BETHESDA, MD USA (UroToday.com) - In today’s second prostate cancer session, Dr. Jeffrey Karnes discussed the role of surgery in patients with oligometastatic disease with biochemical failure. He began by identifying that 33% of patients have biochemical recurrence, which can be indicative of local or distant relapse. 11C-Choline PET is a useful tool in identifying location of disease, and has been incorporated in NCCN’s 2014 guidelines. Those with nodal-only metastases have a more favorable prognosis than those with bony or visceral metastases.
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Historically, these patients have been treated with hormone therapy. This, however, is not curative. The fundamental question remains, can we cure metastatic prostate cancer? Toujer and colleagues demonstrated good survival outcomes in men with oligometastatic disease without hormones, with those having Gleason < 8, negative margins, and fewer than 2 lymph nodes positive having the longest biochemical recurrence-free survival. Dr. Karnes listed the shortcomings of hormones, including the associated toxicities, quality of life changes, the autonomous nature of nodal metastases, and the possibility that nodal metastases may harbor castration resistant disease.
He continued by reporting his initial case of salvage lymph node dissection in 2007: this was a 60-year-old male, s/p high-dose brachytherapy, with recurrence in a single obturator lymph node. Salvage node dissection was performed, and the patient is alive today and has PSA less than 0.2, to date. This launched the Mayo Clinic series of salvage lymph node dissection which includes 52 cases, where all men had radical prostatectomy in the past. Four cases were pN1, 9 were pNx, and 78% received post-RP therapy. Of note, 50% of these patients had normal scans using conventional CT or MRI, while all had positive 11C-Choline PET scans. The median number of nodes removed in this series was 22 (range 7-62), whereas the median was only 5 in the original prostatectomy, thus highlighting the importance of extended nodal dissection at the time of prostatectomy. A median of 4 nodes were positive (range 1-31) at salvage node dissection. At a median follow-up of 20 months, 24 patients had no further therapy, 18 underwent hormone therapy, and 10 had multimodal therapy. Twenty-nine patients had PSA < 0.2, while 8 had biochemical recurrence after PSA originally became < 0.2. Median time to biochemical recurrence after salvage node dissection was 438 days.
Dr. Karnes acknowledged that limitations include a heterogeneous treatment group and short follow-up, selection bias, along with the lack of a comparable control group. However, he concluded that at this time, salvage node dissection remains a valid treatment option in well-selected patients, and that this novel treatment deserves further study. Optimal patients have not been defined, but likely include those with low PSA, pelvic-only lesions, Gleason score < 8, and longer interval to BCR.
R. Jeffrey Karnes, MD
Mayo Clinic, Rochester, MN USA
Nikhil Waingankar, MD* from the 2014 Winter Meeting of the Society of Urologic Oncology (SUO) "Defining Excellence in Urologic Oncology" - December 3 - 5, 2014 - Bethesda, MD USA
*Fox Chase Cancer Center, Philadelphia, PA USA