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Re: Perineural Invasion Predicts Increased Recurrence, Metastasis, and Death From Prostate Cancer Following Treatment With Dose-Escalated Radiation Therapy
PROSTATE CANCER
911
Re: Perineural Invasion Predicts Increased Recurrence, Metastasis, and Death From Prostate Cancer Following Treatment With Dose-Escalated Radiation Therapy F. Y. Feng, Y. Qian, M. H. Stenmark, S. Halverson, K. Blas, S. Vance, H. M. Sandler and D. A. Hamstra University of Michigan Medical Center and Ann Arbor Veteran Affairs Medical System, Ann Arbor, Michigan Int J Radiat Oncol Biol Phys 2011; 81: e361– e367.
Purpose: To assess the prognostic value of perineural invasion (PNI) for patients treated with dose-escalated external-beam radiation therapy for prostate cancer. Methods and Materials: Outcomes were analyzed for 651 men treated for prostate cancer with EBRT to a minimum dose ⱖ75 Gy. We assessed the impact of PNI as well as pretreatment and treatment-related factors on freedom from biochemical failure (FFBF), freedom from metastasis (FFM), cause-specific survival (CSS), and overall survival. Results: PNI was present in 34% of specimens at biopsy and was significantly associated with higher Gleason score (GS), T stage, and prostate-specific antigen level. On univariate and multivariate analysis, the presence of PNI was associated with worse FFBF (hazard ratio ⫽ 1.7, p ⬍0.006), FFM (hazard ratio ⫽ 1.8, p ⬍0.03), and CSS (HR ⫽ 1.4, p ⬍0.05) compared with absence of PNI; there was no difference in overall survival. Seven-year rates of FFBF, FFM, and CCS were 64% vs. 80%, 84% vs. 92%, and 91% vs. 95% for those patients with and without PNI, respectively. On recursive partitioning analysis, PNI predicted for worse FFM and CSS in patients with GS 8 –10, with FFM of 67% vs. 89% (p ⬍0.02), and CSS of 69% vs. 91%, (p ⬍0.04) at 7 years for those with and without PNI, respectively. Conclusions: The presence of PNI in the prostate biopsy predicts worse clinical outcome for patients treated with dose-escalated external-beam radiation therapy. Particularly in patients with GS 8 –10 disease, the presence of PNI suggests an increased risk of metastasis and prostate cancer death. Editorial Comment: The finding of perineural invasion on needle biopsy is another indication for adjuvant hormonal therapy in patients who are going to be treated with radiation. This study shows that despite the use of high dose external beam radiotherapy (greater than 75 Gy), the presence of perineural invasion in the prostatic biopsy independently predicted a worse clinical outcome. Although the finding was most pronounced in patients with Gleason 8 to 10 disease, the authors believe that the finding also applies to all Gleason scores, including patients with Gleason score 2 to 7. Although the absolute rates of clinical failure in men with Gleason 6 disease were clearly lower, and as a result the absolute impact of perineural invasion would be lower, the finding of perineural invasion clearly predicts worse cancer specific survival in these men. For this reason at Hopkins all patients with perineural invasion are advised to receive 4 months of adjuvant hormonal therapy. In contrast, in patients undergoing surgery we found that perineural invasion was not an independent predictor of biochemical progression following surgery.1 This represents another reason why surgery may be preferable to radiation in men with aggressive disease, especially young healthy patients. Patrick C. Walsh, M.D. 1. Loeb S, Epstein JI, Humphreys EB et al: Does perineural invasion on prostate biopsy predict adverse prostatectomy outcomes? BJU Int 2010; 105: 1510.
911
Re: Perineural Invasion Predicts Increased Recurrence, Metastasis, and Death From Prostate Cancer Following Treatment With Dose-Escalated Radiation Therapy F. Y. Feng, Y. Qian, M. H. Stenmark, S. Halverson, K. Blas, S. Vance, H. M. Sandler and D. A. Hamstra University of Michigan Medical Center and Ann Arbor Veteran Affairs Medical System, Ann Arbor, Michigan Int J Radiat Oncol Biol Phys 2011; 81: e361– e367.
Purpose: To assess the prognostic value of perineural invasion (PNI) for patients treated with dose-escalated external-beam radiation therapy for prostate cancer. Methods and Materials: Outcomes were analyzed for 651 men treated for prostate cancer with EBRT to a minimum dose ⱖ75 Gy. We assessed the impact of PNI as well as pretreatment and treatment-related factors on freedom from biochemical failure (FFBF), freedom from metastasis (FFM), cause-specific survival (CSS), and overall survival. Results: PNI was present in 34% of specimens at biopsy and was significantly associated with higher Gleason score (GS), T stage, and prostate-specific antigen level. On univariate and multivariate analysis, the presence of PNI was associated with worse FFBF (hazard ratio ⫽ 1.7, p ⬍0.006), FFM (hazard ratio ⫽ 1.8, p ⬍0.03), and CSS (HR ⫽ 1.4, p ⬍0.05) compared with absence of PNI; there was no difference in overall survival. Seven-year rates of FFBF, FFM, and CCS were 64% vs. 80%, 84% vs. 92%, and 91% vs. 95% for those patients with and without PNI, respectively. On recursive partitioning analysis, PNI predicted for worse FFM and CSS in patients with GS 8 –10, with FFM of 67% vs. 89% (p ⬍0.02), and CSS of 69% vs. 91%, (p ⬍0.04) at 7 years for those with and without PNI, respectively. Conclusions: The presence of PNI in the prostate biopsy predicts worse clinical outcome for patients treated with dose-escalated external-beam radiation therapy. Particularly in patients with GS 8 –10 disease, the presence of PNI suggests an increased risk of metastasis and prostate cancer death. Editorial Comment: The finding of perineural invasion on needle biopsy is another indication for adjuvant hormonal therapy in patients who are going to be treated with radiation. This study shows that despite the use of high dose external beam radiotherapy (greater than 75 Gy), the presence of perineural invasion in the prostatic biopsy independently predicted a worse clinical outcome. Although the finding was most pronounced in patients with Gleason 8 to 10 disease, the authors believe that the finding also applies to all Gleason scores, including patients with Gleason score 2 to 7. Although the absolute rates of clinical failure in men with Gleason 6 disease were clearly lower, and as a result the absolute impact of perineural invasion would be lower, the finding of perineural invasion clearly predicts worse cancer specific survival in these men. For this reason at Hopkins all patients with perineural invasion are advised to receive 4 months of adjuvant hormonal therapy. In contrast, in patients undergoing surgery we found that perineural invasion was not an independent predictor of biochemical progression following surgery.1 This represents another reason why surgery may be preferable to radiation in men with aggressive disease, especially young healthy patients. Patrick C. Walsh, M.D. 1. Loeb S, Epstein JI, Humphreys EB et al: Does perineural invasion on prostate biopsy predict adverse prostatectomy outcomes? BJU Int 2010; 105: 1510.