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Commentary on Long-term follow-up of patients with prostate cancer and nodal metastases treated by pelvic lymphadenectomy and radical prostatectomy: The positive impact of adjuvant radiotherapy
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A.R. Gottschalk / Urologic Oncology: Seminars and Original Investigations 27 (2009) 456 – 464
radiotherapy. Collective analysis of all three modalities does, however, find an overall better outcome for PG3 (relative risk, 0.655; 95% confidence interval, 0.472– 0.909; P ⫽ 0.0113). This difference survives statistically after multivariate analysis. The study does have several limitations, including the lack of reporting of percent tissue involved or number of positive cores, both known prognostic factors, but the study does provide additional, confirmatory evidence that PG4 confers a poorer outcome after each of the three treatment modalities. More notably, it suggests that the outcome penalty may be greater with monotherapeutic brachytherapy than with the other two modalities. doi:10.1016/j.urolonc.2009.05.001 Mark A. Ritter, M.D., Ph.D.
References [1] Partin AW, Mangold LA, Lamm DA, et al. Contemporary update of prostate cancer staging nomograms (Partin Tables) for the new millennium. Urology 2001;58:843– 8. [2] Potters L, Purrazzella R, Brustein S, et al. The prognostic significance of Gleason grade in patients treated with permanent prostate brachytherapy. Int J Radiat Oncol Biol Phys 2003;56:749 –54. [3] Merrick GS, Galbreath RW, Butler WM, et al. Primary Gleason pattern does not impact survival after permanent interstitial brachytherapy for Gleason score 7 prostate cancer. Cancer 2007;110:289 –96.
Commentary on Long-term follow-up of patients with prostate cancer and nodal metastases treated by pelvic lymphadenectomy and radical prostatectomy: The positive impact of adjuvant radiotherapy. Da Pozzo LF, Cozzarini C, Briganti A, Suardi N, Salonia A, Bertini R, Gallina A, Bianchi M, Fantini GV, Bolognesi A, Fazio F, Montorsi F, Rigatti P, Department of Urology, Vita-Salute University, Milan, Italy. Eur Urol 2009 Feb 4 [Epub ahead of print] Recent large, prospective, randomized studies have demonstrated that adjuvant radiotherapy (RT) is a safe and effective procedure for preventing disease recurrence in locally advanced prostate cancer (PCa) patients. However, no study has ever tested the role of adjuvant RT in node-positive patients after radical prostatectomy (RP). We hypothesized that adjuvant RT with early hormone therapy (HT) might improve long-term outcomes of patients with PCa and nodal metastases treated with RP and extended pelvic lymph node dissection (ePLND). This retrospective study included 250 consecutive patients with pathologic lymph node invasion. We assessed factors predicting long-term biochemical recurrence (BCR)-free and cancer-specific survival (CSS) in node-positive PCa patients treated with RP, ePLND, and adjuvant treatments between 1988 and 2002 in a tertiary academic center. All patients received adjuvant treatments according to the treating physician after detailed patient information: 129 patients (51.6%) were treated with a combination of RT and HT, while 121 patients (48.4%) received adjuvant HT alone. BCR-free survival and CSS in patients with node-positive PCa: Mean follow-up was 95.9 months (median: 91.2). BCR-free survival and CSS rates at 5, 8, and 10 years were 72%, 61%, 53%, and 89%, 83%, 80%, respectively. In multivariable Cox regression models, adjuvant RT and the number of positive nodes were independent predictors of BCR-free survival (P ⫽ 0.002 and P ⫽ 0.003, respectively) as well as of CSS (P ⫽ 0.009 and P ⫽ 0.01, respectively). Moreover, there was significant gain in predictive accuracy when adjuvant RT was included in multivariable models predicting BCR-free survival and CSS (gain: 3.3% and 3%, respectively; all P ⬍ 0.001). Our data showed excellent long-term outcome for node-positive PCa patients treated with radical surgery plus adjuvant treatments. This study is the first to report a significant protective role for adjuvant RT in BCR-free survival and CSS of node-positive patients.
Commentary This is a retrospective analysis of 250 patients found to have positive lymph nodes at the time of radical prostatectomy and extended lymph node dissection. They were subsequently treated with either hormonal therapy alone or hormonal therapy plus radiation therapy. The results are very interesting from both the surgical and radiotherapy perspective. Improved biochemical recurrence-free survival and cancer-specific survival was seen with fewer positive lymph nodes in those who received radiotherapy. The long-term outcome for these node positive patients is quite favorable, and gives some credence to aggressive therapy for these patients. All patients underwent radical prostatectomy and extended lymph node dissection, and the data seem to suggest that the better the lymph node staging, the better the patient outcome. The fact that the radiotherapy target was the prostatic fossa and periprostatic tissue begs the question: would pelvic radiation plus hormonal therapy for lymph node positive patients improve outcome from prostate bed radiation and hormonal therapy? doi:10.1016/j.urolonc.2009.05.003 Alexander R. Gottschalk, M.D., Ph.D.
A.R. Gottschalk / Urologic Oncology: Seminars and Original Investigations 27 (2009) 456 – 464
radiotherapy. Collective analysis of all three modalities does, however, find an overall better outcome for PG3 (relative risk, 0.655; 95% confidence interval, 0.472– 0.909; P ⫽ 0.0113). This difference survives statistically after multivariate analysis. The study does have several limitations, including the lack of reporting of percent tissue involved or number of positive cores, both known prognostic factors, but the study does provide additional, confirmatory evidence that PG4 confers a poorer outcome after each of the three treatment modalities. More notably, it suggests that the outcome penalty may be greater with monotherapeutic brachytherapy than with the other two modalities. doi:10.1016/j.urolonc.2009.05.001 Mark A. Ritter, M.D., Ph.D.
References [1] Partin AW, Mangold LA, Lamm DA, et al. Contemporary update of prostate cancer staging nomograms (Partin Tables) for the new millennium. Urology 2001;58:843– 8. [2] Potters L, Purrazzella R, Brustein S, et al. The prognostic significance of Gleason grade in patients treated with permanent prostate brachytherapy. Int J Radiat Oncol Biol Phys 2003;56:749 –54. [3] Merrick GS, Galbreath RW, Butler WM, et al. Primary Gleason pattern does not impact survival after permanent interstitial brachytherapy for Gleason score 7 prostate cancer. Cancer 2007;110:289 –96.
Commentary on Long-term follow-up of patients with prostate cancer and nodal metastases treated by pelvic lymphadenectomy and radical prostatectomy: The positive impact of adjuvant radiotherapy. Da Pozzo LF, Cozzarini C, Briganti A, Suardi N, Salonia A, Bertini R, Gallina A, Bianchi M, Fantini GV, Bolognesi A, Fazio F, Montorsi F, Rigatti P, Department of Urology, Vita-Salute University, Milan, Italy. Eur Urol 2009 Feb 4 [Epub ahead of print] Recent large, prospective, randomized studies have demonstrated that adjuvant radiotherapy (RT) is a safe and effective procedure for preventing disease recurrence in locally advanced prostate cancer (PCa) patients. However, no study has ever tested the role of adjuvant RT in node-positive patients after radical prostatectomy (RP). We hypothesized that adjuvant RT with early hormone therapy (HT) might improve long-term outcomes of patients with PCa and nodal metastases treated with RP and extended pelvic lymph node dissection (ePLND). This retrospective study included 250 consecutive patients with pathologic lymph node invasion. We assessed factors predicting long-term biochemical recurrence (BCR)-free and cancer-specific survival (CSS) in node-positive PCa patients treated with RP, ePLND, and adjuvant treatments between 1988 and 2002 in a tertiary academic center. All patients received adjuvant treatments according to the treating physician after detailed patient information: 129 patients (51.6%) were treated with a combination of RT and HT, while 121 patients (48.4%) received adjuvant HT alone. BCR-free survival and CSS in patients with node-positive PCa: Mean follow-up was 95.9 months (median: 91.2). BCR-free survival and CSS rates at 5, 8, and 10 years were 72%, 61%, 53%, and 89%, 83%, 80%, respectively. In multivariable Cox regression models, adjuvant RT and the number of positive nodes were independent predictors of BCR-free survival (P ⫽ 0.002 and P ⫽ 0.003, respectively) as well as of CSS (P ⫽ 0.009 and P ⫽ 0.01, respectively). Moreover, there was significant gain in predictive accuracy when adjuvant RT was included in multivariable models predicting BCR-free survival and CSS (gain: 3.3% and 3%, respectively; all P ⬍ 0.001). Our data showed excellent long-term outcome for node-positive PCa patients treated with radical surgery plus adjuvant treatments. This study is the first to report a significant protective role for adjuvant RT in BCR-free survival and CSS of node-positive patients.
Commentary This is a retrospective analysis of 250 patients found to have positive lymph nodes at the time of radical prostatectomy and extended lymph node dissection. They were subsequently treated with either hormonal therapy alone or hormonal therapy plus radiation therapy. The results are very interesting from both the surgical and radiotherapy perspective. Improved biochemical recurrence-free survival and cancer-specific survival was seen with fewer positive lymph nodes in those who received radiotherapy. The long-term outcome for these node positive patients is quite favorable, and gives some credence to aggressive therapy for these patients. All patients underwent radical prostatectomy and extended lymph node dissection, and the data seem to suggest that the better the lymph node staging, the better the patient outcome. The fact that the radiotherapy target was the prostatic fossa and periprostatic tissue begs the question: would pelvic radiation plus hormonal therapy for lymph node positive patients improve outcome from prostate bed radiation and hormonal therapy? doi:10.1016/j.urolonc.2009.05.003 Alexander R. Gottschalk, M.D., Ph.D.