Salvage Lymph Node Dissection Shows Suboptimal Benefit in Node-Positive Prostate Cancer

Salvage lymph node dissection (sLND) alone was shown to be an inadequate intervention for patients with prostate cancer and nodal recurrence, according to findings from a recent study published in European Urology.^1,2

The multi-institutional series, presented at the 2020 European Association of Urology Virtual Congress, revealed that of 189 patients who experienced prostate-specific antigen (PSA) rise and nodal-only recurrence following radical prostatectomy and sLND, the probability of freedom from cancer-specific and all-cause mortality at 10 years was 66% and 64%, respectively.

Long-term analysis showed that 110 patients had a clinical recurrence (CR), and 163 patients had a biochemical recurrence (BCR). The 10-year CR-free and BCR-free survival rates were 31% and 11%, respectively.

The long-term impact of sLND in patients who experience node-only recurrent prostate cancer had not been well defined, lead study author Carlo A. Bravi, MD, of IRCCS Ospedale San Raffaele in Milan, Italy, and co-investigators wrote.

According to Bravi and co-investigators, results of the study indicate that men with node-only recurrent prostate cancer are at a high risk of systemic dissemination at the time of sLND.

Patients who were included in the study were enrolled between 2002 and 2011 from 11 tertiary referral centers.

Lymph node recurrence was determined by 11C-choline or 68Ga-prostate-specific membrane antigen ligand positron emission tomography/computed tomography (PET/CT).

Regarding methods, Kaplan-Meier analyses were used to determine the probability of freedom for each outcome. The risk of prostate cancer–specific mortality was determined by Cox regression analysis. Notably, this measurement was adjusted for various parameters including the use of additional treatment after sLND.

Additional findings from the study showed that 145 patients received androgen deprivation therapy (ADT) after sLND. Moreover, the median time to ADT was 41 months.

At a median interquartile range follow-up of 87 months (range, 51-104), 48 patients had died. Forty-five of these patients had died from prostate cancer.

Similar findings were observed in sensitivity analyses among men with pelvic-only positive PET/CT scans. Comparable results were also seen after excluding men on ADT at the time of PET/CT scans and men with a PSA level higher than the 75th percentile after sLND.

Multivariable analyses indicated that patients who had a PSA response after sLND (HR, 0.45; P = .001) and those receiving ADT within 6 months following sLND (HR, 0.51; P = .010) had a lower risk of death from prostate cancer.

Ultimately, about one-third of patients had died within 10 years of receiving sLND for PET-detected nodal recurrence, Bravi and co-investigators wrote. Of these patients, the majority had died as a direct result of their prostate cancer.

A minority of patients derived significant long-term, durable survival from sLND; however, these patients appeared to benefit from the addition of other treatments following radical prostatectomy.

“In the future it will be interesting to compare the genomic profile of patients who successfully respond to sLND compared with those who recurred early after surgery,” concluded study author, Nicola Fossati, MD, of IRCCS Ospedale San Raffaele.

References:

1. Bravi CA, Fossati N, Gandaglia G, et al. Long-term outcomes of salvage lymph node dissection for nodal recurrence of prostate cancer after radical prostatectomy: not as good as previously thought [published online ahead of print, July 2, 2020]. Eur Urol. doi:10.1016/j.eururo.2020.06.043
2. Long-term outcomes of salvage lymph node dissection for nodal recurrence of prostate cancer after radical prostatectomy: not as good as previously thought. News release. July 2, 2020. Accessed July 21, 2020. bit.ly/2ZRJS9O.