Sachdev Sean, Carroll Peter, Sandler Howard, Nguyen Paul L, Wafford Eileen, Auffenberg Gregory, Schaeffer Edward, Roach Mack, Evans Christopher P, Hussain Maha
Robert H. Lurie Comprehensive Cancer Center, Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
UCSF Hellen Diller Family Comprehensive Cancer Center, Department of Urology, University of California, San Francisco.
JAMA Oncol. 2020 Nov 1;6(11):1793-1800. doi: 10.1001/jamaoncol.2020.2832.
After radical prostatectomy, adverse pathologic features and postoperative prostate-specific antigen (PSA) levels can herald disease recurrence or progression. Postoperative radiotherapy (RT) remains beneficial in this setting.
To examine the evidence supporting the use of postoperative RT as well as recent advances that help determine timing, scope, and use in combination with androgen deprivation therapy (ADT) with or without lymphatic irradiation.
A search was conducted of MEDLINE (Ovid), Embase (Elsevier), and the Cochrane Library (Wiley) databases, in addition to clinical trial registries. The reference list of included studies was reviewed for relevant articles. The search was limited to studies published between January 1, 2014, and December 31, 2019.
After 548 citations were screened, 27 articles were selected for inclusion. In addition to conventional imaging, positron-emission tomographic (PET)-based radiotracers can aid in disease localization. While PET imaging may influence management with RT, studies are underway examining this issue, and several limitations must be considered, such as limited detectability at lower PSA levels and regional sensitivity. Available genomic classifiers can risk stratify patients or assess potential added benefit of RT. Prospective validation is underway with cooperative group trials. Adjuvant RT, on the basis of adverse pathologic features (such as extraprostatic extension or positive margins) is beneficial in terms of disease control, but it is unclear whether this therapy translates into more meaningful clinical benefit (eg, improved overall survival and a reduction in metastasis), which has been demonstrated by only 1 older, prospective randomized study. Preliminary data suggest that for a relatively favorable-risk population (low Gleason score but with positive margins), PSA monitoring may be a reasonable alternative in some men. Use of androgen deprivation therapy and lymphatic irradiation should be considered in higher-risk cohorts (those with high PSA, high Gleason score, seminal vesicle invasion or node positivity) in conjunction with postoperative RT.
The findings of this review suggest that postprostatectomy RT should be considered for men with prostate cancer in the setting of adverse pathologic features; in carefully selected patients with favorable characteristics, close PSA monitoring is an option. Androgen deprivation therapy and pelvic lymphatic irradiation should be considered for higher risk cohorts (eg, higher PSA values, higher Gleason score). PET imaging and molecular studies remain unproven as decision tools.
根治性前列腺切除术后，不良病理特征和术后前列腺特异性抗原（PSA）水平可预示疾病复发或进展。在此情况下，术后放疗（RT）仍然有益。
审查支持使用术后放疗的证据以及有助于确定放疗时机、范围以及与雄激素剥夺治疗（ADT）联合使用（无论是否进行淋巴照射）的最新进展。
除临床试验注册库外，还对MEDLINE（Ovid）、Embase（爱思唯尔）和Cochrane图书馆（威利）数据库进行了检索。对纳入研究的参考文献列表进行审查以查找相关文章。检索限于2014年1月1日至2019年12月31日期间发表的研究。
在筛选了548篇引文后，选择了27篇文章纳入。除了传统成像外，基于正电子发射断层扫描（PET）的放射性示踪剂可有助于疾病定位。虽然PET成像可能会影响放疗管理，但相关研究正在进行中，并且必须考虑一些局限性，如较低PSA水平时的检测能力有限以及区域敏感性。可用的基因组分类器可对患者进行风险分层或评估放疗的潜在额外益处。合作组试验正在进行前瞻性验证。基于不良病理特征（如前列腺外侵犯或切缘阳性）的辅助放疗在疾病控制方面是有益的，但尚不清楚这种治疗是否能转化为更有意义的临床益处（如改善总生存期和减少转移），这仅在一项较早的前瞻性随机研究中得到证实。初步数据表明，对于风险相对较低的人群（Gleason评分低但切缘阳性），PSA监测在某些男性中可能是一种合理的选择。对于高风险队列（PSA高、Gleason评分高、精囊侵犯或淋巴结阳性者），应考虑在术后放疗的同时使用雄激素剥夺治疗和淋巴照射。
本综述结果表明，对于具有不良病理特征的前列腺癌男性患者应考虑进行前列腺切除术后放疗；对于精心挑选的具有良好特征的患者，密切的PSA监测是一种选择。对于高风险队列（如PSA值较高、Gleason评分较高），应考虑使用雄激素剥夺治疗和盆腔淋巴照射。PET成像和分子研究作为决策工具仍未得到证实。
