Definitive Radiation Therapy and Survival in Clinically Node-Positive Prostate Cancer

Abstract

SummaryThe survival benefit of combined radiation therapy and androgen deprivation therapy compared with androgen deprivation therapy alone for clinically lymph nodee positive prostate cancer remains controversial. We identified clinically nodepositive, nonmetastatic prostate cancer patients from the Veterans Affairs system and compared mortality outcomes between treatment groups. We found that definitive treatment with radiation therapy improved prostate cancerespecific mortality and all-cause Purpose: The survival benefit of combined radiation therapy (RT) and androgen deprivation therapy (ADT) compared with ADT alone for clinically lymph nodeepositive prostate cancer remains controversial. Methods and Materials: We identified patients with clinically node-positive, nonmetastatic prostate cancer diagnosed between 2000 and 2015 and treated with ADT (n Z 450) or ADT-RT (n Z 198) from a national Veterans Affairs database. We compared prostate cancerespecific mortality (PCSM) and all-cause mortality (ACM) between treatment groups using multivariable competing-risks regression and Cox regression, respectively. An interaction term between ADT-RT and prostate-specific antigen (PSA) level (dichotomized about the median) was included in the multivariable models. Results: ADT-RT was associated with improved PCSM among patients with PSA levels less than the median of 26 ng/mL (sub-distribution hazard ratio, 0.50; 95% confidence interval [CI] 0.28-0.88; P Z .02) but not greater than the median (hazard ratio [HR], 1.15; 95% CI 0.67-1.96; P Z .62) (P Z .038 for interaction). ADT-RT was also associated with improved ACM among patients with PSA levels less than the median (HR, 0.38; 95% CI 0.25-0.57; P < .001) but not greater than the median (HR, 0.91; 95% CI 0.60-1.38; P Z .66) (P Z .004 for interaction). Conclusions: Definitive treatment with ADT-RT is associated with improved PCSM and ACM among patients with clinically node-positive prostate cancer and lower Reprint requests to: Brent S.

Role of Locoregional Treatment in Vulvar Cancer With Pelvic Lymph Node Metastases: Time to Reconsider FIGO Staging?

“…Cervical cancer with para-aortic lymph node involvement used to be considered M1 disease, 16 but multiple studies have shown good oncologic outcomes with definitive local treatment, [17][18][19] resulting in an eventual shift of paraaortic lymph node involvement to be considered regional nodal disease. 2 Similar findings have been shown in nodepositive [20][21][22] and distant metastatic prostate cancer. 23 The role for definitive RT, generally with chemotherapy, in the management of unresectable vulvar cancer is well documented from multiple prospective studies, 15,24 with contemporary series showing feasibility of using advanced techniques with good oncologic outcomes in well-selected patients.…”

Clinical outcomes of definitive whole pelvic radiotherapy for clinical lymph node metastatic prostate cancer

“…1 Several studies have shown that addition of local treatment (surgery and RT) to ADT improves treatment outcome. [2][3][4][5][6][7][8][9] Thus, in the NCCN guideline 2018, external beam RT combined with ADT ± abiraterone and prednisone is regarded as one of the standard therapies along with ADT ± abiraterone and prednisone. 1 The guideline further recommends nodal radiation and dose escalation to clinically positive nodes considering the tolerance dose of surrounding tissue.…”

“…1 Recently, some retrospective and database studies have demonstrated the benefits of adding definitive local treatment including radical prostatectomy (RP) and/or RT to ADT for cN1 patients. [2][3][4][5][6][7][8][9] However, the appropriate radiation field and its dose have not been well determined. Some studies include pelvic nodal area 4,7,9 and others include only the prostate and seminal vesicles.…”

Elective nodal radiotherapy in prostate cancer

“…Table 1 gives an overview of prospective trials evaluating the value of whole pelvis radiotherapy in four different settings: (1) patients with cN0 (clinically node negative) disease and a substantial risk (term varies largely between studies) 1,3,7,8,11,14,20,24 of pathologically involved nodes in the primary setting, (2) patients with cN1 (clinically node positive) disease in the primary setting, [25][26][27][28][29][30][31] (3) patients with adjuvant pN1 (pathologically node positive) disease in the postoperative setting, 12,[32][33][34][35][36][37] and (4) patients with pNx (unknown node status) and pN0 (pathologically node negative) disease in the postoperative salvage setting. [38][39][40] Patients with cN0 disease in the primary setting…”

“…When suspected positive pelvic nodes are present on CT imaging, adding whole pelvis radiotherapy to androgen deprivation therapy significantly improves survival. [25][26][27]31 With the advent of modern biological imaging techniques, such as PSMA PET-CT, the likeli hood that pelvic nodes will be found earlier, more frequently, and will be more widespread is high, as shown in several trials. 27,[42][43][44][45] In patients with cN1 disease in the primary setting, androgen deprivation therapy is standard management and, in our opinion, whole pelvis radio therapy should always be added, including the application of a simultaneously integrated boost to PSMA PET-positive nodes.…”