Introduction: Pathologic nodal invasion in patients post-prostatectomy is becoming increasingly pertinent, particularly in light of the recent trend towards operative intervention in patients harboring high risk disease. PSA persistence post-operatively poses a management dilemma, with a stark absence of recommendations by authoritative guidelines. We aimed to highlight the experience of this clinical scenario at a high volume institution and report long-term oncologic outcomes.
Methods: We identified patients who underwent radical prostatectomy between 1988 and 2017, had lymph node involvement, and had persistent elevated prostate-specific antigen. Post-operative imaging and management strategies were collated. Probability of metastasis-free survival (MFS), prostate cancer specific survival (CSS) and overall survival (OS) among this cohort of men using Kaplan-Meier methods.
Results: We identified 258 patients meeting the elgibility criteria, of which 128 patients developed metastasis. The 5-year and 10-year MFS probability was 52% (95% CI 45%, 58%) and 38% (95% CI 29%, 47%), respectively. We identified 58 patients who died of any cause, 48 from disease. The 5 and 10-year survival probabilities from disease are 89% (95% CI 84%, 93%), and 68% (95% CI 58%, 76%), respectively; and from any cause are 87% (95% CI 81%, 91%), and 63% (95% CI 53%, 71%), respectively. Post-operative imaging was obtained for 77% of patients, of whom 87% had a negative scan. Post-operative treatment included hormonal deprivation in 88% of men, observation alone in 7%, adjuvant radiotherapy in 4%, and combined chemotherapy and hormonal therapy in 1%.
Conclusions: In the absence of clear pre-existing data or guidelines, we highlight our experience of patients with nodal invasion and PSA persistence post-prostatectomy. We highlight compromised metastatases-free survival and overall survival. Further, we highlight the limited role for conventional imaging in this cohort.
Source of Funding: Sidney Kimmel Center for Prostate and Urologic Cancers at MSKCC and NIH/NCI grants P50CA092629. Marlon Perera is sponsored by the Australian-America Fulbright Commission administered through a 2021-2022 Fulbright Future Scholarship funded by The Kinghorn Foundation.