BACKGROUND

This investigation explored the clinical features, pathological outcomes, and biochemical recurrence (BCR) duration among high-risk prostate cancer (HRPC) patients who have undergone neoadjuvant therapy (NAT) in combination with radical prostatectomy (RP) and pelvic lymph node dissection (PLND). Additionally, we identified prognostic indicators that discern pathological complete response (pCR) or minimal residual disease (MRD) and BCR.

METHODS

In total, we examined 76 HRPC patients, who received NAT with either androgen deprivation therapy (ADT) plus apalutamide or ADT plus abiraterone, with subsequent RP and PLND. We conducted a genetic evaluation of patients receiving neoadjuvant apalutamide. Additionally, patient pathological outcomes, circulating prostate-specific antigen (PSA) response rates, and BCR duration were analyzed. Lastly, we employed uni- and multivariate analyses to screen for prognostic factors that govern pCR or MRD and BCR duration.

RESULTS

Patient median age and median PSA at presentation were 69 years (IQR: 66-73), and 47.6 ng/mL (IQR: 24.1-105.75), respectively. We observed marked changes in pCR or MRD rates between the two cohorts. In particular, the ADT plus apalutamide cohort (51.5%) exhibited enhanced rates relative to the ADT plus abiraterone cohort (25.6%) (p = 0.03). The median BCR duration was substantially prolonged among neoadjuvant apalutamide cohort relative to the neoadjuvant abiraterone cohort (261 days vs. 76 days, p = 0.04). Using multivariate analysis, we revealed that the postintervention pre-RP PSA content (≤ 0.1 ng/mL vs. > 0.1 ng/mL) remained a substantial stand-alone indicator of pCR or MRD (odds ratio: 10.712, 95% CI: 2.725-42.105, p < 0.001). Furthermore, supplemental analyses revealed that the ADT plus apalutamide cohort exhibited an augmented serum response rate, which, in turn, reduced the post-intervention pre-RP PSA content. Based on our genetic profiling of the neoadjuvant apalutamide cohort demonstrated high-frequency deleterious changes in the AR axis (30.3%), followed by TP53 mutations (15.15%). Patients with defective AR axis experienced a remarkably shorter median BCR duration relative to patients with other or no genetic alterations (52.5 days vs. 286 and 336 days, respectively, p < 0.0001). Furthermore, using multivariate analysis, we demonstrated that achieving pCR or MRD (hazard ratio [HR]: 0.170, 95% CI: 0.061-0.477, p < 0.001) and presence of defective AR signaling (HR: 11.193, 95% CI: 3.499-35.806, p < 0.001) were strong stand-alone indicators of BCR.

CONCLUSIONS

Herein, we demonstrated the superior performance of ADT plus apalutamide in achieving pCR or MRD and in extending BCR duration among HRPC patients. Post-intervention pre-RP PSA content as well as genetic shifts, especially in the AR axis, are critical indicators of patient pathological and clinical outcomes. These findings highlight the significance of genetic testing and PSA content monitoring in treating HRPC patients.