Initial Therapy With Radical Prostatectomy for High Risk Localized Prostate Cancer
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No AccessJournal of UrologyDiscussion1 Dec 2006Initial Therapy With Radical Prostatectomy for High Risk Localized Prostate Cancer James E. Montie James E. MontieJames E. Montie More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2006.06.073AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract Purpose: This study provides a perspective on initial treatment in select patients with high risk, localized prostate cancer. Materials and Methods: A select literature review was done with commentary on the philosophy of initial surgery followed by adjuvant or salvage therapies. Results: Early detection and associated stage migration identify a cadre of men with unfavorable but apparently localized prostate cancer who historically would not have been viewed as appropriate candidates for radical prostatectomy. Decreased morbidity from radical prostatectomy and data demonstrating improved outcomes in some patients treated with multimodal therapy protocols provide a rationale for including radical prostatectomy as part of an aggressive treatment plan to achieve optimal local elimination of cancer. Data suggest that radical prostatectomy and adjuvant or possibly even salvage radiation therapy may provide the best elimination of large local cancers. Whether such an approach provides results that are better than or even as good as those of the common standard of radiation therapy plus androgen deprivation therapy remains to be seen and, if so, at what cost to the patient in terms of adverse effects. However, it is likely that optimal elimination of local disease is needed to achieve the maximum benefit from adjuvant systemic endocrine, chemotherapy or targeted treatments. In other words optimal local therapy may be necessary but not sufficient. Conclusions: Initial radical prostatectomy may have a role for treating high risk localized prostate cancer. References 1 : The changing face of prostate cancer. J Clin Oncol2005; 23: 8146. Google Scholar 2 : An evaluation of the decreasing incidence of positive surgical margins in a large retropubic prostatectomy series. J Urol2004; 171: 28. Google Scholar 3 : Cancer progression and survival rates following anatomical radical retropubic prostatectomy in 3,478 consecutive patients: long-term results. J Urol2004; 172: 910. Link, Google Scholar 4 : Improved biochemical relapse-free survival with increased external radiation doses in patients with localized prostate cancer: the combined experience of nine institutions in patients treated in 1994 and 1995. Int J Radiat Oncol Biol Phys2005; 612: 415. Google Scholar 5 : Factors affecting recurrence rates after prostatectomy or radiotherapy in localized prostate carcinoma patients with biopsy Gleason score 8 or above. Cancer2002; 95: 2302. Google Scholar 6 : Isolated seminal vesicle invasion imparts better outcomes after radical retropubic prostatectomy for clinically localized prostate cancer: prognostic stratification of pT3b disease by nodal and margin status. Urology2005; 66: 152. Google Scholar 7 : Radical prostatectomy for clinically advanced (cT3) prostate cancer since the advent of prostate-specific antigen testing: 15-year outcome. BJU Int2005; 95: 751. Google Scholar 8 : Long-term outcome following radical prostatectomy in men with clinical T3 prostate cancer. J Urol2005; 173: 662. Google Scholar 9 : Radical radiation for localized prostate cancer: local persistence of disease results in a late wave of metastases. J Clin Oncol2002; 20: 3199. Google Scholar 10 : Long term results of 3D conformal radiotherapy following radical prostatectomy. Urology2003; 62: 93. Google Scholar 11 : In 111-labeled capromab pendetide radioimmunoscintigraphy and prognosis for durable biochemical response to salvage radiation therapy in men after failed prostatectomy. J Clin Oncol2003; 21: 1715. Google Scholar 12 : Personal communication. : 2005. Google Scholar 13 : The precise location and nature of the nerves to the male human urethra: histological and immunohistochemical studies with three-dimensional reconstruction. Eur Urol2005; 48: 858. Google Scholar 14 : Prospective assessment of patient-reported urinary continence following radical prostatectomy. J Urol2000; 164: 774. Google Scholar 15 : Wide excision (nonnerve sparing) radical retropubic prostatectomy using an initial perirectal dissection. J Urol1997; 157: 251. Link, Google Scholar 16 : Introperative nerve stimulation with measurement of urethral sphincter pressure changes during radical retropubic prostatectomy: a feasibility study. J Urol2003; 169: 2225. Link, Google Scholar 17 : Nomograms are superior to staging and risk grouping systems for identifying high-risk patients: preoperative application in prostate cancer. Curr Opin Urol2003; 13: 111. Google Scholar 18 : Treatment of patients with high risk localized prostate cancer: results from Cancer of the Prostate Strategic Urological Research Endeavor (CaPSURE). J Urol2005; 173: 1557. Link, Google Scholar 19 : Validation of the Kattan preoperative nomogram for prostate cancer recurrence using a community based cohort: results from Cancer of the Prostate Strategic Urological Research Endeavor (CaPSURE). J Urol2004; 171: 2255. Link, Google Scholar 20 : Preoperative PSA velocity and the risk of death from prostate cancer after radical prostatectomy. N Engl J Med2004; 351: 125. Google Scholar Department of Urology, University of Michigan, Ann Arbor, Michigan© 2006 by American Urological AssociationFiguresReferencesRelatedDetails Volume 176Issue 6SDecember 2006Page: S27-S29 Advertisement Copyright & Permissions© 2006 by American Urological AssociationKeywordsprostatic neoplasmsprostatectomysalvage therapyriskprostateMetricsAuthor Information James E. Montie More articles by this author Expand All Advertisement PDF DownloadLoading ...Keywords:
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Treatment options for patients with recurrent disease after radical prostatectomy include salvage radiotherapy of the prostatic bed and/or androgen deprivation therapy. To establish an effective treatment strategy for recurrent disease after radical prostatectomy, we retrospectively analyzed the outcome of salvage radiation monotherapy in such cases.Data from 61 men who had undergone salvage radiation monotherapy for biochemical recurrent disease after radical prostatectomy were retrospectively reviewed. In all patients, salvage radiotherapy consisted of iraradiation to the prostatic bed (70 Gy) using three-dimensional conformal radiotherapy techniques. Treatment outcome was analyzed to identify predictive factors of salvage radiotherapy.The biochemical recurrence-free survival after salvage radiation monotherapy at 2 and 5 years was 55% and 38%, respectively. Cox proportional regression models revealed that the independent predictive factors for biochemical recurrence were Gleason Score ≥ 8, negative surgical margin, and PSA velocity ≥ 0.38 ng/mL/year. Negative surgical margin and PSA velocity ≥ 0.8 ng/mL/year were significantly associated with poor response in the serum PSA levels after salvage radiotherapy.Based on our findings, we propose a treatment strategy for biochemical recurrent disease after radical prostatectomy. Patients with Gleason score ≤ 7, positive surgical margin, and PSA velocity < 0.38 ng/mL/year are categorized the most favorable group, so that eradication by salvage radiation monotherapy could be expected. Other patients could be divided to two groups depending on surgical margin status and PSA velocity: 1) patients who might require combination of SRT and short-term androgen deprivation therapy and 2) patients who should be treated by androgen deprivation monotherapy.
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The optimal management of isolated local recurrence of prostate cancer following radical prostatectomy remains unknown. Salvage radiotherapy to the prostatic bed is one of management options. This article reviews the efficacy of salvage radiotherapy. The available data suggest that salvage radiotherapy offers excellent clinical local control. However, the probability of long-term disease free survival with salvage radiotherapy alone appears small as a significant proportion of patients develop distant metastases and rising prostate specific antigen (PSA) following radiotherapy. A strategy of combining systemic therapy with local salvage treatment needs to be explored for this poor prognostic group.
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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.
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Prostate specific antigen (PSA) failure occurs in 20% to 50% of patients who undergo radical prostatectomy. There is no consensus on how PSA failure should be managed. Recently, salvage radiotherapy is reported to be an effective treatment for PSA failure, and 20%-70% of cases are recurrence-free. The aim of salvage radiotherapy is a cure and this is quite different from other options, for example, endocrine therapy. Salvage radiotherapy is likely to become more important as a treatment for PSA failure after radical prostatectomy.
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Failure of non-surgical primary treatment for localized prostate cancer is a common occurrence, with rates of disease recurrence ranging from 20% to 60%. In a large proportion of patients, disease recurrence is clinically localized and therefore potentially curable. Unfortunately, due to the complex and potentially morbid nature of salvage treatment, radical salvage surgery is uncommonly performed. In an attempt to decrease the morbidity of salvage therapy without sacrificing oncologic efficacy, a number of experienced centers have utilized robotic assistance to perform minimally invasive salvage radical prostatectomy. Herein, we critically evaluate the existing literature on salvage robotic radical prostatectomy with a focus on patient selection, perioperative complications and functional and early oncologic outcomes. These results are compared with contemporary and historical open salvage radical prostatectomy series and supplemented with insights we have gained from our experience with salvage robotic radical prostatectomy. The body of evidence by which conclusions regarding the efficacy and safety of robotic salvage radical prostatectomy can be drawn comprises fewer than 200 patients with limited follow-up. Preliminary results are promising and some outcomes have been favorable when compared with contemporary open salvage prostatectomy series. Advantages of the robotic platform in the performance of salvage radical prostatectomy include decreased blood loss, short length of stay and improved visualization. Greater experience is required to confirm the long-term oncologic efficacy and functional outcomes as well as the generalizability of results achieved at experienced centers.
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PURPOSE: We compared the treatment outcomes of salvage radical prostatectomy and salvage cryotherapy for patients with locally recurrent prostate cancer after initial radiation therapy.MATERIALS AND METHODS: 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.RESULTS: 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).CONCLUSIONS: 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. PMID: 19524984
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