Contemporary Update of a Multi-Institutional Predictive Nomogram for Salvage Radiotherapy After Radical Prostatectomy

Tendulkar, Rahul D.; Agrawal, Shree; Gao, Tianming; Efstathiou, Jason A.; Pisansky, Thomas M.; Michalski, Jeff M.; Koontz, Bridget F.; Hamstra, Daniel A.; Feng, Felix Y.; Liauw, Stanley L.; Abramowitz, Matthew C.; Pollack, Alan; Anscher, Mitchell S.; Moghanaki, Drew; Den, Robert B.; Stephans, Kevin L.; Zietman, Anthony L.; Lee, William R.; Kattan, Michael W.; Stephenson, Andrew J.

doi:10.1200/jco.2016.67.9647

Cited by 321 publications

(301 citation statements)

References 21 publications

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“…This is lower than expected from the literature for biochemical response at this median PSA level (3). There are several possible reasons for this.…”

Section: Discussioncontrasting

confidence: 62%

“…It remains the last chance for cure in these men, with around 56% of men achieving complete biochemical response at 5 y after RT (2,3,11). Studies have shown that low serum PSA values after RP are correlated to significantly better treatment outcomes, supporting early SRT at a serum PSA of less than 0.2 ng/mL or less than 0.5 ng/mL (3).…”

Section: Discussionmentioning

confidence: 99%

“…Salvage radiation treatment (SRT) to the prostatic fossa (or fossa 1 pelvic nodes in higher risk patients) is the only potentially curative treatment option for patients with biochemical failure after RP. The 5-y progression-free survival rate in patients undergoing salvage radiation treatment (RT) is 56%, varying from 71% in men with pre-RT PSA level of less than 0.01-0.2 ng/mL, down to 18% in men with a PSA greater than 1.5 ng/mL undergoing SRT without androgen-deprivation therapy (ADT) (1)(2)(3)(4). This indicates that men with low-volume recurrent PC benefit the most from SRT; and that there are a significant number of patients who do not show a lasting PSA response after salvage.…”

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confidence: 99%

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Treatment Outcomes from ⁶⁸Ga-PSMA PET/CT–Informed Salvage Radiation Treatment in Men with Rising PSA After Radical Prostatectomy: Prognostic Value of a Negative PSMA PET

et al. 2017

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See an invited perspective on this article on page 1969.68 Ga-PSMA (prostate-specific membrane antigen) PET/CT is increasingly used in men with prostate-specific antigen (PSA) failure after radical prostatectomy (RP) to triage those who will benefit from salvage radiation treatment (SRT). This study examines the value of PSMA-informed SRT in improving treatment outcomes in the context of biochemical failure after RP. Methods: We analyzed men with rising PSA after RP with PSA readings between 0.05 and 1.0 ng/mL, considered eligible for SRT at the time of PSMA. For each patient, clinical and pathologic features as well as scan results, including site of PSMA-positive disease, number of lesions, and a certainty score, were documented. Subsequent management, including SRT, and most recent PSA were recorded using medical records. Treatment response was defined as both PSA # 0.1 ng/mL and .50% reduction in PSA. Multivariate logistic regression analysis was performed for association of clinical variables and treatment response to SRT. Results: One hundred sixty-four men were included. PSMA was positive in 62% (n 5 102/164): 38 of 102 in the prostatic fossa, 41 of 102 in pelvic nodes, and 23 of 102 distantly. Twenty-four patients received androgen-deprivation therapy (ADT) and were excluded for outcomes analysis. In total, 99 of 146 received SRT with a median follow-up after radiation treatment of 10.5 mo (interquartile range, 6-14 mo). Overall treatment response after SRT was 72% (n 5 71/99). Forty-five percent (n 5 27/60) of patients with a negative PSMA underwent SRT whereas 55% (33/60) did not. In men with a negative PSMA who received SRT, 85% (n 5 23/27) demonstrated a treatment response, compared with a further PSA increase in 65% (22/34) in those not treated. In 36 of 99 patients with disease confined to the prostate fossa on PSMA, 81% (n 5 29/36) responded to SRT. In total, 26 of 99 men had nodal disease on PSMA, of whom 61% (n 5 16/26) had treatment response after SRT. On multivariate logistic regression analysis, PSMA and serum PSA significantly correlated with treatment response, whereas pT stage, Gleason score, and surgical margin status did not. Conclusion: PSMA PET is independently predictive of treatment response to SRT and stratifies men into a high treatment response to SRT (negative or fossa-confined PSMA) versus men with poor response to SRT (nodes or distant-disease PSMA). In particular, a negative PSMA PET result predicts a high response to salvage fossa radiotherapy.Key Words: prostate specific membrane antigen; PSMA; PET/CT; treatment outcome; biochemical failure; post radical prostatectomy J Nucl Med 2017; 58:1972 58: -1976 58: DOI: 10.2967 Radi cal prostatectomy (RP) is the most widely used treatment for men with localized prostate cancer (PC). After surgery, patients are monitored with serial prostate-specific antigen (PSA) measurements. Approximately 20%-50% of pT2-3, node-negative PC patients treated with RP will experience biochemical recurrence, particularly those with poorly differentiat...

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“…This is lower than expected from the literature for biochemical response at this median PSA level (3). There are several possible reasons for this.…”

Section: Discussioncontrasting

confidence: 62%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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Treatment Outcomes from ⁶⁸Ga-PSMA PET/CT–Informed Salvage Radiation Treatment in Men with Rising PSA After Radical Prostatectomy: Prognostic Value of a Negative PSMA PET

et al. 2017

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“…Large studies have not yet demonstrated a clear benefit for adjuvant over early salvage treatment with radiation [4][5][6] . However, clinical evidence consistently suggests that early treatment with lower PSAs (≤0.2ng/ml) at the time of salvage radiotherapy is associated with improved treatment outcomes.…”

Section: ***mentioning

confidence: 99%

Salvage Radiotherapy after radical prostatectomy: Preserving patient quality of life with modern treatment techniques

Korzeniowski

2017

CUAJ

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In this issue of CUAJ, readers will come across an article that showcases oncologic and functional outcomes after salvage radiation for biochemical failure for prostate cancer treated with robot-assisted radical prostatectomy (RARP). The article is particularly interesting because it involves a cohort of men treated with modern radiotherapy and surgical techniques. The disciplines of Urologic and Radiation oncology have each benefited from technological innovations and this has contributed to the improved functional outcomes seen in this study. Advances in surgical technique with the advent of RARP have shortened hospital stays, decreased perioperative complications, and improved urinary function. Similarly, radiation oncology has seen improvements in treatment planning and delivery that allow highly conformal treatments to be delivered with reduced genitourinary and gastrointestinal toxicity.

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“…The interquartile range (IQR) for baseline PSA at the time of randomization on the GETUG trial was 0.2–0.5 ng/mL. A recent multi-institutional cohort found the PSA at the time of salvage radiotherapy to be significantly higher (IQR 0.3–1.1) (7). The men in the GETUG study, therefore, were referred for radiation therapy relatively early.…”

mentioning

confidence: 99%

Invited commentary on GETUG-AFU 16

Lee

2016

Transl. Androl. Urol.

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Contemporary Update of a Multi-Institutional Predictive Nomogram for Salvage Radiotherapy After Radical Prostatectomy

Abstract: Early SRT at low PSA levels after RP is associated with improved FFBF and DM rates. Contemporary nomograms can estimate individual patient outcomes after SRT in the modern era.

Cited by 321 publications

References 21 publications

Treatment Outcomes from ⁶⁸Ga-PSMA PET/CT–Informed Salvage Radiation Treatment in Men with Rising PSA After Radical Prostatectomy: Prognostic Value of a Negative PSMA PET

Treatment Outcomes from ⁶⁸Ga-PSMA PET/CT–Informed Salvage Radiation Treatment in Men with Rising PSA After Radical Prostatectomy: Prognostic Value of a Negative PSMA PET

Salvage Radiotherapy after radical prostatectomy: Preserving patient quality of life with modern treatment techniques

Invited commentary on GETUG-AFU 16

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Contemporary Update of a Multi-Institutional Predictive Nomogram for Salvage Radiotherapy After Radical Prostatectomy

Abstract: Early SRT at low PSA levels after RP is associated with improved FFBF and DM rates. Contemporary nomograms can estimate individual patient outcomes after SRT in the modern era.

Cited by 321 publications

References 21 publications

Treatment Outcomes from 68Ga-PSMA PET/CT–Informed Salvage Radiation Treatment in Men with Rising PSA After Radical Prostatectomy: Prognostic Value of a Negative PSMA PET

Treatment Outcomes from 68Ga-PSMA PET/CT–Informed Salvage Radiation Treatment in Men with Rising PSA After Radical Prostatectomy: Prognostic Value of a Negative PSMA PET

Salvage Radiotherapy after radical prostatectomy: Preserving patient quality of life with modern treatment techniques

Invited commentary on GETUG-AFU 16

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Treatment Outcomes from ⁶⁸Ga-PSMA PET/CT–Informed Salvage Radiation Treatment in Men with Rising PSA After Radical Prostatectomy: Prognostic Value of a Negative PSMA PET

Treatment Outcomes from ⁶⁸Ga-PSMA PET/CT–Informed Salvage Radiation Treatment in Men with Rising PSA After Radical Prostatectomy: Prognostic Value of a Negative PSMA PET