San Diego, CA USA (UroToday.com) In this session, Dr. Briganti explained the case of a 65 year-old gentleman who chose surgical therapy for his prostate cancer (cT3a, Gleason 4+3, PSA 21.6). At 6 years, the man experienced his first biochemical recurrence (BCR) and underwent prostate-specific membrane antigen (PSMA) PET-CT confirming lymphatic recurrence.
Dr. Briganti lamented the challenge of when to start androgen deprivation therapy (ADT) in patents with asymptomatic, advanced disease. He asked the question whether it would be beneficial to detect recurrence in these patients using novel imaging modalities and what the endpoint of image-guided therapy for lymph node recurrent disease should be. Is it cure? Is it delay in time to clinical progression and death?
Dr. Briganti has been using a fair amount of PSMA PET-CT which has improved sensitivity relative to choline PET (94% versus 65%). Since detection is improved, the next logical question is whether or not these image detected nodal metastases should be resected? In a small, institutional cohort of 72 patients who underwent salvage lymphadenectomy (sLND) for image-detected lymph node metastasis demonstrated a 15% biochemical recurrence (BCR) free, 40% clinical recurrence free (CRF) at 5 years, and 75% cancer specific (CS) survivals at 5 years. These results have been confirmed by others and at 8 years the CRF-free and CS survivals are 40% and 79.4%, respectively.
So, how can we identify the optimal candidate? Initial studies suggested that pelvic lymph node involvement only, lower PSA at sLND, and number of positive lymph nodes may be the best candidates. However, other studies have conflicted with these findings. Therefore, optimal candidate identification is a work in progress due to small sample sizes, patients with variable PCa history, nonstandardized extent of sLND, and different multimodal approaches used in the initial treatment algorithm. He called for novel biomarkers and randomized, controlled trials to help guide surgical decision making for these patients.
Presented By: Alberto Briganti, MD