Disturbing Pattern of Recurrence in Men Post Radical Prostatectomy

Gerald Chodak, MD


April 12, 2017

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Hello. I am Dr Gerald Chodak for Medscape. Today I want to talk about the pattern of recurrence in men who have undergone a radical prostatectomy.

Parker and coworkers[1] published a report in which they looked at 41 men who had undergone a radical prostatectomy between 2008 and 2015. All of these men underwent a PET choline scan to detect recurrences following a PSA recurrence. In this group of patients, the median PSA at the time of the choline PET scan was rather high at 3.1 ng/mL. Nevertheless, they divided the patients into the following different categories: those in whom there was an in-field recurrence, meaning that the radiation field would cover the area of recurrent disease; a second group called the edge-of-field recurrence, for those men who would end up not getting the full dose of 45 Gy that would normally be administered; and a third group of men for out-of-field recurrences, meaning that, even if they got the radiation, the location of the recurrence would not be covered. Therefore, radiation is highly unlikely to be helpful.

What they found is somewhat disturbing: Only 12% of the patients had in-field recurrences, 24% had edge-of-field recurrences, and a full 88% of patients had recurrences that were outside the field of radiation. These findings have implications both for men getting radiation and men getting surgery.

In the case of men getting surgery, who were in the high-risk category and were going to get a pelvic lymph node dissection, doing a limited lymph node dissection is not going to identify or remove many of the metastases that are already present. Whether removing them is curative, or whether or not simply adding adjuvant ADT would be helpful in those cases, is unclear. Nevertheless, why bother doing a lymph node dissection unless you are going to remove the lymph nodes that are highly likely to be involved with cancer?

The second implication is for men who are going to get adjuvant radiation therapy. We know from the randomized trial of early versus optional adjuvant therapy for men who have had high-risk radical prostatectomy that only about 1 out of 12 men benefitted, which is not surprising given that the field of radiation would be inadequate in most of the cases.[2] It would mean that if men are going to get adjuvant radiation, one has to consider either doing a combination trial of ADT with salvage radiation or giving a higher dose or wider field of radiation therapy. Both of those are likely to increase the risk for side effects.

For now, we have some interesting and helpful information to understand why a lot of men recur, and recur even if they get adjuvant radiation therapy or even if they get a limited pelvic lymph node dissection. This information is important and should help design future trials to solve these problems.

I look forward to your comments. Thank you.


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