Radical prostatectomy improves progression-free and cancer-specific survival in men with lymph node positive prostate cancer in the prostate-specific antigen era: a confirmatory study

Abstract

Study type: Therapy (outcomes research).

Level of evidence: 2b. What's known on the subject? and What does the study add? Historically, surgeons were reluctant to perform radical prostatectomy (RP) in LN positive disease. Nowadays, a shift towards multimodal treatment strategies in such patients, comprising RP with extended lymph node dissection followed by radiation and/or hormonal therapy can be detected. However, this change of paradigm is not supported by evidence derived from treatment guidelines. Retrospective studies on this topic, comprising small numbers of patients from the pre-PSA era in the US suggest a survival advantage, if RP is performed. Our analyses of cancer control rates between patients with discontinued vs. completed prostatectomy revealed a superior clinical progression free- and cancer specific-survival rate in those patients with completed prostatectomy. These results add knowledge on treatment outcome of a current patient population since previous retrospective studies include patients from the pre-PSA era.

Objective: To assess the prognostic role of radical prostatectomy (RP) in lymph node (LN) positive patients with prostate cancer (PCa) in a contemporary RP cohort.

Patients and methods: Between 1992 and 2004, 158 consecutive patients with clinically localized PCa and regional LN metastasis were identified. Fifty patients underwent LN dissection and discontinued RP, combined with early hormonal therapy (HT) (RP-), whereas, in 108 patients, RP was completed followed by adjunctive HT (RP+). Clinical progression-free- (CPFS) and cancer-specific survival (CSS) were studied using Kaplan-Meier analysis. Disease characteristics and the impact of RP on CPFS and CSS were further assessed using Cox proportional hazard models. A matched pair analysis between RP- and RP+ patients was performed based on clinical and pathological factors.

Results: Median follow-up was 98 months (interquartile range, 88-113). Five- and 10-year CPFS was 77% and 61% for RP+ patients vs 61% and 31%, for RP- patients (P=0.005), respectively. A similar trend was observed for CSS (84% and 76% for RP+ vs 81% and 46% for RP-; P=0.001). Type of treatment (RP- vs RP+) and number of positive LN were multivariate predictors of CPFS and CSS (all P≤0.05). In the matched pair analyses, RP+ patients showed superior CPFS and CSS (P<0.005).

Conclusions: RP had a beneficial impact, resulting in the superior survival of patients with LN positive PCa after controlling for LN tumour burden in a contemporary RP series. The findings obtained in the present study support the role of RP as an important component of multimodal strategies of LN positive PCa.