AUA 2020: Radical Prostatectomy for Patients with High-Risk, Very-High Risk, or Metastatic Prostate Cancer:... - UroToday

(UroToday.com) Guideline-recommended management of high-risk prostate cancer is radical prostatectomy with pelvic lymph node dissection or radiation therapy with/without systemic therapy. Increasingly, patients with regional (N1) and distant (M1) metastases are being considered for definitive local therapy. However, the oncological value of local treatment in high-risk and metastatic prostate cancer remains controversial. At the AUA 2020 virtual meeting, Brian Lane, MD, PhD, and colleagues presented results of their investigation of the oncologic outcomes of surgery for patients categorized as high-risk, very-high risk, or with suspected metastatic (N1 and/or M1) prostate cancer at the time of radical prostatectomy.

For this study, the MUSIC registry was queried for all patients undergoing radical prostatectomy from January 2012 to December 2018. Of the 9,208 patients, 2,086 patients (22%) were classified as having high-risk prostate cancer or higher. High-risk prostate cancer was defined as having PSA ≥20 or cT3-4 or biopsy grade group (bGG) 4-5; very-high risk prostate cancer was defined as having ≥2 high-risk features, or >4 cores of bGG 4-5, or primary pattern 5.  Metastatic prostate cancer was defined as clinical N1 and/or M1 disease. The primary outcome was biochemical recurrence after radical prostatectomy (PSA ≥ 0.2 more than 30 days after surgery), and the secondary outcomes were: (i) the presence/absence of extraprostatic extension, (ii) seminal vesicle invasion, (iii) positive lymph nodes (N1), (iv) positive surgical margins, and (v) perioperative events. The pre-treatment and oncologic outcomes of the high-risk, very-high risk, and metastatic groups were compared.  Kaplan-Meier analysis of biochemical recurrence and multivariable analyses were performed with significance set at p < 0.05.

There were 844 patients that were high-risk, 1,052 that were very-high risk, and 190 that were N1 or M1. Pelvic lymph node dissection was performed in 91.5% of high-risk patients, 95.7% of very-high risk, and 94.6% of N1 or M1 patients. At median follow-up of 20.8 months after radical prostatectomy, overall 3-year biochemical recurrence-free probability was 66% for high-risk, 49% for very-high risk, and 47% for metastatic prostate cancer patients (p<0.001):

In multivariable analysis, the highly significant predictors of biochemical recurrence included PSA (HR 3.35, 95% CI 2.32-4.83 for PSA>50; HR 2.35, 95% CI 1.87-2.96 for PSA 20.1-50; HR 2.07, 95% CI 1.71-2.51 for PSA 10-20 vs PSA ≤ 10) and risk group (HR 1.63, 95% CI 1.22-2.18 for metastatic disease, and HR 1.45, 95% CI 1.18-1.77 for very-high risk vs. high-risk disease). bGG 3-5, cT2-T4, and African-American race (black vs white: HR 1.64, 95% CI 1.33-2.02) were also significant biochemical recurrence predictors.

Dr. Lane concluded this presentation of men under radical prostatectomy for high-risk disease in the MUSIC registry with the following take-home messages:

• Nearly 25% of radical prostatectomies were performed for high-risk or higher prostate cancer
• Although these patients are clearly at higher risk for biochemical recurrence and many received additional treatments for prostate cancer, the majority are disease-free 3 years after surgery
• Radical prostatectomy with pelvic lymph node dissection appears to be an oncologically-sound approach for patients with high-risk and very-high risk prostate cancer
• Patients with suspicion of N1 or M1 disease that undergo radical prostatectomy with pelvic lymph node dissection appear to have similar oncologic outcomes to non-metastatic very-high risk patients
• The value of local treatment in the setting of confirmed metastatic disease is the focus of ongoing clinical trials, and is best performed in this setting

Presented by: Brian Lane, MD, PhD, Spectrum Health, Grand Rapids, MI

Written by: Zachary Klaassen, MD, MSc, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, Augusta, GA, USA, Twitter: @zklaassen, at the 2020 American Urological Association (AUA) Annual Meeting, Virtual Experience #AUA20, June 27-28, 2020.