Sood Akshay, Zhang Lawrence T, Keeley Jacob, Butaney Mohit, Stricker Maxwell, Andrews Jack R, Grauer Ralph, Peabody James O, Rogers Craig G, Menon Mani, Abdollah Firas
VCORE-Vattikuti Urology Institute Center for Outcomes Research, Analytics and Evaluation, Henry Ford Hospital, Detroit, MI, USA.
Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA.
Prostate Cancer Prostatic Dis. 2024 Mar;27(1):58-64. doi: 10.1038/s41391-022-00572-z. Epub 2022 Jul 6.
Optimal postsurgical management of prostate cancer (PCa) patients with nodal metastasis at the time of radical prostatectomy remains unclear. We sought to examine the role of postoperative PSA kinetics and pathologic tumor characteristics in guiding additional hormonal therapy use in pN1 men.
In total, 297 pN1 PCa patients treated with radical prostatectomy and ePLND between 2002 and 2018 were identified within our prospectively maintained institutional cancer data-registry. Following surgery, these patients were managed with either immediate androgen deprivation therapy (iADT) or observation with deferred ADT (dADT). The former was defined as ADT given within ≤6 months of surgery and the latter as >6 months. The primary outcome was metastasis. Regression-tree analysis was used to stratify patients into novel risk-groups based on post-prostatectomy tumor characteristics and PSA kinetics and the corresponding metastasis risk. Multivariable Cox regression analyses tested the impact of iADT versus observation ± dADT on metastasis, cancer-specific mortality, and overall mortality within each risk-group separately.
The median follow-up was 6.1 years (IQR 3.2-9.0). Regression-tree analysis stratified patients into 3 novel risk-groups (Harrell's C-index 0.79) based on PSA-nadir and time to biochemical failure: group 1 (low-risk) included patients with time to biochemical recurrence >6 months (n = 115), while groups 2 and 3 included patients with biochemical failure within ≤6 months with a postoperative PSA-nadir <1.05 ng/mL (group 2 [intermediate-risk], n = 125) or ≥1.05 ng/mL (group 3 [high-risk], n = 57), respectively. No other patient or tumor characteristics were significant for risk stratification. Within each risk-group, the 10-year metastasis-free survival rates with iADT versus observation ± dADT use were: group 1, 100% versus 95.4% (Log-rank p = 0.738), group 2, 80.6% versus 53.5% (Log-rank p = 0.016), and group 3, 41.5% versus 0% (Log-rank p = 0.015), respectively. Adjusted Cox regression analyses confirmed the benefit of iADT utilization in reducing metastasis in group 2 (p = 0.029) and group 3 (p = 0.008) patients, with no benefit for group 1 patients (p = 0.918). Similar results were noted for cancer-specific and overall mortality.
Following radical prostatectomy, early postoperative PSA kinetics may provide valuable information for guiding the timing of ADT initiation-this may reduce over- and undertreatment of pN1 PCa men.
前列腺癌（PCa）患者在根治性前列腺切除术时伴有淋巴结转移，术后的最佳管理方案仍不明确。我们试图研究术后前列腺特异抗原（PSA）动力学和病理肿瘤特征在指导pN1男性患者使用额外激素治疗中的作用。
在我们前瞻性维护的机构癌症数据登记处中，识别出2002年至2018年间接受根治性前列腺切除术和扩大盆腔淋巴结清扫术（ePLND）的297例pN1 PCa患者。术后，这些患者接受即刻雄激素剥夺治疗（iADT）或观察并延迟雄激素剥夺治疗（dADT）。前者定义为在术后≤6个月内给予ADT，后者定义为>6个月。主要结局是转移。采用回归树分析，根据前列腺切除术后肿瘤特征和PSA动力学以及相应的转移风险，将患者分层为新的风险组。多变量Cox回归分析分别测试了iADT与观察±dADT对各风险组内转移、癌症特异性死亡率和总死亡率的影响。
中位随访时间为6.1年（四分位间距3.2 - 9.0年）。回归树分析根据PSA最低点和生化复发时间将患者分层为3个新的风险组（Harrell's C指数为0.79）：第1组（低风险）包括生化复发时间>6个月的患者（n = 115），而第2组和第3组分别包括生化复发时间≤6个月且术后PSA最低点<1.05 ng/mL（第2组[中风险]，n = 125）或≥1.05 ng/mL（第3组[高风险]，n = 57）的患者。没有其他患者或肿瘤特征对风险分层有显著意义。在每个风险组中，使用iADT与观察±dADT的10年无转移生存率分别为：第1组，100%对95.4%（对数秩检验p = 0.738），第2组，80.6%对53.5%（对数秩检验p = 0.016），第3组，41.5%对0%（对数秩检验p = 0.015）。调整后的Cox回归分析证实，iADT用于降低第2组（p = 0.029）和第3组（p = 0.008）患者转移的益处，而对第1组患者无益处（p = 0.918）。癌症特异性死亡率和总死亡率也有类似结果。
根治性前列腺切除术后，早期术后PSA动力学可为指导ADT开始时机提供有价值的信息，这可能减少pN1 PCa男性患者的过度治疗和治疗不足。
