Surgically staged patients with prostatic carcinoma treated with definitive radiotherapy: fifteen-year results

doi:10.1016/0090-4295(94)90178-3

Urology

Volume 43, Issue 5, May 1994, Pages 640-644

https://doi.org/10.1016/0090-4295(94)90178-3 Get rights and content

Abstract

Objective. To assess the long-term outcome of patients with lymphadenectomy-staged prostate cancer treated with external beam radiotherapy.

Methods. A retrospective analysis was performed on all patients with prostate cancer who underwent staging pelvic lymphadenectomy before treatment with definitive radiotherapy from 1970 to February 1978. This included 71 patients who were evaluated for a minimum of fifteen years. No patients were lost to follow-up. Thirty-five patients were node negative and 36 were node positive.

Results. Fifteen-year actuarial overall survival, cause-specific survival, and local control for the 20 patients with clinically organ-confined disease (T1 b-T2 NOMO) was 40 percent, 75 percent, and 92 percent, respectively. The results for the 15 T3 NOMO patients were 15 percent, 22 percent, and 60 percent. Patients with positive nodes did much worse, with rates of 5 percent, 6 percent, and 45 percent. Thirty-four patients received hormonal therapy at the time of first failure. No patient who was clinically free of disease at fifteen years had an elevated level of prostate-specific antigen (PSA).

Conclusions. Our data suggest excellent results in a cohort of patients (T1 b-T2 NOMO) treated with primary radiotherapy who would be considered candidates for radical prostatectomy. Outcome is significantly worse in patients with T3 lesions and node-positive disease.

References (21)

G.E. Hanks et al.
Comparison of pathologic and clinical evaluation of lymph nodes in prostate cancer: implications of RTOG data for patient management and trial design and stratification
Int J Radiat Oncol Biol Phys
(1992)
W.T. Sause et al.
Prostatic carcinoma: 5-year follow-up of patients with surgically staged disease undergoing extended field radiation
J Urol
(1986)
G.E. Hanks et al.
Outcome for lymph node dissection negative T-lb, T-2 (A2,B) prostate cancer treated with external beam radiation therapy in RTOG 77-06
Int J Radiat Oncol Biol Phys
(1991)
S.O. Asbell et al.
Elective pelvic irradiation in stage A2, B carcinoma of the prostate: analysis of RTOG 7706
Int J Radiat Oncol Biol Phys
(1988)
M.A. Bagshaw
Current conflicts in the management of prostatic cancer
Int J Radiat Oncol Biol Phys
(1986)
R.G. Middleton et al.
Patient survival and local recurrence rate following radical prostatectomy for prostatic carcinoma
J Urol
(1986)
D.F. Paulson et al.
Radical prostatectomy for clinical stage T1-2N0M0 prostatic adenocarcinoma: long-term results
J Urol
(1990)
M.L. Blute et al.
Pattern of failure after radical retropubic prostatectomy for clinically and pathologically localized adenocarcinoma of the prostate: influence of tumor deoxyribonucleic acid ploidy
J Urol
(1989)
W.R. Morgan et al.
Long-term evaluation of radical prostatectomy as treatment for clinical stage C (T3) prostate cancer
Urology
(1993)
M.V. Pilepich et al.
Extended field (periaortic) irradiation in carcinoma of the prostate-analysis of RTOG 7506
Int J Radiat Oncol Biol Phys
(1986)

There are more references available in the full text version of this article.

Cited by (29)

Lymphadenectomy and prostate cancer: A statement of the committee of cancerology of the French association of urology
2012, Progres en Urologie
L’envahissement ganglionnaire est la première étape du processus métastatique dans le cancer de la prostate. Il contre-indique a priori le traitement local. Avant traitement, la détection des métastases ganglionnaires repose essentiellement sur la mise en évidence de ganglions hypertrophiés sur le scanner et l’IRM. Les performances diagnostiques de l’IRM ne sont pas meilleures que celles du scanner car ces deux méthodes utilisent les mêmes critères pour distinguer les ganglions normaux des ganglions métastatiques que sont la taille, la forme et l’architecture interne du ganglion. Le ganglion sentinelle est encore du domaine de centres experts. La meilleure évaluation du statut ganglionnaire repose sur le curage ganglionnaire. Limité au territoire ilio-obturateur, il sous-estime le risque de métastases ganglionnaires. C’est le curage ganglionnaire étendu « standard » associant au curage ilio-obturateur, un curage iliaque interne et iliaque externe bilatéral jusqu’à la bifurcation iliaque qui doit être effectué en cas de cancer de la prostate de risque intermédiaire ou élevé. La qualité d’un curage ganglionnaire nécessite au moins dix ganglions. L’envahissement ganglionnaire est un facteur de mauvais pronostic mais la valeur thérapeutique du curage ganglionnaire et son éventuelle influence sur le pronostic n’a pas été établie. Néanmoins, il semble exister une sous-population avec un ou deux ganglions envahis sans effraction capsulaire de meilleur pronostic. En cas d’envahissement ganglionnaire, l’hormonothérapie immédiate après chirurgie est le traitement de référence même s’il est actuellement remis en question en particulier dans cette sous-population et si le taux de PSA postopératoire est nul. Le rôle de la radiothérapie reste également à préciser. En revanche, il n’y aucun rôle pour une chimiothérapie.
Lymph node invasion is the first step of metastatic evolution of prostate cancer. In this case, today, no local treatment should be proposed. Detection of lymph node invasion is performed by CT-scan and RMI, which show hypertrophied nodes. No difference in term of sensibility and specificity is observed between CT-scan and RMI. Invaded nodes are defined by modifications of size, form, and aspect of the architecture of nodes. Sentinel node belongs to expert centers. Surgical lymphadenectomy remains the best way to evaluate lymph node status. Limited to ilio-obturator land, it underestimates the risk of lymph node invasion: Extended lymph node excision defined by the association of bilateral ilio-obturator, internal iliaca and external iliaca lymphadenectomy should be systematically proposed to intermediate and high risk prostate cancer. A “well done” lymphadenectomy is represented by more than 10 nodes removed. Lymph node invasion represents bad prognosis. However, therapeutic value and influence of prognosis of lymphadenectomy in prostate cancer is still not established. Therefore, one or two invade lymph nodes represented a population of patients with better prognosis, specially if no capsular effraction is observed. After radical prostatectomy, in case of lymph node invasion, immediate hormonotherapy is the standard; however, this treatment is discussed in case of low number of invaded nodes (one or two) and if postoperative PSA is equal to zero. In this case, radiotherapy is still in evaluation and chemotherapy has no indication.
Role of Radiation Therapy for the Treatment of Lymph Nodes in Urologic Malignancies
2011, Urologic Clinics of North America
Citation Excerpt :
Based on the available results, WPRT can be considered in cases where the risk of lymph node involvement is greater than 15%; however, WPRT should be used judiciously considering the potential for worse gastrointestinal toxicity with larger field size. The use of RT alone for men with node-positive disease has been associated with high rates of local and distant recurrence.35–38 RT alone has been used primarily for palliation for men with known lymph node involvement.
Relative influence of Gleason score and pretreatment PSA in predicting survival following brachytherapy for prostate cancer
2003, Brachytherapy
Purpose: To evaluate 10-year survival rates after prostate brachytherapy and to assess the relative importance of pretreatment prostate-specific antigen (PSA) and Gleason score in predicting cancer death.
Materials and Methods: A retrospective review was performed on all patients treated with permanent brachytherapy for stage T1 or T2 primary prostate cancer at a single institution from December 1988 through June 30, 1998. The study cohort consisted of 1266 patients with a median follow-up of 4.1 years and a maximum of 12.6 years. Actuarial survival and cause-specific survival rates were calculated as the primary endpoints, and compared at 5 and 10 years. Groups studied consist of PSA≤4, PSA 4.1–10, and PSA≥10 as well as Gleason 2–4, 5–6, and 7–10. Multivariate and univariate analysis were performed looking at stage, grade, PSA, and risk group as variables.
Results: The median age at the time of treatment was 73 years and at the time of analysis 603 patients were known to be alive. Overall survival is 38% at 10 years, however most deaths were unrelated to prostate cancer. Cause specific survival at 5 and 10 years is 98% and 87%. Both grade (≥Gleason 7) and PSA (≥10 ng/ml) predict adversely for cancer death within 10 years. Patients with low grade or PSA at presentation reveal prostate cancer-specific survival of 91% and 98%, respectively. By contrast, men with high grade or high PSA presentation have survival of 66% and 69% at 10 years. In multivariate analysis, the presence of one of these adverse features carries a hazard ratio of cancer death of 4.7 and 6.4, while the presence of multiple risk factors places patients in an unfavorable risk group with a hazard ratio of 27.
Conclusions: Biochemical disease-free survival is a useful tool to assess prostate cancer treatments and is predicted based on established pretreatment risk groups. Long-term cancer-specific survival is ultimately a more important endpoint. Brachytherapy is reported here to be an excellent therapeutic alternative for selected early stage patients with prostate cancer. This is based on 10-year cause specific survival, which may also be predicted by stage, grade, PSA, and risk group. Of these, the risk group remains the most powerful parameter to identify those patients at highest risk of biochemical failure and death from prostate cancer.
Addition of radiation therapy to androgen ablation improves outcome for subclinically node-positive prostate cancer
2001, Urology
Objectives. To determine the outcome for node-positive prostate cancer treated by early androgen ablation with or without prostatic radiation.
Methods. Two hundred fifty-five men with lymphadenectomy-proven pelvic nodal metastases treated with early androgen ablation alone (n = 183) or with combined ablation and radiation (n = 72) between 1984 and 1998 were retrospectively reviewed for disease outcome and survival. Post-treatment disease status was based on the prostate-specific antigen levels or on the clinical and radiographic status for patients treated before 1987. Univariate and multivariate statistics were used to determine the prognostic factors and assess the influence of radiation treatment.
Results. With a median follow-up of 9.4 years, the 5, 10, and 13-year overall survival rate for those treated with early ablation alone was 83%, 46%, and 21%, respectively. The freedom from relapse or rising prostate-specific antigen rate for these patients was 41%, 25%, and 19% at 5, 10, and 13 years, respectively. Distant metastasis and local recurrence occurred with a 10-year actuarial incidence of 44% and 51%, respectively. With a median follow-up of 6.2 years, the 5 and 10-year overall survival rate for those treated with radiation and ablation was 92% and 67%, respectively. The freedom from relapse or rising prostate-specific antigen rate in these men was 91% and 80% at 5 and 10 years, respectively. The superior outcome for combined ablation and radiation was substantial and statistically significant in the univariate and multivariate analyses.
Conclusions. Early androgen ablation alone has little curative potential for node-positive prostate cancer. The addition of prostatic radiation to ablation resulted in substantial and significant improvement in disease control and patient survival.
Long-term results of a randomized trial for the treatment of stages B2 and C prostate cancer: Radical prostatectomy versus external beam radiation therapy with a common endocrine therapy in both modalities
1999, Urology
Objectives. To improve the treatment of locally advanced prostate cancer (Stages B2 and C), a prospective randomized trial was conducted to compare radical prostatectomy versus external beam radiotherapy with the combination of endocrine therapy in both modalities.
Methods. One hundred patients were enrolled and 95 were evaluated. Forty-six patients underwent radical prostatectomy with pelvic lymph node dissection, and 49 were treated with radiation by linear accelerator with 40 to 50 Gy to the whole pelvis and a 20-Gy boost to the prostatic area. For all patients, endocrine therapy was initiated 8 weeks before surgery or radiation, and continued thereafter. The living patients were asked to respond to a quality-of-life questionnaire.
Results. The follow-up period ranged from 6.0 to 94.4 months (median 58.5). The progression-free and cause-specific survival rates at 5 years were 90.5% and 96.6% in the surgery group and 81.2% and 84.6% in the radiation group, respectively. The surgery group had better progression-free and cause-specific survival rates (P = 0.044 and 0.024, respectively). More patients in the surgery group complained of urinary incontinence. The questionnaire revealed that quality of life was less disturbed in the radiation group.
Conclusions. Radical prostatectomy combined with endocrine therapy may contribute to the survival benefit of patients with locally advanced prostate cancer. External beam radiotherapy in combination with endocrine therapy can be used in selected patients because of its low morbidity.
Deferred treatment of locally advanced nonmetastatic prostate cancer: A long-term followup
1999, Journal of Urology
We prospectively investigated long-term survival in select men with locally advanced, nonmetastatic prostate cancer managed with deferred treatment.
A total of 50 patients with prostate cancer clinically outside the prostatic capsule and without distant metastases were included in a surveillance protocol. The men were treated if and when symptoms occurred or upon request. The series was followed until December 1994. No patient was lost to followup.
Median patient age at diagnosis was 71 years. All patients were followed more than 144 months or died before then. Actual (cumulative incidence) overall and disease specific survival rates at 5, 10 and 12 years were 68 and 90, 34 and 74, and 26 and 70%, respectively. A third of the patients had not received antitumor treatment at followup or before death.
When managed with deferred treatment nonpoorly differentiated, locally advanced nonmetastatic prostate cancer seems to have a poorer survival outcome than similarly managed clinically localized prostate cancer. However, compared with other treatments and in terms of survival deferred treatment may be an option for select patients with such tumors and a life expectancy of 10 years or less.

View all citing articles on Scopus

View full text

Surgically staged patients with prostatic carcinoma treated with definitive radiotherapy: fifteen-year results

Abstract

Int J Radiat Oncol Biol Phys

J Urol

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

J Urol

J Urol

J Urol

Urology

Int J Radiat Oncol Biol Phys