Elsevier

European Urology

Volume 67, Issue 2, February 2015, Pages 299-309
European Urology

Prostate Cancer
Long-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

https://doi.org/10.1016/j.eururo.2014.02.011Get rights and content

Abstract

Background

Prostate cancer (PCa) patients with lymph node recurrence after radical prostatectomy (RP) are usually managed with androgen-deprivation therapy. Despite the absence of prospective randomized studies, salvage lymph node dissection (LND) has been proposed as an alternative treatment option.

Objective

To examine long-term outcomes of salvage LND in patients with nodal recurrent PCa documented by 11C-choline positron emission tomography/computed tomography (PET/CT) scan.

Design, setting, and participants

Overall, 59 patients affected by biochemical recurrence (BCR) with 11C-choline PET/CT scan with pathologic activity treated between 2002 and 2008 were included.

Intervention

Pelvic and/or retroperitoneal salvage LND.

Outcome measurements and statistical analyses

Biochemical response (BR) was defined as prostate-specific antigen (PSA) <0.2 ng/ml at 40 d after surgery. BCR for those who achieved BR was defined as a PSA >0.2 ng/ml. Clinical recurrence (CR) was defined as a positive PET/CT scan after salvage LND in the presence of a rising PSA. Kaplan-Meier curves assessed time to BCR, CR, and cancer-specific mortality (CSM). Cox regression analyses were fitted to assess predictors of CR.

Results and limitations

Median follow-up after salvage LND was 81.1 mo. Overall, 35 patients (59.3%) achieved BR. The 8-yr BCR-free survival rate in patients with complete BR was 23%. Overall, the 8-yr CR- and CSM-free survival rates were 38% and 81%, respectively. In multivariable analyses evaluating preoperative variables, PSA at salvage LND represented the only predictor of CR (p = 0.03). When postoperative variables were considered, BR and the presence of retroperitoneal lymph node metastases were significantly associated with the risk of CR (all p ≤ 0.04). Our study is limited by the lack of a control group.

Conclusions

Salvage LND may represent a therapeutic option for patients with BCR after RP and nodal pathologic uptake at 11C-choline PET/CT scan. Although most patients progressed to BCR after salvage LND, roughly 40% of them experienced CR-free survival.

Patient summary

Salvage lymph node dissection may represent a therapeutic option for selected patients with nodal recurrence after radical prostatectomy. Roughly 40% of men did not show any further clinical recurrence at long-term follow-up after surgery.

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.

References (38)

  • P. Rigatti et al.

    Pelvic/retroperitoneal salvage lymph node dissection for patients treated with radical prostatectomy with biochemical recurrence and nodal recurrence detected by [11C]choline positron emission tomography/computed tomography

    Eur Urol

    (2011)
  • C.A. Jilg et al.

    Salvage lymph node dissection with adjuvant radiotherapy for nodal recurrence of prostate cancer

    J Urol

    (2012)
  • P. Berkovic et al.

    Salvage stereotactic body radiotherapy for patients with limited prostate cancer metastases: deferring androgen deprivation therapy

    Clin Genitourin Cancer

    (2013)
  • B. De Bari et al.

    Salvage therapy of small volume prostate cancer nodal failures: a review of the literature

    Crit Rev Oncol Hematol

    (2014)
  • S.H. Culp et al.

    Might men diagnosed with metastatic prostate cancer benefit from definitive treatment of the primary tumor? A SEER-based study

    Eur Urol

    (2014)
  • S.A. Boorjian et al.

    Natural history of biochemical recurrence after radical prostatectomy with adjuvant radiation therapy

    J Urol

    (2012)
  • M. Picchio et al.

    The role of choline positron emission tomography/computed tomography in the management of patients with prostate-specific antigen progression after radical treatment of prostate cancer

    Eur Urol

    (2011)
  • V. Scattoni et al.

    Detection of lymph-node metastases with integrated [11C]choline PET/CT in patients with PSA failure after radical retropubic prostatectomy: results confirmed by open pelvic-retroperitoneal lymphadenectomy

    Eur Urol

    (2007)
  • N. Suardi et al.

    A nomogram predicting long-term biochemical recurrence after radical prostatectomy

    Cancer

    (2008)
  • Cited by (0)

    Both authors contributed equally to the manuscript.

    View full text