Prostate CancerLong-term Outcomes of Salvage Lymph Node Dissection for Clinically Recurrent Prostate Cancer: Results of a Single-institution Series with a Minimum Follow-up of 5 Years
Introduction
Radical prostatectomy (RP) represents a first-line treatment modality for patients with localized prostate cancer (PCa) and a life expectancy of at least 10 yr [1]. Although this approach is associated with excellent cancer control rates [2], [3], a non-negligible proportion of patients still experiences biochemical recurrence (BCR) and clinical progression after surgery [4], [5]. Of note, these individuals represent subjects at a higher risk of dying from cancer-specific mortality (CSM) [6], [7]. In these patients, pelvic and/or distant lymph nodes may represent the site of recurrent disease [8]. Men experiencing nodal recurrence after surgery are currently considered as affected by systemic disease, and they are thus managed with medical treatments such as androgen-deprivation therapy (ADT) [9]. However, evidence exists supporting heterogeneous survival among clinically recurrent patients [10], [11]. In particular, patients with nodal recurrence showed more favorable outcomes compared with patients with bone or visceral metastases after primary treatment [10]. In addition, ADT does not represent a potential curative treatment, and many of these men ultimately develop castration-resistant disease [12], [13]. Moreover, ADT is associated with significant toxicity at long term [14], [15], [16]. On the basis of these considerations, imaging-guided therapies such as salvage lymph node dissection (LND) have been proposed for lymph node recurrent patients [17], [18], [19], [20], [21], [22].
Although clinical guidelines do not currently recommend this approach, salvage LND might have two main aims: to delay further cancer recurrence and to postpone the use of systemic treatments [21]. Previous studies showed that approximately 70% of individuals treated with imaging-guided salvage LND were free from further clinical recurrence (CR) at 5-yr follow-up [17], [18]. Although these results are promising, their applicability in clinical practice is still limited by the lack of data with adequate follow-up supporting the oncologic safety and rationale of salvage LND. We aimed at examining the long-term BCR-, CR-, and CSM-free survival rates in a cohort of patients treated with salvage LND for nodal recurrence documented by 11C-choline positron emission tomography/computed tomography (PET/CT) scan after RP. In particular, we present an update of our previous study with mature data from patients with at least a 5-yr follow-up [17].
Section snippets
Study population
The current study included 59 patients who experienced postoperative BCR after RP. Postoperative BCR was defined as two consecutive prostate-specific antigen (PSA) values >0.2 ng/ml. All patients included in the study had pathologic lymph nodal uptake at 11C-choline PET/CT scan, suggesting the presence of nodal recurrence. All patients also underwent conventional imaging such as abdominal CT scan and bone scan using technetium Tc 99m methylene diphosphonate (MDP) to exclude any other sites of
Baseline characteristics
Table 1 depicts the baseline characteristics of all patients included in the study. Mean age at salvage LND was 66.6 yr (median: 64). Overall, 41 patients and 18 patients had one and two positive spots, respectively, at 11C-choline PET/CT scan, and 36 patients (61.0%), 10 patients (16.9%), and 13 patients (22.0%) had pelvic, retroperitoneal, and pelvic plus retroperitoneal positive spots, respectively, at 11C-choline PET/CT. Only 5 patients (8.4%) had a positive CT scan; the other 54 had a
Discussion
Salvage LND was recently proposed as a possible treatment option for men with lymph node recurrent PCa after RP [17], [18], [19], [20]. This approach has shown to lead to BR and delayed clinical progression in roughly 30% of patients evaluated at intermediate-term follow-up [17], [18]. However, the lack of long-term data on the oncologic safety of this approach limits its adoption in clinical practice, and currently salvage LND is not recommended by any international guideline. In the face of
Conclusions
Salvage LND may represent a therapeutic option for patients with BCR after RP and nodal pathologic uptake at 11C-choline PET/CT scan. BCR soon after surgery can be achieved in a consistent proportion of patients. Although most patients invariably progressed to BCR after salvage LND, roughly 40% of them did not show any further CR at long-term follow-up. Ideal candidates for such an approach are patients with a small volume of nodal recurrence limited to the pelvic area.
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Both authors contributed equally to the manuscript.