Neoadjuvant radiotherapy (RT) in prostate cancer remains investigational. This prospective pilot study evaluated the feasibility, perioperative safety, and preliminary outcomes of neoadjuvant RT combined with androgen-deprivation therapy (ADT), followed by robot-assisted radical prostatectomy (RP), in high-risk locally advanced disease.
Patients with high-risk locally advanced prostate cancer (clinical stage T3a-T3b, Gleason score ≥8, or prostate-specific antigen [PSA] ≥ 20 ng/mL) were prospectively enrolled. All patients received neoadjuvant RT (50 Gy in 25 fractions) with 3 months of ADT, then robot-assisted RP with pelvic lymph node dissection. A retrospective contemporaneous RP-alone cohort served as controls. Primary outcomes included perioperative safety, pathological response, and postoperative PSA levels. Secondary endpoints included oncological outcomes, functional outcomes, and MRI-derived imaging biomarkers.
In total, 10 patients received neoadjuvant RT, and 11 patients served as controls. The median PSA at diagnosis was 19.46 ng/mL in the neoadjuvant group and 15.52 ng/mL in controls. No major complications occurred. Pathological downstaging was observed in 60% of the neoadjuvant group, whereas none occurred in controls (4/11 showed upstaging). At 12 months, urinary continence was achieved in four patients. After a median follow-up of 16.4 months, five patients developed biochemical recurrence, and one progressed to bone metastasis. Post-treatment changes in apparent diffusion coefficient values and T2-weighted MRI signals were associated with improved pathological outcomes, suggesting potential predictive value.
Neoadjuvant RT with ADT followed by RP is feasible and well tolerated in high-risk locally advanced prostate cancer. Although pathological downstaging was observed, this pilot study does not support definitive conclusions regarding oncologic benefit, and larger prospective studies are warranted.
Annals of surgical oncology. 2026 Jul 09 [Epub ahead of print]
Chi-Shin Tseng, Chih-Kai Chang, Hsing-Ju Li, Yen-Ting Liu, Shi-Wei Huang, Chao-Yuan Huang, Jason Chia-Hsien Cheng
Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan., Department of Medical Imaging, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan., Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan., Department of Biomedical Engineering, National Taiwan University, Taipei, Taiwan., Department of Urology, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan., Department of Urology, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan. ., Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan. .