TY - JOUR
T1 - Long-term Outcomes of Salvage Lymph Node Dissection for Nodal Recurrence of Prostate Cancer After Radical Prostatectomy
T2 - Not as Good as Previously Thought
AU - Bravi, Carlo A.
AU - Fossati, Nicola
AU - Gandaglia, Giorgio
AU - Suardi, Nazareno
AU - Mazzone, Elio
AU - Robesti, Daniele
AU - Osmonov, Daniar
AU - Juenemann, Klaus Peter
AU - Boeri, Luca
AU - Jeffrey Karnes, R.
AU - Kretschmer, Alexander
AU - Buchner, Alexander
AU - Stief, Christian
AU - Hiester, Andreas
AU - Nini, Alessandro
AU - Albers, Peter
AU - Devos, Gaëtan
AU - Joniau, Steven
AU - Van Poppel, Hendrik
AU - Shariat, Shahrokh F.
AU - Heidenreich, Axel
AU - Pfister, David
AU - Tilki, Derya
AU - Graefen, Markus
AU - Gill, Inderbir S.
AU - Mottrie, Alexander
AU - Karakiewicz, Pierre I.
AU - Montorsi, Francesco
AU - Briganti, Alberto
N1 - Publisher Copyright:
© 2020 European Association of Urology
PY - 2020/11
Y1 - 2020/11
N2 - Background: Long-term outcomes of patients treated with salvage lymph node dissection (sLND) for nodal recurrence of prostate cancer (PCa) remain unknown. Objective: To investigate long-term oncological outcomes after sLND in a large multi-institutional series. Design, setting, and participants: The study included 189 patients who experienced prostate-specific antigen (PSA) rise and nodal-only recurrence after radical prostatectomy (RP) and underwent sLND at 11 tertiary referral centers between 2002 and 2011. Lymph node recurrence was documented by positron emission tomography/computed tomography (PET/CT) scan using either 11C-choline or 68Ga prostate-specific membrane antigen ligand. Outcome measurements and statistical analysis: The primary outcome of the study was cancer-specific mortality (CSM). The secondary outcomes were overall mortality, clinical recurrence (CR), biochemical recurrence (BCR), and androgen deprivation therapy (ADT)-free survival after sLND. The probability of freedom from each outcome was calculated using Kaplan-Meier analyses. Cox regression analysis was used to predict the risk of prostate CSM after accounting for several parameters, including the use of additional treatments after sLND. Results and limitations: At long term, 110 and 163 patients experienced CR and BCR, respectively, with CR-free and BCR-free survival at 10 yr of 31% and 11%, respectively. After sLND, a total of 145 patients received ADT, with a median time to ADT of 41 mo. At a median (interquartile range) follow-up for survivors of 87 (51, 104) mo, 48 patients died. Of them, 45 died from PCa. The probabilities of freedom from cancer-specific and all-cause death at 10 yr were 66% and 64%, respectively. Similar results were obtained in sensitivity analyses in patients with pelvic-only positive PET/CT scan, as well as after excluding men on ADT at PET/CT scan and patients with PSA level at sLND higher than the 75th percentile. At multivariable analyses, patients who had PSA response after sLND (hazard ratio [HR]: 0.45; p = 0.001), and those receiving ADT within 6 mo from sLND (HR: 0.51; p = 0.010) had lower risk of death from PCa. Conclusions: A third of men treated with sLND for PET-detected nodal recurrence of PCa died at long term, with PCa being the main cause of death. Salvage LND alone was associated with durable long-term outcomes in a minority of men who significantly benefited from additional treatments after surgery. Taken together, all these data argue against the use of metastasis-directed therapy alone for patients with node-only recurrent PCa. These men should instead be considered at high risk of systemic dissemination already at the time of sLND. Patient summary: We assessed long-term outcomes of patients treated with salvage lymph node dissection (sLND) for node-recurrent prostate cancer (PCa). In contrast with prior evidence, we found that the majority of these men recurred after sLND and eventually died from PCa. A significant survival benefit associated with the administration of androgen deprivation therapy after sLND suggests that sLND should be considered part of a multimodal approach rather than an exclusive treatment strategy. At long-term follow-up, the majority of patients treated with salvage lymph node dissection (sLND) for node-recurrent prostate cancer (PCa) recurred and eventually died from PCa. We found a significant survival benefit associated with the administration of androgen deprivation therapy after sLND, suggesting that sLND should be considered part of a multimodal approach rather than an exclusive treatment strategy.
AB - Background: Long-term outcomes of patients treated with salvage lymph node dissection (sLND) for nodal recurrence of prostate cancer (PCa) remain unknown. Objective: To investigate long-term oncological outcomes after sLND in a large multi-institutional series. Design, setting, and participants: The study included 189 patients who experienced prostate-specific antigen (PSA) rise and nodal-only recurrence after radical prostatectomy (RP) and underwent sLND at 11 tertiary referral centers between 2002 and 2011. Lymph node recurrence was documented by positron emission tomography/computed tomography (PET/CT) scan using either 11C-choline or 68Ga prostate-specific membrane antigen ligand. Outcome measurements and statistical analysis: The primary outcome of the study was cancer-specific mortality (CSM). The secondary outcomes were overall mortality, clinical recurrence (CR), biochemical recurrence (BCR), and androgen deprivation therapy (ADT)-free survival after sLND. The probability of freedom from each outcome was calculated using Kaplan-Meier analyses. Cox regression analysis was used to predict the risk of prostate CSM after accounting for several parameters, including the use of additional treatments after sLND. Results and limitations: At long term, 110 and 163 patients experienced CR and BCR, respectively, with CR-free and BCR-free survival at 10 yr of 31% and 11%, respectively. After sLND, a total of 145 patients received ADT, with a median time to ADT of 41 mo. At a median (interquartile range) follow-up for survivors of 87 (51, 104) mo, 48 patients died. Of them, 45 died from PCa. The probabilities of freedom from cancer-specific and all-cause death at 10 yr were 66% and 64%, respectively. Similar results were obtained in sensitivity analyses in patients with pelvic-only positive PET/CT scan, as well as after excluding men on ADT at PET/CT scan and patients with PSA level at sLND higher than the 75th percentile. At multivariable analyses, patients who had PSA response after sLND (hazard ratio [HR]: 0.45; p = 0.001), and those receiving ADT within 6 mo from sLND (HR: 0.51; p = 0.010) had lower risk of death from PCa. Conclusions: A third of men treated with sLND for PET-detected nodal recurrence of PCa died at long term, with PCa being the main cause of death. Salvage LND alone was associated with durable long-term outcomes in a minority of men who significantly benefited from additional treatments after surgery. Taken together, all these data argue against the use of metastasis-directed therapy alone for patients with node-only recurrent PCa. These men should instead be considered at high risk of systemic dissemination already at the time of sLND. Patient summary: We assessed long-term outcomes of patients treated with salvage lymph node dissection (sLND) for node-recurrent prostate cancer (PCa). In contrast with prior evidence, we found that the majority of these men recurred after sLND and eventually died from PCa. A significant survival benefit associated with the administration of androgen deprivation therapy after sLND suggests that sLND should be considered part of a multimodal approach rather than an exclusive treatment strategy. At long-term follow-up, the majority of patients treated with salvage lymph node dissection (sLND) for node-recurrent prostate cancer (PCa) recurred and eventually died from PCa. We found a significant survival benefit associated with the administration of androgen deprivation therapy after sLND, suggesting that sLND should be considered part of a multimodal approach rather than an exclusive treatment strategy.
KW - Androgen deprivation therapy
KW - Metastasis-directed therapy
KW - Neoplasm recurrence
KW - Positron emission tomography scan
KW - Prostate cancer
KW - Salvage lymph node dissection
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U2 - 10.1016/j.eururo.2020.06.043
DO - 10.1016/j.eururo.2020.06.043
M3 - Article
C2 - 32624288
AN - SCOPUS:85087374818
SN - 0302-2838
VL - 78
SP - 661
EP - 669
JO - European urology
JF - European urology
IS - 5
ER -