Salvage Radical Prostatectomy for Radiation-recurrent Prostate Cancer: A Multi-institutional Collaboration

Abstract

Background Oncologic outcomes in men with radiation-recurrent prostate cancer (PCa) treated with salvage radical prostatectomy (SRP) are poorly defined. Objective To identify predictors of biochemical recurrence (BCR), metastasis, and death following SRP to help select patients who may benefit from SRP. Design, setting, and participants This is a retrospective, international, multi-institutional cohort analysis. There was a median follow-up of 4.4 yr following SRP performed on 404 men with radiation-recurrent PCa from 1985 to 2009 in tertiary centers. Intervention Open SRP. Measurements BCR after SRP was defined as a serum prostate-specific antigen (PSA) ≥0.1 or ≥0.2 ng/ml (depending on the institution). Secondary end points included progression to metastasis and cancer-specific death. Results and limitations Median age at SRP was 65 yr of age, and median pre-SRP PSA was 4.5 ng/ml. Following SRP, 195 patients experienced BCR, 64 developed metastases, and 40 died from PCa. At 10 yr after SRP, BCR-free survival, metastasis-free survival, and cancer-specific survival (CSS) probabilities were 37% (95% confidence interval [CI], 31–43), 77% (95% CI, 71–82), and 83% (95% CI, 76–88), respectively. On preoperative multivariable analysis, pre-SRP PSA and Gleason score at postradiation prostate biopsy predicted BCR (p = 0.022; global p < 0.001) and metastasis (p = 0.022; global p < 0.001). On postoperative multivariable analysis, pre-SRP PSA and pathologic Gleason score at SRP predicted BCR (p = 0.014; global p < 0.001) and metastasis (p < 0.001; global p < 0.001). Lymph node involvement (LNI) also predicted metastasis (p = 0.017). The main limitations of this study are its retrospective design and the follow-up period. Conclusions In a select group of patients who underwent SRP for radiation-recurrent PCa, freedom from clinical metastasis was observed in >75% of patients 10 yr after surgery. Patients with lower pre-SRP PSA levels and lower postradiation prostate biopsy Gleason score have the highest probability of cure from SRP.

Management of Biochemical Recurrence After Primary Treatment of Prostate Cancer: A Systematic Review of the Literature

“…However, it must be weighed against the risk of adverse events from the salvage RP, which are increased from the primary setting because of the fibrosis and poor wound healing induced by the radiation [46]. The best contemporary evidence in this area comes from a retrospective, international, multi-institutional cohort analysis of 404 men with radiation-recurrent PCa [47]. The authors reported a 5-yr BCR-free, metastasis-free, and cancerspecific survival (CSS) of 48%, 83%, and 92%, respectively, following salvage RP.…”

Multivariable model development and internal validation for prostate cancer specific survival and overall survival after whole-gland salvage Iodine-125 prostate brachytherapy

“…It is possible that factors not taken into account for this analysis, such as pre-salvage Gleason grade 8 and morphological findings on MRI (and/or functional sequences), might have additional predictive ability for progression and survival. These were not available in the current patient cohort.…”

“…However, there is no data on predictive factors for survival (PCaSS and OS). Predictive factors for survival in other salvage modalities (such as radical prostatectomy and cryosurgery) are more comprehensively defined, because of larger patient numbers and longer follow-up 7,8 . These factors (PSA pre-salvage, primary Gleason score, T-stage [both only univariable] and nadir after salvage, among other) are possibly important for salvage brachytherapy as well, but are not quantified in this setting with multivariable models.…”

“…Local salvage therapy is a potentially curative treatment for these prostate-confined recurrences. Whole-gland salvage can be performed using different techniques and is able to achieve long term biochemical control and survival and thereby postpone the use of androgen deprivation therapy (ADT) in carefully selected patient groups [5][6][7][8][9] . Risk factors for failure and mortality for salvage brachytherapy have not been comprehensively defined, because of small series with often limited events 5,9,10 .…”

Salvage radical prostatectomy: a few good men

“…Chade et al [1] published the largest series of patients undergoing SRP through a multicentre collaborative effort, and were able to identify 404 patients treated between 1985 and 2009; other large series were limited to 50-200 patients. In their systematic review of studies published between 1980 and 2011, Chade et al [2] reported 5-and 10-year biochemical recurrence-free survival rates of 47-82% and 28-53%, respectively.…”