Adjuvant pelvic RT after N+ prostatectomy

[seper]

What's the best evidence supporting adding XRT to hormones, when positive node(s) were found in the prostatectomy specimens? Thanks

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[medgator]

Old study

Addition of radiation therapy to androgen ablation improves outcome for subclinically node-positive prostate cancer - PubMed

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.

pubmed.ncbi.nlm.nih.gov

 

[Ray D. Ayshun]

What's the best evidence supporting adding XRT to hormones, when positive node(s) were found in the prostatectomy specimens? Thanks

This is the one I was taught

Impact of Adjuvant Radiotherapy in Node-positive Prostate Cancer Patients: The Importance of Patient Selection - PubMed

Using institutional data, we have previously developed an algorithm to identify the optimal candidates for adjuvant radiotherapy (aRT) among men with pN1 prostate cancer (PCa) at radical prostatectomy (RP). This study aimed to test the external validity of our previous findings using a...

pubmed.ncbi.nlm.nih.gov

 

[seper]

I wonder if this situation should be looked at more critically, "in the modern era". These patients are often being pushed into RT despite double-whammy of postop injury and leuprolide

 

[ramsesthenice]

I wonder if this situation should be looked at more critically, "in the modern era". These patients are often being pushed into RT despite double-whammy of postop injury and leuprolide

It’s always an interesting question when you see someone who unexpectedly ended up pN+ but has a negative post op PSA. Do you treat or watch the PSA? I’m not quite sure we know yet. If they have a lot of high risk factors I typically do but I’ve become more comfortable watching people too if it is their preference.

 

[Palex80]

It’s always an interesting question when you see someone who unexpectedly ended up pN+ but has a negative post op PSA. Do you treat or watch the PSA?

We treat based on the Abdollah criteria, as referenced above.
For those with still elavated PSA we always get a PSMA scan (if not already done preop).

 

[Chartreuse Wombat]

Androgen suppression plus radiation versus radiation alone for patients with stage D1/pathologic node-positive adenocarcinoma of the prostate: updated results based on national prospective randomized trial Radiation Therapy Oncology Group 85-31 - Pub

Pending the results of randomized trials, patients with adenocarcinoma of the prostate who have pathologically involved pelvic lymph nodes (pathologic node-positive or clinical stage D1) should be considered for external-beam irradiation plus immediate hormonal manipulation rather than radiation...

pubmed.ncbi.nlm.nih.gov

 

[evilbooyaa]

It’s always an interesting question when you see someone who unexpectedly ended up pN+ but has a negative post op PSA. Do you treat or watch the PSA? I’m not quite sure we know yet. If they have a lot of high risk factors I typically do but I’ve become more comfortable watching people too if it is their preference.

As Palex said, doesn't necessarily have to be ALL pN+ getting immediate adjuvant.

I think some break to allow for recovery of continence not unreasonable.

 

[ramsesthenice]

As Palex said, doesn't necessarily have to be ALL pN+ getting immediate adjuvant.

I think some break to allow for recovery of continence not unreasonable.

Don’t get wrong, I practice the same as you both. Only admitting it’s a fair question as to whether or not concepts regarding adjuvant vs salvage apply to any patients with undetectable PSA and occult N+ disease. Good residents always ask about the nuances here.

 

[evilbooyaa]

Don’t get wrong, I practice the same as you both. Only admitting it’s a fair question as to whether or not concepts regarding adjuvant vs salvage apply to any patients with undetectable PSA and occult N+ disease. Good residents always ask about the nuances here.

I agree that using RADICALS or RAVES to defend salvage in N+ setting is inappropriate. I don't think there's a 100% right answer here, but will be a patient-centered discussion.

 

[seper]

Once hormones have started, close PSA follow up is obviously not feasible. So we always treat

 

[Palex80]

Once hormones have started, close PSA follow up is obviously not feasible. So we always treat

If you are going to give ADT for N+, then you should treat with RT too.

However, with STAMPEDE data now showing benefit in N+ M0 with more intensive systemic treatment, the benefit of RT may shrink if these patients will be receiving ADT + further systemic treatment (so far we only have Abiraterone-data, but it's highly likely that these patients will also benefit from Enzalutamide, Apalutamide, Daralutamide).

 

[seper]

100% agree

If you are going to give ADT for N+, then you should treat with RT too.

However, with STAMPEDE data now showing benefit in N+ M0 with more intensive systemic treatment, the benefit of RT may shrink if these patients will be receiving ADT + further systemic treatment (so far we only have Abiraterone-data, but it's highly likely that these patients will also benefit from Enzalutamide, Apalutamide, Daralutamide).

 

[RickyScott]

If you are going to give ADT for N+, then you should treat with RT too.

However, with STAMPEDE data now showing benefit in N+ M0 with more intensive systemic treatment, the benefit of RT may shrink if these patients will be receiving ADT + further systemic treatment (so far we only have Abiraterone-data, but it's highly likely that these patients will also benefit from Enzalutamide, Apalutamide, Daralutamide).

great, look forward to losing another indication.

 

[Ray D. Ayshun]

great, look forward to losing another indication.

There was still a pretty decent ffs benefit in that population I believe. As with breast, maybe worth wondering if 2 years of abi or whatever, is better or worse that 6 weeks of rt.

 

[DoctwoB]

If you are going to give ADT for N+, then you should treat with RT too.

However, with STAMPEDE data now showing benefit in N+ M0 with more intensive systemic treatment, the benefit of RT may shrink if these patients will be receiving ADT + further systemic treatment (so far we only have Abiraterone-data, but it's highly likely that these patients will also benefit from Enzalutamide, Apalutamide, Daralutamide).

Would have to dive into their definitions of N+ again, but there may be a big difference between cN+ and pN+ patients, presumably who where cN0 on imaging.

Not looking at XRT, but with respect to immediate vs. delayed ADT we have the old messing trial. DEFINE_ME
Despite this trial showing an OS advantage, standard of care never seemed to budge. The vast majority of Uros don't give ADT on node positive disease. There are a lot of issues with the trial, ranging from small cohorts, to the fact that "progression" was generally symptomatically based, when pretty much anyone these days would use PSA kinetics and start treatment earlier.

It's a mixed bag and is/should be patient centered. Up to 30% of patients with pN+ disease on RALP will never recur. So lifelong ADT +/- XRT is overtreating a big chunk of patients. As mentioned, we have no data on salvage vs. adjuvant in node positive setting. Personally If PSA undetectable I observe. If PSA detectable in the past would refer to salvage, now I'd get a PSMA pet and go from there.

 

[seper]

Would have to dive into their definitions of N+ again, but there may be a big difference between cN+ and pN+ patients, presumably who where cN0 on imaging.

Not looking at XRT, but with respect to immediate vs. delayed ADT we have the old messing trial. DEFINE_ME
Despite this trial showing an OS advantage, standard of care never seemed to budge. The vast majority of Uros don't give ADT on node positive disease. There are a lot of issues with the trial, ranging from small cohorts, to the fact that "progression" was generally symptomatically based, when pretty much anyone these days would use PSA kinetics and start treatment earlier.

It's a mixed bag and is/should be patient centered. Up to 30% of patients with pN+ disease on RALP will never recur. So lifelong ADT +/- XRT is overtreating a big chunk of patients. As mentioned, we have no data on salvage vs. adjuvant in node positive setting. Personally If PSA undetectable I observe. If PSA detectable in the past would refer to salvage, now I'd get a PSMA pet and go from there.

30% surgical cure is a gross overestimation. See RTOG 8531 above, etc

 

[DoctwoB]

30% surgical cure is a gross overestimation. See RTOG 8531 above, etc

30% for all comers with positive nodes on a prostatectomy may be an overestimate. 25-30% for cN0 pN1 limited nodal disease is probably accurate

Disease progression and survival of patients with positive lymph nodes after radical prostatectomy. Is there a chance of cure? - PubMed

Meticulous lymph node dissection reveals a high rate of metastases (25%). In patients with positive nodes time to progression is significantly correlated with the number of diseased nodes. Some patients with minimal metastatic disease remain free of prostate specific antigen relapse for more...

pubmed.ncbi.nlm.nih.gov

Their experience mirrors the dataset of the institution where I trained, where our own internal data suggested around 25-30% BCR free survival, albeit the the selection bias that cN+ patients were rarely included/operated on.