Martini-Klinik Prostate Cancer Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
World J Urol. 2023 Sep;41(9):2343-2350. doi: 10.1007/s00345-023-04534-5. Epub 2023 Jul 29.
Metastasis-directed therapy is a feasible option for low PSA, recurrent locoregional metastatic prostate cancer. After initial salvage surgery, patients with good response might consider a repeat salvage surgery in case of recurrent, isolated, and PSMA-positive metastases. This analysis aimed to evaluate the oncological outcome and safety of repeat PSMA-targeted radioguided surgery (RGS) after either prior RGS or "standard" salvage lymph node dissection (SLND).
We identified 37 patients undergoing repeat RGS after prior SLND (n = 21) (SLND-RGS) or prior RGS (n = 16) (RGS-RGS) between 2014 and 2021 after initial radical prostatectomy with or without pelvic radiation therapy at two German tertiary referral centers. Kaplan-Meier analyses and uni-/multivariable Cox regression models were used to investigate factors associated with biochemical recurrence-free survival (BRFS) and treatment-free survival (TFS) after repeat salvage surgery.
Complete Biochemical Response (cBR, PSA < 0.2 ng/ml) was observed in 20/32 patients (5 NA). Median overall BRFS [95% confidence interval (CI)] after repeat salvage surgery was 10.8 months (mo) (5.3-22). On multivariable regression, only age (HR 1.09, 95% CI 1.01-1.17) and preoperative PSA (HR 1.23, 95% CI 1.01-1.50) were associated with shorter BRFS, although PSA (HR 1.16, 95% CI 0.99-1.36) did not achieve significant predictor status in univariable analysis before (p value = 0.07). Overall, one year after second salvage surgery, 89% of the patients (number at risk: 19) did not receive additional treatment and median TFS was not reached. Clavien-Dindo grade > 3a complications were observed in 8% (3/37 patients). Limitations are the retrospective evaluation, heterogeneous SLND procedures, lack of long-term follow-up data, and small cohort size.
In this study, repeat RGS was safe and provided clinically meaningful biochemical recurrence- and treatment-free intervals for selected cases. Patients having low preoperative PSA seemed to benefit most of repeat RGS, irrespective of prior SLND or RGS or the time from initial RP/first salvage surgery.
对于 PSA 水平较低、局部复发转移性前列腺癌患者，转移导向治疗是一种可行的选择。在初始挽救性手术后，如果出现复发、孤立且 PSMA 阳性的转移，对反应良好的患者可能会考虑再次进行挽救性手术。本分析旨在评估在初次根治性前列腺切除术后，无论是否接受盆腔放疗，在两个德国三级转诊中心对既往接受过挽救性淋巴结清扫术（SLND）（n=21）（SLND-RGS）或既往接受过放射性导向手术（RGS）（n=16）（RGS-RGS）的患者进行重复 PSMA 靶向放射性引导手术（RGS）的肿瘤学结局和安全性。
我们在 2014 年至 2021 年期间，在两家德国三级转诊中心，对 37 例在初次根治性前列腺切除术后接受过挽救性手术的患者进行了重复 RGS 治疗，其中 21 例患者既往接受过 SLND（SLND-RGS），16 例患者既往接受过 RGS（RGS-RGS）。采用 Kaplan-Meier 分析和单变量/多变量 Cox 回归模型，研究重复挽救性手术后生化无复发生存（BRFS）和治疗无复发生存（TFS）的相关因素。
32 例患者中有 20 例（5 例未达到）达到完全生化缓解（cBR，PSA<0.2ng/ml）。重复挽救性手术后的中位总体 BRFS[95%置信区间（CI）]为 10.8 个月（5.3-22）。多变量回归分析显示，仅年龄（HR 1.09，95%CI 1.01-1.17）和术前 PSA（HR 1.23，95%CI 1.01-1.50）与较短的 BRFS 相关，尽管 PSA（HR 1.16，95%CI 0.99-1.36）在单变量分析中未达到显著预测状态（p 值=0.07）。总体而言，在第二次挽救性手术后一年，89%（风险人数：19）的患者未接受额外治疗，且中位 TFS 尚未达到。观察到 8%（37 例患者中有 3 例）的 Clavien-Dindo 分级>3a 并发症。研究的局限性在于回顾性评估、挽救性淋巴结清扫术程序的异质性、缺乏长期随访数据以及队列规模较小。
在这项研究中，重复 RGS 是安全的，并为选定病例提供了具有临床意义的生化复发和治疗无复发生存期。术前 PSA 水平较低的患者似乎从重复 RGS 中获益最大，无论其既往是否接受过 SLND 或 RGS，还是初次 RP/初次挽救性手术的时间。
