Department of Internal Medicine, Johns Hopkins Bayview Hospital, Baltimore, MD.
Department of Radiology and Nuclear Medicine, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway.
Urol Oncol. 2019 Apr;37(4):289.e19-289.e26. doi: 10.1016/j.urolonc.2018.09.016. Epub 2018 Nov 13.
The recurrence patterns of high-risk, N1 prostate cancer after radiation therapy (RT) including the pelvic lymph nodes have not been fully investigated.
We have a prospective clinical study since 2004 that has followed 138 men with locally advanced prostate cancer (T1-T4N0-N1M0) treated with definitive RT encompassing the prostate and pelvic lymph nodes and long-term androgen deprivation therapy (ADT). Forty nine of the 52 patients that developed recurrence were imaged at biochemical failure to detect the site of recurrence.
Imaging identified the site of recurrence in 46 patients. Twenty five patients had prostatic recurrence only, none had local lymph node recurrence only, 11 had distant metastases only, 7 had prostatic recurrence and distant metastases, 2 had prostatic recurrence, local nodal recurrence and distant metastases, and 1 had local nodal recurrence with distant metastases. The mean time to recurrence was 62 months for prostate only, 40 months for distant only and 50 months for prostate and distant recurrence. There was a 69% recurrence rate for patients with magnetic resonance imaging -detected N1 disease. There was significantly longer survival for patients with prostate recurrence only compared to patients with distant recurrence (P < 0.018). Five-year prostate cancer-specific survival were 85% for prostate only, 44% for distant only and 48% for prostate and distant recurrence (prostate only vs. distant only; P = 0.008, prostate only vs. prostate and distant; P = 0.018, distant vs. prostate and distant; P = 0.836).
The predominant recurrence pattern for high-risk, N1 prostate cancer was prostatic recurrence and distant spread after pelvic RT and androgen deprivation therapy. Our data argue for further local dose escalation and pelvic nodal radiation to prevent recurrence in these sites. Lymph node metastasis at initial staging with an magnetic resonance imaging was a strong predictor of recurrence and poor survival and may identify patients in need of more aggressive treatment.
放射治疗（RT）包括盆腔淋巴结后高危 N1 前列腺癌的复发模式尚未得到充分研究。
自 2004 年以来，我们进行了一项前瞻性临床研究，该研究随访了 138 名局部晚期前列腺癌（T1-T4N0-N1M0）患者，这些患者接受了根治性 RT 治疗，包括前列腺和盆腔淋巴结以及长期雄激素剥夺治疗（ADT）。在生化失败时对 49 例出现复发的患者进行影像学检查以检测复发部位。
影像学在 46 例患者中确定了复发部位。25 例患者仅出现前列腺复发，无局部淋巴结单独复发，11 例患者仅出现远处转移，7 例患者仅出现前列腺和远处转移，2 例患者仅出现前列腺、局部淋巴结和远处转移，1 例患者仅出现局部淋巴结和远处转移。仅前列腺复发的平均复发时间为 62 个月，仅远处转移的平均复发时间为 40 个月，前列腺和远处转移的平均复发时间为 50 个月。MRI 检测到 N1 疾病的患者复发率为 69%。仅前列腺复发的患者与远处转移的患者相比，生存时间明显更长（P<0.018）。仅前列腺复发的患者 5 年前列腺癌特异性生存率为 85%，仅远处转移的患者为 44%，前列腺和远处转移的患者为 48%（仅前列腺 vs. 仅远处转移；P=0.008，仅前列腺 vs. 前列腺和远处转移；P=0.018，远处转移 vs. 前列腺和远处转移；P=0.836）。
高危 N1 前列腺癌经盆腔 RT 和雄激素剥夺治疗后，主要的复发模式为前列腺复发和远处播散。我们的数据表明需要进一步提高局部剂量和盆腔淋巴结放疗，以预防这些部位的复发。初始分期时 MRI 检查发现淋巴结转移是复发和预后不良的强烈预测因素，可能识别出需要更积极治疗的患者。
