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Evaluation and Treatment for High-Risk Prostate Cancer

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Prostate Cancer

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Abstract

In this case discussion, we will consider an otherwise healthy 58-year-old man with high-risk prostate cancer, serum PSA of 32 ng/mL, and clinical evidence of regional lymph node metastasis. A digital rectal exam reveals a bulky prostate with bilateral nodularity, but does not appear to be fixed in the pelvis. A standard 12-core transrectal ultrasound (TRUS)-guided systematic biopsy is performed, demonstrating 10 of 12 cores involved by Gleason 4 + 4 = 8 prostate cancer. Seventy-five percent of biopsy tissue is involved by cancer. A multiparametric MRI is performed, and a Prostate Imaging Reporting and Data System (PIRADSv2) score of 5 is assigned, with mulitifocal prostate tumor and bilateral extracapsular extension. A staging contrast-enhanced pelvic CT scan demonstrates a single enlarged 1.2-cm lymph node in the left obturator fossa. A bone scan is performed and is unremarkable. The patient desires aggressive therapy and recounts that his father underwent a radical prostatectomy at the age of 67.

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References

  1. American Joint Committee on Cancer. In: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A, editors. AJCC cancer staging manual. 7th ed. New York: Springer; 2010.

    Chapter  Google Scholar 

  2. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Prostate Cancer (Version 2.2017). http://www.nccn.org/professionals/physician_gls/pdf/prostate.pdf. Accessed 31 July 2017.

  3. National Cancer Institute. SEER Stat Fact Sheets: Prostate Cancer. http://seer.cancer.gov/statfacts/html/prost.html. Accessed 31 July 2017.

  4. Memorial Sloan Kettering Cancer Center. Pre-Radical Prostatectomy Nomogram. https://www.mskcc.org/nomograms/prostate/pre-op. Accessed 31 July 2017.

  5. Cooperberg MR, Pasta DJ, Elkin EP, et al. The University of California, San Francisco Center of the Prostate Risk Assessment score: a straightforward and reliable preoperative predictor of disease recurrence after radical prostatectomy. J Urol. 2005;173:1938–42.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Muralidhar V, Mahal BA, Nguyen PL. Conditional cancer-specific mortality in T4, N1, or M1 prostate cancer: implications for long-term prognosis. Radiat Oncol. 2015;10:155.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Hovels AM, Heesakkers RA, Adang EM, et al. The diagnostic accuracy of CT and MRI in the staging of pelvic lymph nodes in patients with prostate cancer: a meta-analysis. Clin Radiol. 2008;63:387–95.

    Article  CAS  PubMed  Google Scholar 

  8. Fossati N, Willemse PM, Van den Broeck T, et al. The benefits and harms of different extents of lymph node dissection during radical prostatectomy for prostate cancer: a systematic review. Eur Urol. 2017;72:84–109.

    Article  PubMed  Google Scholar 

  9. Segall G, Delbeke D, Stabin MG, et al. SNM practice guideline for sodium 18F-fluoride PET/CT bone scans 1.0. J Nucl Med. 2010;51:1813–20.

    Article  PubMed  Google Scholar 

  10. Even-Sapir E, Metser U, Mishani E, et al. The detection of bone metastases inpatients with high-risk prostate cancer: 99mTc-MDP Planar bone scintigraphy, single- and multi-field-of-view SPECT,18F-fluoride PET, and 18F-fluoride PET/CT. J Nucl Med. 2006;47:287–97.

    PubMed  Google Scholar 

  11. Simpath SC, Sampath SC, Mosci C, et al. Detection of osseous metastasis by 18F-NaF/18F-FDG PET/CT versus CT alone. Clin Nucl Med. 2015;40:e173–7.

    Article  Google Scholar 

  12. Araz M, Aras G, Küçük OZ. The role of 18F–NaF PET/CT in metastatic bone disease. J Bone Oncol. 2015;4:92–7.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Woo S, Suh CH, Kim SY, et al. Diagnostic performance of magnetic resonance imaging for the detection of bone metastasis in prostate cancer: a systematic review and meta-analysis. Eur Urol. 2018;73(1):81–91. https://doi.org/10.1016/j.eururo.2017.03.042.

    Article  PubMed  Google Scholar 

  14. Maurer T, Gschwend JE, Rauscher I, et al. Diagnostic efficacy of 68gallium-PSMA-PET compared to conventional imaging in lymph node stating of 130 consecutive patients with intermediate to high-risk prostate cancer. J Urol. 2016;195:1436–43.

    Article  PubMed  Google Scholar 

  15. Rud E, Baco E, Klotz D, et al. Does preoperative magnetic resonance imaging reduce the rate of positive surgical margins at radical prostatectomy in a randomized clinical trial? Eur Urol. 2015;68:487–96.

    Article  PubMed  Google Scholar 

  16. Somford DM, Hamoen EH, Futterer JJ, et al. The predictive value of endorectal 3 Tesla multiparametric magnetic resonance imaging for extraprostatic extension in patients with low, intermediate and high risk prostate cancer. J Urol. 2013;190:1728–34.

    Article  CAS  PubMed  Google Scholar 

  17. Park BH, Jeon HG, Jeong BC, et al. Influence of magnetic resonance imaging in the decision to preserve or resect neurovascular bundles at robotic assisted laparoscopic radical prostatectomy. J Urol. 2014;192:82–8.

    Article  PubMed  Google Scholar 

  18. Salerno J, Finelli A, Morash C, et al. Multiparametric magnetic resonance imaging for pre-treatment local staging of prostate cancer: a Cancer Care Ontario clinical practice guideline. Can Urol Assoc J. 2016;10:332–9.

    Article  Google Scholar 

  19. Pritchard CC, Mateo J, Walsh MF, et al. Inherited DNA-repair gene mutations in men with metastatic prostate cancer. N Engl J Med. 2016;375:443–53.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Robinson D, Van Allen EM, Wu YM, et al. Integrative clinical genomics of advanced prostate cancer. Cell. 2015;161:1215–28.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Mateo J, Carreira S, Sandhu S, et al. DNA-repair defects and olaparib in metastatic prostate cancer. N Engl J Med. 2015;373:1697–708.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Abdollah F, Seisen T, Vetterlein M, et al. Efficacy of local treatment in patients with prostate cancer with clinically pelvic lymph node-positive disease at initial diagnosis. J Clin Oncol. 2017;35(Suppl 6S):Abstract 164.

    Article  Google Scholar 

  23. Schroder FH, Kurth KH, Fossa SD, et al. Early versus delayed endocrine treatment of T2-T3 pN1-3 M0 prostate cancer without local treatment of the primary tumor: final results of the European Organisation for the Research and Treatment of Cancer protocol 30846 after 13 years of follow-up (a randomised control trial). Eur Urol. 2009;55:14–22.

    Article  PubMed  Google Scholar 

  24. Engel J, Bastian PJ, Baur H, et al. Survival benefits of radical prostatectomy in lymph node-positive patients with prostate cancer. Eur Urol. 2010;57:754–61.

    Article  PubMed  Google Scholar 

  25. Grimm MO, Kamphausen S, Hugenschmidt H, et al. Clinical outcome of patients with lymph node positive prostate cancer after radical prostatectomy versus androgen deprivation. Eur Urol. 2002;41:628–34.

    Article  PubMed  Google Scholar 

  26. James ND, de Bono JS, Spears MR, et al. Abiraterone for prostate cancer not previously treated with hormone therapy. N Engl J Med. 2017;377:338–51.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Stattin P, Sandin F, Thomsen FB, et al. Association of radical local treatment with mortality in men with very high-risk prostate cancer: a semiecologic, nationwide, population-based study. Eur Urol. 2017;72:125–34.

    Article  PubMed  Google Scholar 

  28. Wawroschek F, Wagner T, Hamm M. The influence of serial sections, immunohistochemistry, and extension of pelvic lymph node dissection on the lymph node status in clinically localized prostate cancer. Eur Urol. 2003;43:132–6.

    Article  PubMed  Google Scholar 

  29. Ji J, Yuan H, Wang L, et al. Is the impact of the extent of lymphadenectomy in radical prostatectomy related to the disease risk? A single center prospective study. J Surg Res. 2012;178:779–84.

    Article  PubMed  Google Scholar 

  30. Touijer KA, Mazzola CR, Sjoberg DD, et al. Long-term outcomes of patients with lymph node metastasis treated with radical prostatectomy without adjuvant androgen-deprivation therapy. Eur Urol. 2014;65:20–5.

    Article  PubMed  Google Scholar 

  31. Steuber T, Budaus L, Walz J, et al. Radical prostatectomy improves progression-free and cancer-specific survival in men with lymph node positive prostate cancer in the prostate-specific antigen era: a confirmatory study. BJU Int. 2011;107:1755–61.

    Article  PubMed  Google Scholar 

  32. Frohmuller HG, Theiss M, Manseck A, et al. Survival and quality of life of patients with stage D1 (T1-3 pN1-2 M0) prostate cancer: radical prostatectomy plus androgen deprivation versus androgen deprivation alone. Eur Urol. 1995;27:202–6.

    Article  CAS  PubMed  Google Scholar 

  33. Zurita AJ, Pisters LL, Wang X, et al. Integrating chemohormonal therapy and surgery in known or suspected lymph node metastatic prostate cancer. Prostate Cancer Prostatic Dis. 2015;18:276–80.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. Messing EM, Manola J, Yao J, et al. Immediate versus deferred androgen deprivation treatment in patients with node-positive prostate cancer after radical prostatectomy and pelvic lymphadenectomy. Lancet Oncol. 2006;7:472–9.

    Article  CAS  PubMed  Google Scholar 

  35. Cadeddu JA, Partin AW, Epstein JI, et al. Stage D1 (T1-3, N1-3, M0) prostate cancer: a case-controlled comparison of conservative treatment versus radical prostatectomy. Urology. 1997;50:251–5.

    Article  CAS  PubMed  Google Scholar 

  36. Abdollah FR, Karnes J, Suardi N, et al. Impact of adjuvant radiotherapy on survival of patients with node-positive prostate cancer. J Clin Oncol. 2014;32:3939–48.

    Article  PubMed  Google Scholar 

  37. Touijer KA, Karnes JR, Passoni N, et al. Survival outcomes of men with lymph node-positive prostate cancer after radical prostatectomy: a comparative analysis of different postoperative management strategies. Eur Urol. 2017. Epub ahead of print.

    Google Scholar 

  38. Kaplan JR, Kowalczyk KJ, Borza T, et al. Patterns of care and outcomes of radiotherapy for lymph node positivity after radical prostatectomy. BJU Int. 2013;111:1208–14.

    Article  PubMed  Google Scholar 

  39. Zareba P, Eastham JA, Scardino PT, Touijer K. Contemporary patterns of care and outcomes of men found to have lymph node metastases at the time of radical prostatectomy. J Urol. 2017;198:1077–84.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Eade TN, Hanlon AL, Horwitz EM, et al. What dose of external-beam radiation is high enough for prostate cancer? Int J Radiat Oncol Biol Phys. 2007;68:682–9.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Catton CN, Lukka H, Gu CS, et al. Randomized trial of a hypofractionated radiation regimen for the treatment of localized prostate cancer. J Clin Oncol. 2017;35:1884–90.

    Article  PubMed  Google Scholar 

  42. Lee WR, Dignam JJ, Amin MB, et al. Randomized phase III noninferiority study comparing two radiotherapy fractionation schedules in patients with low-risk prostate cancer. J Clin Oncol. 2016;34:2325–32.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Dearnaley D, et al. Five year outcomes of a phase III randomised trial of conventional or hypofractionated high dose intensity modulated radiotherapy for prostate cancer (CRUK/06/016): report from the CHHiP trial investigators group. Abstract 8LBA, European Cancer Congress 2015. Eur J Cancer. 2015;51(suppl 3):S712.

    Article  Google Scholar 

  44. Incrocci L, Wortel RC, Aluwini SA, et al. Hypofractionated vs. conventionally fractionated radiation therapy for prostate cancer: 5-year oncologic outcomes of the Dutch randomized phase 3 HYPRO trial. Abstract LBA2, ASTRO 2015. Int J Radiat Oncol Biol Phys. 2015;93(3 suppl).

    Google Scholar 

  45. King CR, Freeman D, Kaplan I, et al. Stereotactic body radiotherapy for localized prostate cancer: pooled analysis from a multi-institutional consortium of prospective phase II trials. Radiother Oncol. 2013;109:217–21.

    Article  PubMed  Google Scholar 

  46. Pommier P, Chabaud S, Lagrange JL, et al. Is there a role for pelvic irradiation in localized prostate adenocarcinoma? Preliminary results of GETUG-01. J Clin Oncol. 2007;25:5366–73.

    Article  PubMed  Google Scholar 

  47. Lawton CA, DeSilvio M, Roach M, et al. An update of the phase III trial comparing whole pelvic to prostate only radiotherapy and neoadjuvant to adjuvant total androgen suppression: updated analysis of RTOG 94-13, with emphasis on unexpected hormone/radiation interactions. Int J Radiat Oncol Biol Phys. 2007;69:646–55.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Warde P, Mason M, Ding K, et al. Combined androgen deprivation therapy and radiation therapy for locally advanced prostate cancer: a randomised, phase 3 trial. Lancet. 2011;273:2104–11.

    Article  Google Scholar 

  49. Zagars GK, Pollack A, von Eschenbach AC. Addition of radiation therapy to androgen ablation improves outcome for subclinically node-positive prostate cancer. Urology. 2011;58:233–9.

    Article  Google Scholar 

  50. Tward JD, Kokeny KE, Shrieve DC, et al. Radiation therapy for clinically node-positive prostate adenocarcinoma is correlated with improved overall and prostate cancer-specific survival. Pract Radiat Oncol. 2013;3:234–40.

    Article  PubMed  Google Scholar 

  51. James ND, Spears MR, Clarke NW, et al. Impact of node status and radiotherapy on failure-free survival in patients with newly-diagnosed non-metastatic prostate cancer: data from >690 patients in the control arm of the STAMPEDE trial. Oral abstract 18. Int J Radiat Oncol Biol Phys. 2014;90(1 suppl):S13.

    Article  Google Scholar 

  52. Widmark A, Klepp O, Solber A, et al. Endocrine treatment, with or without radiotherapy, in locally advanced prostate cancer (SPCG-7/SFUO-3): an open randomised phase III trial. Lancet. 2009;373:301–8.

    Article  CAS  PubMed  Google Scholar 

  53. Lawton CA, Winter K, Grignon D, et al. Androgen suppression plus radiation versus radiation alone for patients with stage D1/pathologic node-positive adenocarcinoma of the prostate: updated results based on national prospective randomized trial Radiation Therapy Oncology Group 85-31. J Clin Oncol. 2005;23:800–7.

    Article  PubMed  Google Scholar 

  54. Sweeney CJ, Chen YH, Carducci M, et al. Chemohormonal therapy in metastatic hormone-sensitive prostate cancer. N Engl J Med. 2015;373:737–46.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  55. James ND, Sydes MR, Clarke NW, et al. Addition of docetaxel, zoledronic acid, or both to first-line long-term hormone therapy in prostate cancer (STAMPEDE): survival results from an adaptive, multiarm, multistage, platform randomised controlled trial. Lancet. 2016;387:1163–77.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  56. Gravis G, Boher JM, Joly F, et al. Androgen deprivation therapy (ADT) plus docetaxel versus ADT alone in metastatic non castrate prostate cancer: impact of metastatic burden and long-term survival analysis of the randomized phase 3 GETUG-AFU15 trial. Eur Urol. 2016;70:256–62.

    Article  CAS  PubMed  Google Scholar 

  57. Fizazi K, Faivre L, Lesaunier F, et al. Androgen deprivation therapy plus docetaxel and estramustine versus androgen deprivation therapy alone for high-risk localized prostate cancer (GETUG 12): a phase 3 randomised controlled trial. Lancet Oncol. 2015;16:787–94.

    Article  CAS  PubMed  Google Scholar 

  58. Aus G, Hugosson J, Norlen L. Need for hospital care and palliative treatment for prostate cancer treated with noncurative intent. J Urol. 1995;154:466–9.

    Article  CAS  PubMed  Google Scholar 

  59. Wiegand LR, Hernandez M, Pisters LL, et al. Surgical management of lymph-node-positive prostate cancer: improves symptomatic control. BJU Int. 2010;107:1238–42.

    Article  PubMed  Google Scholar 

  60. Schultheiss TE, Lee WR, Hunt MA, et al. Late GI and GU complications in the treatment of prostate cancer. Int J Radiat Oncol Biol Phys. 1997;37:3–11.

    Article  CAS  PubMed  Google Scholar 

  61. Harsolia A, Vargas C, Yan D, et al. Predictors for chronic urinary toxicity after the treatment of prostate cancer with adaptive three-dimensional conformal radiotherapy: dose-volume analysis of a phase II dose-escalation study. Int J Radiat Oncol Biol Phys. 2007;69:1100–9.

    Article  PubMed  Google Scholar 

  62. Zelefsky M, Eastham J, Cronin A, et al. Metastasis after radical prostatectomy or external beam radiotherapy for patients with clinically localized prostate cancer: a comparison of clinical cohorts adjusted for case mix. J Clin Oncol. 2010;28:1508–13.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Cooperberg M, Vickers A, Broering J, et al. Comparative risk-adjusted mortality outcomes after primary surgery, radiotherapy, or androgen-deprivation therapy for localized prostate cancer. Cancer. 2010;116:5226–34.

    Article  PubMed  Google Scholar 

  64. Briganti A, Karnes RJ, Da Pozzo LF, et al. Combination of adjuvant hormonal and radiation therapy significantly prolongs survival of patients with pT2-4 pN+ prostate cancer: results of a matched analysis. Eur Urol. 2011;59:832–40.

    Article  CAS  PubMed  Google Scholar 

  65. Lin CC, Gray PJ, Jemal A, et al. Androgen deprivation with or without radiation therapy for clinically node-positive prostate cancer. J Natl Cancer Inst. 2015;107:djv119.

    Article  PubMed  Google Scholar 

  66. Rusthoven CG, Carlson JA, Waxweiler TV, et al. The impact of definitive local therapy for lymph node-positive prostate cancer: a population-based study. Int J Radiat Oncol Biol Phys. 2014;88:1064–73.

    Article  PubMed  Google Scholar 

  67. Granfors T, Modiq H, Damber JE, et al. Long-term followup of a randomized study of locally advanced prostate cancer treated with combined orchiectomy and external radiotherapy versus radiotherapy alone. J Urol. 2006;176:544–7.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, Sidney Kimmel Center for Prostate and Urologic Cancers, New York, NY, USA

    Lucas W. Dean M.D. & Karim A. Touijer M.D.

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  1. Lucas W. Dean M.D.
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  2. Karim A. Touijer M.D.
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Correspondence to Karim A. Touijer M.D. .

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Editors and Affiliations

  1. Department of Urologic Surgery and Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA

    Sam S. Chang

  2. Department of Urology, University of Oklahoma Medical Center, Oklahoma City, Oklahoma, USA

    Michael S. Cookson

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Dean, L.W., Touijer, K.A. (2018). Evaluation and Treatment for High-Risk Prostate Cancer. In: Chang, S., Cookson, M. (eds) Prostate Cancer. Springer, Cham. https://doi.org/10.1007/978-3-319-78646-9_10

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