Salvage extended PLND efficacious in some with prostate cancer

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Salvage extended pelvic lymph node dissection (ePLND) may be highly beneficial for selected prostate cancer patients with biochemical recurrence and clinically recurrent nodal disease, say German researchers.

Orlando, FL-Salvage extended pelvic lymph node dissection (ePLND) may be highly beneficial for selected prostate cancer patients with biochemical recurrence and clinically recurrent nodal disease, say German researchers.

ePLND may be able to achieve immediate complete PSA response and biochemical recurrence freedom in nearly 50% of patients, the researchers reported at the AUA annual meeting in Orlando, FL. Although 88.9% of patients received androgen deprivation therapy (ADT) postoperatively, the authors say adopting this approach may also help to postpone ADT and prolong biochemical-free survival without ADT. In addition, they found that patients with preoperatively hormone-resistant prostate cancers may again respond to ADT after ePLND.

The researchers, led by first author Daniar K. Osmonov, MD, of University Hospital Schleswig-Holstein in Kiel, Germany, conducted a retrospective single-center study that included 54 patients with recurrent prostate cancer. All of the patients underwent salvage ePLND between November 2003 and June 2012 based on biochemical recurrence and/or suspect findings on 11-choline positron emission tomography-computed tomography. The researchers were able to evaluate the postoperative course of the disease in 45 patients. They analyzed PSA levels, the duration of the biochemical recurrence-free period, and ADT use. They also looked at rates of bone metastases, risk factors of cancer-specific mortality, overall survival rates, and cancer-specific survival rates.

Thirty-six patients (80%) were hormone resistant and nine patients (20%) did not require ADT at all prior to salvage ePLND. However, after a mean 42.7 months following salvage ePLND, 40 patients (88.9%) received ADT. PSA levels dropped in 31 patients (68.9%) immediately after salvage ePLND. The mean duration of biochemical recurrence freedom after operation was 31.4 months.

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53% of patients respond to post-op ADT

The authors were pleased to see that 24 patients (53.3%), who had been castration resistant, were again ADT responders following salvage ePLND. The 5-year biochemical recurrence-free survival rate was estimated to be 30%. The cancer-specific survival rate and overall survival rate were 91.7% at 3 years of follow-up and 80.6% at 5 years of follow-up.

The development of bone metastases after ePLND appeared to be the only significant risk factor for cancer-specific mortality.

Co-author Alexey V. Aksenov, MD, said prostate cancer tends to recur in 20% to 40% of men after primary treatment. He noted that the diagnosis and management of lymph node disease are controversial, and today, the role of ePLND in patients with prostate cancer recurrence remains unclear. Currently, there is a lack of long-term follow-up and survival data. The combination of surgical treatment methods with consecutive ADT makes it difficult to evaluate the impact of salvage ePLND alone on cancer-specific survival.

“We have found that the 5-year survival after salvage ePLND is 80.6%, and we think this is a big opportunity in the treatment of recurrent prostate cancer,” said Dr. Aksenov. “It is an extended surgery and takes from 2 up to 4 hours depending on how far the dissection should go retroperitoneally. The procedure often requires a 1-week hospital stay. We see a few (10%-15%), mostly minor complications with these patients.

“We believe this treatment option is very promising, but multicenter prospective studies are needed to make a reliable output.”

Dr. Osmonov, who presented the findings, said 10 patients (22.2%) have developed bone metastases at mean follow-up of 34.2 months and seven patients (15.6%) have died at 48-month follow-up. Dr. Osmonov said six of them died from prostate cancer bone metastases.UT