. The objectives are to assess the feasibility of radical prostatectomy (RP) after VTP and describe functional and oncological outcomes. Material and Methodswe retrospectively included 45 patients who underwent salvage RP after VTP for recurrent PCa in 14 surgical centres in Europe between October 2008 and March 2017.Forty-two RP were performed: 16 robot-assisted, 6 by laparoscopy, and 20 by open surgery. Primary endpoints were morbidity and technical difficulties. Secondary endpoints were early and intermediate post-operative functional and oncologic outcomes. ResultsMedian operative time was 180 (150-223) minutes. Median blood loss was 200 (155-363) millilitres. According to the surgeons, the surgery was “easy” for 29 patients (69%), “difficult” for 13 patients (31%). Nerve sparing was feasible for 14 patients (33%). Five (12%) post-operative complications were found: 2 Claviens I, 2 Clavien II and 1 Clavien IIIB. There was 13 pT3 (31%), 21 (50%) pT2c. Surgical margins were positive for 13 patients (31%). PSA was undetectable at 6-12 months for 37 patients (88%). Nine patients had complementary radiotherapy. Four patients had a last PSA > 0.2 ng/mL with a median follow-up of 23 (12-36) months. At one year, 27 patients (64%) were completely continent (no pads), 10 (24%) had low incontinence (1 pads). Four patients (11 %) recovered potency without treatment, and 23 (64%) with appropriate treatment. ConclusionSalvage RP after VTP treatment was feasible and safe without difficulties for most of the surgeons.

Functional outcome and quality of life in patients undergoing salvage radical prostatectomy (SRPE).

212 Background: Salvage radical prostatectomy is one option for patients with locally recurrent disease with proven long term oncologic control. There are concerns about worse functional results due to fibrotic tissue after radiotherapy and patients are treated with palliative systemic androgendreptivation. We retrospectively analyzed continence and quality of life in patients undergoing SRPE. Methods: After biopsy proven local recurrent prostate cancer 138 patients were offered SRPE and extended lymphadenectomy. Continence and quality of life had been collected before 6 and 12 months after surgery. Validated questionaires with ICIQ and EORTC qlq 30 had been used. Results: Präoperatively at 6 monts and 12 months the feed back was available in 93, 84 and 82 patients respectively. Präoperatively there was no or mild incontinence in 38(40.8%), moderate in 33 (35.5%) and strong incontinence in 22 (23.7%) of the patients. There is a significant decrease in the rate of continence after 6 and 12 months to no or mild in 19 (23.1%), moderate in 19 (23.2%) and strong incontinence in 44 (53.7%) of the patients. In 5 patients an artifitial sphinkter was implanted. Quality of life did not change significantly before and 12 months after surgery. Median value of Question 30 was 6 and five respectively. Conclusions: Patients need to be informed about a worse functional outcome and the potential need for further surgical interventions as artificial sphinkter implantion compared to primary radical prostatectomy. Quality of life seems to be affected only moderatly. Nevertheless there is already a rather high rate of any incontinence before surgery that needs to be taken into account.

68-Ga-PSMA-PET in the diagnosis of local recurrent disease after radiotherapy in patients with prostate cancer.

213 Background: For planning salvage procedures in recurrent prostate cancer accurate diagnostic tools are needed. Till now in patients suspicious for isolated local recurrent cancer invasive biopsy was needed. 68-Ga-PSMA-PET is frequently used to identify even small metastatic deposits. We analyzed the diagnostic value to identify local recurrence in patients after radiotherapy undergoing salvage radical prostatectomy, sRPE. Methods: We retrospectively reviewed patients undergoing sRPE with 68-Ga-PSMA-PET as preoperative staging. All patients underwent sRPE and extended lymph node dissection. Sensitivity, Specificity, pos and neg predictive value had been calculated per patient and per prostate lobe. Results: 37 patients with preoperative 68-Ga-PSMA-PEt could be identified. In all but one at least in one lobe PSMA staining could be identified. Mean tumor volume per prostate lobe was 6.22 (0.1-24)ml. Sensitivity, Specificity, neg and pos predictive value per lobe is 80%, 75%, 32% and 96%. Sensitivity to identify cancer recurrence per person irrespective of the side is 95% with a pos predictive value of 100%. Conclusions: 68-Ga-PSMA-PET seems to have a very high diagnistic value to identify local recurrence after radiotherapy. After validation of our experience an invasive biopsy to proof cancer recurrence might be spared.

Oncologic Effect of Cumulative Smoking Exposure in Patients Treated With Salvage Radical Prostatectomy for Radiation-recurrent Prostate Cancer.

The purpose of the present study was to investigate the association of smoking with biochemical recurrence (BCR) and metastasis in radiation-recurrent prostate cancer (PCa) patients undergoing salvage radical prostatectomy (SRP). A total of 214 patients treated with SRP for radiation-recurrent PCa in 5 tertiary referral centers were included from January 2007 to December 2015. Kaplan-Meier analyses were used to assess the time to BCR and metastasis. Pre- and postoperative multivariable Cox proportional hazard regression models were fitted. Overall, 120 (56.1%), 49 (22.9%), and 45 (21%) patients were never, former, and current smokers, respectively. Low-, medium-, and high-cumulative smoking exposure was registered in 59.8%, 16.4%, and 23.8% of cases, respectively. Patients with high cumulative smoking exposure had a significantly greater rate of a pathologic Gleason score of≥ 8 (P= .01) and extracapsular extension (P= .004). Smoking status, cumulative smoking exposure, intensity, and duration were significantly associated with BCR-free survival (P<.001 for all). Smoking status, cumulative smoking exposure, and smoking intensity were significantly associated with metastasis-free survival (P= .03 for all). High cumulative smoking exposure was independently associated with BCR in both pre- (hazard ratio, 2.23; P= .001) and postoperative (hazard ratio, 1.64; P= .04) multivariable models adjusted for the effects of established clinicopathologic features. Smoking cessation did not affect either BCR- or metastasis-free survival (P= .56 and P= .40, respectively). High cumulative smoking exposure was associated with the biologic and clinical aggressiveness of PCa in patients treated with SRP for radiation-recurrent disease. Smoking is a modifiable risk factor that detrimentally affected the outcomes, even in patients with advanced PCa.

Salvage prostatectomy for post-radiation adenocarcinoma with treatment effect: Pathological and oncological outcomes.

Prostate biopsies following localized radiation therapy for prostate cancer often demonstrate residual prostatic carcinoma with treatment effect (CTE). The final oncological outcome of prostatic CTE is currently uncertain. We studied the pathological and oncological outcomes for a large cohort of patients who had CTE on post-radiation therapy biopsy and subsequently underwent salvage radical prostatectomy (SRP). A single-centre retrospective review of all SRPs performed from 1995-2014 was performed. Cases were selected for this analysis if they had had a post-radiation "for-cause" biopsy. Biopsy results were compared to final pathology results following SRP. Pathological and clinical outcomes were compared by extent of treatment effect seen on the post-radiation biopsy. A total of 70 patients who had salvage prostatectomy at MD Anderson Cancer Centre from 2007-2015 met study criteria. CTE was found on biopsy in the absence of other adenocarcinoma in 16 patients. Among them, one (7%) patient had no evidence of carcinoma at the time of salvage prostatectomy, four (27%) had CTE, three (20%) had adenocarcinoma with minimal or partial treatment effect (PTE), and seven (47%) had adenocarcinoma with no treatment effect (NTE). For those with CTE on biopsy, 69% had biochemical recurrence at a median time of 0.4 years (interquartile range [IQR] 0.22-1.52) vs. 52% for all patients (median 0.44 years, IQR 0.11-1.70) and 47% for those with no treatment effect (median 0.62 years, IQR 0.05-1.90). Metastasis developed after salvage prostatectomy in 11.8% of the whole cohort (8/68, median time to metastasis was 3.03 years, IQR 2.45-4.47), 26.7% of patients with CTE (median 3.2 years, IQR 1.96-4.44), and 6.7% of patients with NTE (median 2.45 years, IQR 0.98-2.86). Median recurrence-free survival was 2.78 years (95% confidence interval [CI] 0.84-5.43) for all patients, 0.51 years (95% CI 0.22-2.35) for those with CTE, and 4.95 years (95% CI 0.95-7.08) for those with NTE; the difference was not significant (p=0.13). On multivariate analysis, pre-SRP biopsy Gleason grade <7 (hazard ratio [HR] 0.38; 95% CI 0.14-1.02) and number of biopsy cores positive for carcinoma (HR 1.11; 95% CI 1.00-1.22) were significant for prediction of cancer recurrence. Patients undergoing salvage prostatectomy for CTE or PTE demonstrated in a for-cause biopsy after radiation therapy had pathological evidence of viable, untreated cancer in more than 50% of cases and were at significant risk of adverse pathological features. Patients with CTE may therefore benefit from salvage radical prostatectomy. Our study is limited by its retrospective nature and sample size. More studies are required to further validate our findings and assess the benefit of SRP in this population.

MP69-09 TOPOGRAPHY OF RECURRENT PROSTATE CANCER BASED ON SALVAGE RADICAL PROSTATECTOMY TUMOR MAPS

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy V1 Apr 2016MP69-09 TOPOGRAPHY OF RECURRENT PROSTATE CANCER BASED ON SALVAGE RADICAL PROSTATECTOMY TUMOR MAPS Toshikazu Takeda, Amy Tin, Renato Corradi, Maha Mamoor, Nicole Benfante, Daniel Sjoberg, Samson Fine, James Eastham, Peter Scardino, and Karim Touijer Toshikazu TakedaToshikazu Takeda More articles by this author , Amy TinAmy Tin More articles by this author , Renato CorradiRenato Corradi More articles by this author , Maha MamoorMaha Mamoor More articles by this author , Nicole BenfanteNicole Benfante More articles by this author , Daniel SjobergDaniel Sjoberg More articles by this author , Samson FineSamson Fine More articles by this author , James EasthamJames Eastham More articles by this author , Peter ScardinoPeter Scardino More articles by this author , and Karim TouijerKarim Touijer More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1387AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES When administering radiotherapy (RT) and/or ablation therapy for prostate cancer, physicians seek to preserve the surrounding structure such as the urinary sphincter, neurovascular bundle, bladder, rectal wall, and urethra to reduce toxicity. We hypothesize that the area adjacent to these structures may be undertreated as a result and thus we assessed the patterns of tumor recurrence by reviewing tumor maps from patients undergoing salvage radical prostatectomy (SRP) after RT and/or ablation therapy for prostate cancer. METHODS We identified 236 patients who underwent RT and/or ablation therapy for prostate cancer and proceeded to SRP between 2000 and 2014. Among these 236 patients, 83 had available tumor maps from whole mount slides. We evaluated the detailed pathological characteristics of recurrent prostate cancer in these 83 patients. RESULTS In the 83 patients with tumor maps, median age at SRP was 66 years and median time from primary treatment to SRP was 4.6 years. One third of patients had undergone hormonal therapy with or after the primary treatment and 6% of patients had not undergone RT as their primary treatment, instead opting for cryosurgery or high-intensity focused ultrasound. Pathological Gleason score ≥ 8 was present in 37% of these recurrent prostate cancer cases and pathological stage ≥ T3 in 60%. A single cancer focus was found in 60%, while 88% had tumor in the apex, and 94% had tumor in the mid-gland. Median tumor volume was 1.4 cm3; median minimum distance from the tumor to the urethra was 0.3 cm. Fifty nine patients (71%) had cancer ≤ 0.5cm from the urethra. Six patients (7%) had tumor directly involving the urethra, and 5 of them had urethral invasion at the apex. One patient who had undergone both RT and cryosurgery did not have any tumor and two patients who underwent RT had tumor only in the seminal vesicle. CONCLUSIONS Our results show that many of the recurrences are solitary and in locations near the urethra. This suggests that the technique of preserving the surrounding structure during RT and/or ablation therapy influences the pattern of post-treatment recurrence. Therefore, when recurrence is suspected after RT and/or ablation therapy, biopsy of the area near the urethra and seminal vesicle is needed when considering salvage treatment for curative intent. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e900-e901 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Toshikazu Takeda More articles by this author Amy Tin More articles by this author Renato Corradi More articles by this author Maha Mamoor More articles by this author Nicole Benfante More articles by this author Daniel Sjoberg More articles by this author Samson Fine More articles by this author James Eastham More articles by this author Peter Scardino More articles by this author Karim Touijer More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Pathological Characteristics of Prostate Cancer Recurrence After Radiation Therapy: Implications for Focal Salvage Therapy

Focal therapy is currently under investigation as an alternative to salvage radical prostatectomy for locally recurrent prostate cancer after primary radiation therapy. If patients can be selected properly, focal therapy could enable tumor eradication without the morbidity associated with salvage radical prostatectomy. We describe the pathological features of recurrent prostate cancer in salvage radical prostatectomy specimens and the implications of these results for focal therapy. We gathered data on 50 consecutive patients who had recurrence after primary radiation therapy and underwent salvage radical prostatectomy between 1993 and 2008. Preoperatively prostate specific antigen was less than 10 ng/ml in 49 patients (98%) and biopsy Gleason score was 7 or less in 18 (36%). Salvage radical prostatectomy specimens were analyzed for tumor zonal origin, site and volume, Gleason score and pathological stage. Median preoperative prostate specific antigen was 3.4 ng/ml. Pathological stage was T2 in 23 patients (46%). The salvage radical prostatectomy Gleason score was 7 or less in 17 patients (34%) and surgical margins were negative in 43 (86%). A single cancer focus was found in 33 cases (66%) while there was bilateral involvement in 37 (74%). The base and apex were involved in 23 cases (46%) and 37 tumors (74%) were located within 5.0 mm of the urethra. Median tumor volume was 1.27 cm(3) (range 0.05 to 12.96). Prostate cancer recurrence after radiation therapy is often bilateral and involves multiple zones. It is often high grade, bulky and close to the urethra. These findings suggest that planning salvage focal therapy after radiation failure will be difficult.

Salvage Radical Prostatectomy Following Primary High Intensity Focused Ultrasound for Treatment of Prostate Cancer

High intensity focused ultrasound for the treatment of primary prostate cancer is increasing in a subset of men seeking definitive treatment with reduced morbidity. We review outcomes in men undergoing salvage radical prostatectomy after failed whole gland high intensity focused ultrasound. Prospective data were collected for men presenting with an increasing prostate specific antigen and biopsy proven prostate cancer after high intensity focused ultrasound from 2007 to 2010 who underwent salvage open radical prostatectomy with a 22-month median followup, including prostate specific antigen, prostate volume, pathology results, continence and erectile function. Data for 15 men were available, including median age 64 years (IQR 55-69), Gleason score before high intensity focused ultrasound of 6 (8), Gleason score 7 (7), median cores positive 39% (IQR 17%-63%) and median prostate specific antigen 7 ng/ml (IQR 5-8). Whole gland high intensity focused ultrasound achieved median nadir prostate specific antigen 1.1 ng/ml (IQR 0.5-3.1). Biopsy after high intensity focused ultrasound demonstrated Gleason score 6 (in 3 patients), 7 (9) and 8/9 (3), and 42% (IQR 25%-50%) cores positive and a median time from high intensity focused ultrasound to radical prostatectomy of 22 months (IQR 7-26). Perioperative morbidity was limited to 1 transfusion in a patient with a rectal injury. Pathologically extensive periprostatic fibrosis was found with persistent prostate cancer, as pT3 disease (in 9 of 14), Gleason scores 6 (2), 7 (9) and 8 of 9 (4), with focally positive margins in 3 of 11 (pT3a). Postoperative prostate specific antigen was unrecordable in 14 of 15 patients with further treatment in 2. Postoperative continence (more than 12 months of followup) yielded no pad use in 6 of 10 men with universally poor erectile function. Radical prostatectomy as salvage is feasible for men in whom high intensity focused ultrasound failed, but with a higher morbidity than for primary surgery. Pathology results are alarming given the number of cases with extraprostatic extension yet early followup data suggest acceptable oncologic control. These results should be factored in when counseling men who wish to undergo primary high intensity focused ultrasound.

Salvage open radical prostatectomy after failed radiation therapy: a single center experience.

IntroductionCurrently there is no universally accepted approach for the management of radiation-recurrent prostate cancer. The aim of this study was to detail our experience performing salvage radical prostatectomy for patients who failed primary treatment of prostate cancer with radiation therapy.Material and methodsWe retrospectively queried our institutional database of radical prostatectomy cases for patients who underwent salvage surgery for radiation-recurrent prostate cancer. Patients were assessed for the risk of complications and oncologic outcomes following salvage surgery.ResultsTwenty-four patients with a mean age of 65 years (range 51-74) underwent salvage radical prostatectomy. Fourteen of these patients (58%) received androgen deprivation therapy prior to surgery. Intraoperatively, mean blood loss was estimated at 415 mL (range 100-1000) and 19 (79%) patients received autologous blood. No patient required an allogeneic transfusion or experienced a rectal injury. Postoperative bladder neck contracture and urinary incontinence developed in 17% and 39% of men, respectively. Two (29%) of seven patients remained potent after salvage surgery. No patient developed a fistula. Overall and recurrence-free survival at 5-years was 90% and 39%, respectively. On multivariate analysis, extracapsular extension was the only significant predictor of biochemical recurrence (HR 6.9, 95% CI 1.9-25.3 p = 0.003).ConclusionIn carefully selected patients, salvage radical prostatectomy for radiation-recurrent prostate cancer is a treatment option with acceptable oncologic outcomes and a moderate complication rate.

Rectourethral fistula after radical prostatectomy: Transperineal repair in jack-knife position

Background: Rectourethral fistula is a rare complication of radical prostatectomy. Risk factors include history of pelvic irradiation, cryotherapy, intraoperative rectal injury or transurethral resection of the prostate. Diagnosis of rectourethral fistula requires a high index of suspicion, and complete work-up with endoscopy and imaging studies. The majority of patients require operative intervention, with approaches ranging from transabdominal, transrectal, transanal, and transperineal routes. Method: We report two patients with rectourethral fistula after radical prostatectomy. The first patient was a 59-year-old man who underwent an uncomplicated laparoscopic radical prostatectomy for early prostate cancer in another hospital. The second patient was a 64-year-old man who had local recurrence after cryotherapy for prostate cancer. He underwent salvage radical prostatectomy in a private hospital, which was complicated by intraoperative rectal injury. Results: In both patients, the rectourethral fistulae were successfully repaired with a transperineal approach in the prone jack-knife position. Conclusion: We found that the transperineal approach in the prone jack-knife position offered excellent exposure, allowed versatile surgical manoeuvres and produced successful repair with good continence outcomes.

Locally Recurrent Prostate Cancer After Initial Radiation Therapy: A Comparison of Salvage Radical Prostatectomy Versus Cryotherapy

We compared the treatment outcomes of salvage radical prostatectomy and salvage cryotherapy for patients with locally recurrent prostate cancer after initial radiation therapy. We retrospectively reviewed the medical records of patients who underwent salvage radical prostatectomy at the Mayo Clinic between 1990 and 1999, and those who underwent salvage cryotherapy at M. D. Anderson Cancer Center between 1992 and 1995. Eligibility criteria were prostate specific antigen less than 10 ng/ml, post-radiation therapy biopsy showing Gleason score 8 or less and prior radiation therapy alone without pre-salvage or post-salvage hormonal therapy. We assessed the rates of biochemical disease-free survival, disease specific survival and overall survival in each group. Biochemical failure was assessed using the 2 definitions of 1) prostate specific antigen greater than 0.4 ng/ml and 2) 2 increases above the nadir prostate specific antigen. Mean followup was 7.8 years for the salvage radical prostatectomy group and 5.5 years for the salvage cryotherapy group. Compared to salvage cryotherapy, salvage radical prostatectomy resulted in superior biochemical disease-free survival by both definitions of biochemical failure (prostate specific antigen greater than 0.4 ng/ml, salvage cryotherapy 21% vs salvage radical prostatectomy 61% at 5 years, p <0.001; 2 increases above nadir with salvage cryotherapy 42% vs salvage radical prostatectomy 66% at 5 years, p = 0.002) and in superior overall survival (at 5 years salvage cryotherapy 85% vs salvage radical prostatectomy 95%, p = 0.001). There was no significant difference in disease specific survival (at 5 years salvage cryotherapy 96% vs salvage radical prostatectomy 98%, p = 0.283). After adjusting for post-radiation therapy biopsy Gleason sum and pre-salvage treatment serum prostate specific antigen on multivariate analysis salvage radical prostatectomy remained superior to salvage cryotherapy for the end points of any increase in prostate specific antigen greater than 0.4 ng/ml (HR 0.24, p <0.0001), 2 increases in prostate specific antigen (HR 0.47, p = 0.02) and overall survival (HR 0.21, p = 0.01). Young, healthy patients with recurrent prostate cancer after radiation therapy should consider salvage radical prostatectomy as it offers superior biochemical disease-free survival and may potentially offer the best chance of cure.