Radical prostatectomy and postoperative irradiation in patients with
pathological stage C (T3) carcinoma of the prostate(Petrovich).

LONG-TERM RESULTS OF RADIATION THERAPY FOR PROSTATE
CANCER RECURRENCE FOLLOWING RADICAL PROSTATECTOMY (Cadeddu)

Delayed/Salvage radiation therapy in patients with elevated prostate specific antigen levels after radical prostatectomy. (Medini)

Radioimmunoscintigraphy With In-111-Labeled Capromab Pendetide Predicts Prostate Cancer Response to Salvage Radiotherapy After Failed Radical Prostatectomy(Kahn)


Radical prostatectomy and postoperative irradiation in patients with
pathological stage C (T3) carcinoma of the prostate.

Int J Radiat Oncol Biol Phys 1998;40(1):139-47

Petrovich Z; Lieskovsky G; Langholz B; Formenti S; Baert L; Streeter O;
Skinner DG
Department of Radiation Oncology, University of Southern California
School of Medicine in Los Angeles, 90033, USA.
PURPOSE: Adenocarcinoma of the prostate is the most common human
cancer of internal organs. Radical surgery is regarded by many to be
the treatment of choice for capsule confined disease. Since accurate
preoperative assessment of tumor stage is difficult to define, many
patients are subsequently found to have pathological stage C (T3)
disease. These patients should be considered for adjuvant radiothera-
py. METHODS AND MATERIALS: A group of 201 PS C (T3) unselected
patients, treated with radical prostatectomy and limited pelvic
lymphadenectomy, received postoperative irradiation to the prostate
bed. This radiotherapy was given between 42-90 days after surgery and
consisted of a median dose of 48 Gy. Patient survival, disease free
survival, time to clinical and chemical relapse and the incidence of
local and systemic relapse were analyzed. The influence of multiple
parameters on the treatment outcome including patient age, treatment
period, clinical stage, pathological stage, Gleason's score, prostate
specific antigen (PSA), radiotherapy techniques and radiation dose
were examined using univariate and multivariate analysis. Follow-up
ranged from 3 to 15 years, with a median of 5 years. RESULTS: The
overall 5- and 10-year actuarial survival was 92% and 83% (median >
10 years), respectively and the 5- and 10-year disease-free survival
(clinical and PSA) was 67% and 53% (median > 10 years), respectively.
A total of 61 (30%) patients had a recurrence, including 23 (11%)
patients who had clinical and 38 (19%) who had PSA recurrence. Of the
23 patients with clinical recurrence, 10 (5%) had local recurrence,
including two patients who had local and systemic recurrence.
Pathological stage and Gleason's score were independently predictive
of recurrence (each with p < 0.001 after controlling for the other).
Patients in the worst prognostic category with pathological stage C3
and Gleason's score 8-10 were predicted to be at 7.2 times the risk
of recurrence, compared to stage C1 or C2 and Gleason's score 2-7
patients. Preoperative PSA level (> 25 ng/ml) was also an important
independent factor predicting tumor recurrence, p = 0.05. All other
investigated parameters were not significant in predicting tumor
recurrence. This treatment program was very well tolerated by the
study patients, with seven (3.5%) recorded with major and 18 (9%)
with minor surgical complications, while 65% of patients had minor
and clinically insignificant radiation complications. CONCLUSION:
Surgery followed by moderate dose radiotherapy in patients with PS C
(T3) prostatic carcinoma was well tolerated and resulted in excellent
overall and disease free survival, with a low incidence of local
recurrence. New treatment strategies need to be developed for
patients with C3 tumors and those with high (8-10) Gleason's score
and those with high (> 25 ng/ml) PSA level at diagnosis.

LONG-TERM RESULTS OF RADIATION THERAPY FOR PROSTATE CANCER RECURRENCE FOLLOWING RADICAL PROSTATECTOMY

JEFFREY A. CADEDDU, ALAN W. PARTIN, THEODORE L. DEWEESE AND PATRICK C. WALSH

From the James Buchanan Brady Urological Institute, and Departments of Urology and Radiation Oncology, The
Johns Hopkins Medical Institutions, Baltimore, Maryland

Purpose: Following radical prostatectomy, radiation therapy may be beneficial in select patients with isolated local recurrence.
Pathological stage, Gleason score and the timing of prostate specific antigen (PSA) elevation are useful in distinguishing men
with local recurrence from those with distant metastases. We test the ability of these criteria to predict long-term suppression
of PSA recurrence following post-prostatectomy radiation therapy.

Materials and Methods: Of 1,699 men treated with radical prostatectomy from 1982 to 1995, 82 with an isolated PSA
elevation or local recurrence following surgery underwent radiation therapy to the prostatic bed and were followed for at least
2 years. No patient had evidence of metastases at the time of radiation.

Results: Of the men 17 (21%) had an undetectable PSA (less than 0.2 ng./ml.) for 2 or greater years following radiation. The
5-year actuarial PSA recurrence-free rate after radiation was 10%. PSA remained at undetectable levels for 2 or greater years
in no patients with Gleason score 8 or greater (12 cases), positive seminal vesicles (12) or positive lymph nodes (3), and in
only 1 of 16 men (6%) who had a PSA recurrence within 1 year of prostatectomy. As the interval to PSA recurrence
increased, the likelihood of responding to radiotherapy increased to 44% if initial disease detection occurred 5 or more years
after prostatectomy. There was no demonstrated advantage to radiating men with an isolated PSA elevation before a
documented local recurrence.

Conclusions: Patients with Gleason score 8 or greater, positive seminal vesicles or lymph nodes, or a PSA recurrence within
the first year following surgery rarely benefit from radiation therapy. As the interval to PSA recurrence increases, the likelihood
of responding to radiation therapy increases substantially. These parameters are useful in the selection of patients with prostate
cancer recurrences who are likely to benefit from radiation to the prostatic bed.

Delayed/Salvage radiation therapy in patients with elevated prostate specific antigen levels after radical
prostatectomy.

Medini E, Medini I, Reddy PK, Levitt SH.
Cancer 1996, 78: 1254-1259.

This uncontrolled study evaluated the results of radiotherapy for PSA relapse after radical prostatectomy for
prostate cancer in asymptomatic patients. Relapse was confirmed in 28 of 40 patients on prostatic biopsy. After
a minimum of 5 years follow-up, 8 had died of disease and 10 patients had a lasting remission without PSA
relapse following radiotherapy. This study purports to suggest that radiotherapy may be of benefit in patients post
radical prostatectomy with rising PSA.

Radioimmunoscintigraphy With In-111-Labeled Capromab Pendetide Predicts Prostate Cancer Response to Salvage Radiotherapy After Failed Radical Prostatectomy

By Daniel Kahn, Richard D. Williams, Michael K. Haseman, Nancy L. Reed, Sara J. Miller, and Jack Gerstbrein

J Clin Oncol 16:284-289.

Purpose: We investigated the ability of In-111-capromab pendetide to separate patients who have failed radical prostatectomy into categories of those who would versus those who would not respond to salvage radiotherapy.

Methods: Prostate-specific antigen (PSA) levels in 32 men with prostate cancer who had failed radical prostatectomy and had undergone a whole-body In-111-capromab pendetide scan were followed-up for 13 months (median) after salvage radiotherapy to the pelvis. A logistic regression model was used to determine whether the scan findings, as well as other clinical variables, were associated with a durable complete response (DCR), a nondurable response (NDR), or no response (NR).

Results: Sixteen of 23 (70%) men with a normal scan outside the prostatic fossa achieved a DCR after salvage radiotherapy versus two of nine (22%) who had a positive scan outside the prostate fossa and pelvis (P = .0225, Fisher's exact test). Predicted probability (95% confidence interval [CI]) that a DCR would be obtained with a normal scan was 0.88 (0.55 to 0.98); for men with a positive scan limited to the prostatic fossa it was 0.62 (0.42 to 0.79); and for men with a positive scan outside the pelvis it was 0.27 (0.09 to 0.58). No other variables before radiotherapy showed a significant association with the DCR rate.

Conclusion: Salvage radiotherapy is statistically more likely to lead to a durable complete PSA response in men with prostate cancer who have failed radical prostatectomy and have a negative In-111-capromab pendetide scan outside the pelvis as compared with those who have a positive scan.

J Clin Oncol 16:284-289.