AUA 2019: Estimation of the Risk of Missing Adverse Pathological Prostate Cancer Features after Salvage Radical Prostatectomy in Patients Eligible for Focal Salvage Therapies

Chicago, IL (Urotoday.com) Luca Boeri, MD, presented his talk on the estimation of the risk of missing adverse pathological prostate cancer features after salvage radical prostatectomy in patients eligible for focal salvage therapies at AUA 2019. Focal salvage therapies for locally recurrent prostate cancer (PCa) after primary radiotherapy (RT) can reduce the risk of adverse events associated with radical salvage prostatectomy (sRP) while maintaining cancer control, in selected patients. However, the risk of missing adverse PCa features undergoing FST instead of sRP has never been investigated. Dr. Boeri and colleagues aimed to assess the rates and predictors of adverse PCa features in patients eligible for FST who ultimately underwent sRP.

Dr. Boeri and colleagues reviewed 120 patients with locally recurrent PCa after RT who underwent sRP and extended pelvic lymph node dissection (2000-2016). Metastatic disease was excluded by choline PET and bone scan. Pre RT PSA, clinical stage (cT), biopsy Gleason score (GS) prior to RT and before sRP, prostate-specific antigen (PSA) nadir, PSA before surgery, and pathohistology of sRP specimens were analyzed. Eligibility criteria for FST were based on EAU Guidelines: cT1-cT2 PCa, initial GS ≤7 and pre-salvage PSA < 10 ng/mL. Adverse features after sRP were defined as GS≥ 8, pN+ and seminal vesicle invasion (SVI) at SRP. Descriptive statistics and logistic regression models were used to describe the whole cohort.

Overall, the median (interquartile range) age at sRP was 66.8 (62.1-71.7) years and the median pre sRP PSA was 4.2 (2.2-7.6) ng/mL. 63 (52.5%) patients had a GS≤7, and 54 (45%) men had cT1 disease before sRP. According to EAU Guidelines, 55 (45.8%) patients were eligible for FST. Among those, 22 (40%) patients had adverse PCa features after sRP. In particular, SVI, pN+ and GS≥8 at sRP were found in 12 (21.8%), 9 (16.4%) and 7 (12.7%) men, respectively. In patients with indications for FST, those with adverse PCa features at sRP had higher PSA nadir (0.9 vs. 0.4 ng/mL; p=0.019) and higher rates of GS 4+3 PCa pre sRP (54.5% vs. 18.2%, p=0.01) than those without adverse PCa features. At univariable logistic regression analysis, pre-surgical GS 4+3 (p=0.003) and higher PSA nadir (p=0.018) were associated with the risk of having adverse features at sRP while age, cT, PSA prior to sRP were not.

Dr. Boeri concluded that approximately 40% of patients are potentially eligible for FST showed adverse PCa characteristics when submitted to sRP. In particular, 22% and 16% of those will have SVI and pN+ disease. A confirmatory GS 4+3 biopsy for recurrence and higher PSA nadir were associated with the risk of having adverse PCa features at salvage surgery. These results suggest the need for improving the selection of candidates for FST.

Presented by: Luca Boeri, MD, Department of Urology, Mayo Clinic, Rochester, MN

Written by: Abhishek Srivastava, MD, Society of Urologic Oncology Fellow, Fox Chase Cancer Center, Philadelphia, PA @shekabhishek at American Urological Association's 2019 Annual Meeting (AUA 2019), May 3 – 6, 2019 in Chicago, Illinois