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Speaker: Dr. Yuvaraja Thyavihally, Kokilaben Dhirubhai Ambani Hospital, Mumbai, India
Important Takeaways
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Multimodal Therapy is Key: Management of node-positive prostate cancer requires a combination of surgery, radiation, and ADT for optimal outcomes.
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Radical Prostatectomy Even in Node-Positive Cases: Radical prostatectomy (RP) with extended pelvic lymph node dissection (ePLND) offers survival benefits, even in lymph-node-positive cases.
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Adjuvant Therapy Provides Better Outcomes: Radiation plus ADT post-surgery improves both biochemical recurrence-free survival and overall survival, compared to either modality alone.
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Clinical vs. Pathological N1 Distinction: Clinical N1 is diagnosed with imaging (MRI, PSMA PET-CT), while pathological N1 is detected through surgery and lymph node dissection.
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Management strategies differ slightly based on whether the N1 status is clinical or pathological.
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ADT Plus IMRT as Standard of Care: Long-term ADT with intensity-modulated radiotherapy (IMRT) remains a cornerstone in treating N1 prostate cancer, especially when combined with local treatments.
Key Highlights
TNM Staging and Detection Methods:
Node-positive prostate cancer is defined as the involvement of regional pelvic lymph nodes (N1) or distant non-regional nodes (M1A). Clinically, N1 is diagnosed using imaging techniques, such as MRI, CT, or PSMA PET-CT, which is highly sensitive. Pathologically, N1 is diagnosed post-surgery or via image-guided biopsy. Dr. Thyavihally highlighted that M1A is managed as metastatic prostate cancer, focusing on systemic therapies.
Management Options for Clinically Node-Positive Prostate Cancer:
Dr. Thyavihally discussed the management of clinically N1 prostate cancer, emphasizing the need for multimodal treatment. Options include radical prostatectomy (RP) with lymph node dissection, RT with or without ADT, and ADT alone. While systemic chemotherapy is rarely used, radiation therapy combined with ADT has shown better survival outcomes, improving overall survival by about 10% compared to radiation therapy alone.
Radical Prostatectomy for Node-Positive Disease:
In node-positive prostate cancer, radical prostatectomy with extended lymph node dissection offers a significant survival benefit. Studies show that patients undergoing surgery have 10-year survival rates of 70–80%, especially when combined with adjuvant ADT or radiation therapy. Dr. Thyavihally explained that the extent of lymph node dissection varies depending on the risk profile, with high-risk patients undergoing extended dissection to include lymph nodes near the iliac arteries.
Adjuvant Radiation Therapy and ADT:
Adjuvant RT with ADT has emerged as the standard treatment in node-positive prostate cancer, reducing local recurrence, improving biochemical control, and lowering the risk of metastasis. Early salvage radiation therapy is preferred when lymph nodes are negative, whereas adjuvant radiation is recommended for node-positive cases. Dr. Thyavihally highlighted that combining RT and ADT improves overall survival, with studies showing survival rates of up to 90% in treated patients.
Treatment Outcomes and Clinical Guidelines:
European guidelines strongly recommend multimodal therapy for node-positive prostate cancer. In cases with lymph node involvement, radical prostatectomy followed by adjuvant ADT and radiation therapy is recommended. Chemotherapy is rarely used, but it may be considered in cases with bulky nodal metastasis. Salvage radiation therapy combined with long-term ADT offers the best outcomes for patients with pathological N1 disease, with median overall survival improving by up to 80%.
Prognostic Factors and Salvage Therapy:
Dr. Thyavihally emphasized that the prognosis in node-positive prostate cancer is not solely determined by lymph node involvement but also by the characteristics of the primary tumor, such as the size of metastases and the volume of nodal disease. Larger metastases and extra-nodal extension are associated with poorer outcomes. Salvage radiation therapy combined with ADT is the preferred option for patients with pathological N1 disease, as it significantly improves survival and reduces biochemical recurrence.
Dr. Thyavihally concluded that the management of N1 prostate cancer, characterized by lymph node metastasis, requires a multimodal approach, combining both local and systemic therapies. Approximately 5-10% of newly diagnosed prostate cancer cases present with suspected pelvic metastasis on advanced imaging. The cornerstone of treatment involves long-term androgen deprivation therapy (ADT), supplemented by local therapies such as surgery (radical prostatectomy, RP) and radiation. Radical prostatectomy is generally preferred as the initial step since post-radiation surgery becomes technically challenging. RP, followed by adjuvant radiation and ADT, improves both overall survival and cancer-specific survival, demonstrating the importance of coordinated multimodal treatment for optimal outcomes.
Société Internationale d'Urologie Congress, 23-26 October 2024, New Delhi, India.
