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Pathologic seminal vesicle invasion after radical prostatectomy for patients with prostate carcinoma

1998; Wiley; Volume: 82; Issue: 10 Linguagem: Inglês

10.1002/(sici)1097-0142(19980515)82

1097-0142

Richard K. Valicenti, Leonard G. Gomella, Mohammed Ismail, S. Grant Mullholland, Robert O. Petersen, Benjamin W. Corn,

Prostate Cancer Treatment and Research

CancerVolume 82, Issue 10 p. 1909-1914 Original ArticleFree Access Pathologic seminal vesicle invasion after radical prostatectomy for patients with prostate carcinoma† Effect of early adjuvant radiation therapy on biochemical control Richard K. Valicenti M.D., M.A., Corresponding Author Richard K. Valicenti M.D., M.A. Department of Radiation Oncology, Jefferson Medical College and Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PennsylvaniaDepartment of Radiation Oncology, Thomas Jefferson University Hospital, Bodine Center for Cancer Treatment, 111 S. 11th Street, Philadelphia, PA 19107===Search for more papers by this authorLeonard G. Gomella M.D., Leonard G. Gomella M.D. Department of Urology, Jefferson Medical College and Kimmel Cancer Center, Philadelphia, PennsylvaniaSearch for more papers by this authorMohammed Ismail M.D., Mohammed Ismail M.D. Department of Urology, Jefferson Medical College and Kimmel Cancer Center, Philadelphia, PennsylvaniaSearch for more papers by this authorS. Grant Mullholland M.D., S. Grant Mullholland M.D. Department of Urology, Jefferson Medical College and Kimmel Cancer Center, Philadelphia, PennsylvaniaSearch for more papers by this authorRobert O. Petersen M.D., Ph.D., Robert O. Petersen M.D., Ph.D. Department of Pathology, Jefferson Medical College and Kimmel Cancer Center, Philadelphia, PennsylvaniaSearch for more papers by this authorBenjamin W. Corn M.D., Benjamin W. Corn M.D. Department of Radiation Oncology, Jefferson Medical College and Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PennsylvaniaSearch for more papers by this author Richard K. Valicenti M.D., M.A., Corresponding Author Richard K. Valicenti M.D., M.A. Department of Radiation Oncology, Jefferson Medical College and Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PennsylvaniaDepartment of Radiation Oncology, Thomas Jefferson University Hospital, Bodine Center for Cancer Treatment, 111 S. 11th Street, Philadelphia, PA 19107===Search for more papers by this authorLeonard G. Gomella M.D., Leonard G. Gomella M.D. Department of Urology, Jefferson Medical College and Kimmel Cancer Center, Philadelphia, PennsylvaniaSearch for more papers by this authorMohammed Ismail M.D., Mohammed Ismail M.D. Department of Urology, Jefferson Medical College and Kimmel Cancer Center, Philadelphia, PennsylvaniaSearch for more papers by this authorS. Grant Mullholland M.D., S. Grant Mullholland M.D. Department of Urology, Jefferson Medical College and Kimmel Cancer Center, Philadelphia, PennsylvaniaSearch for more papers by this authorRobert O. Petersen M.D., Ph.D., Robert O. Petersen M.D., Ph.D. Department of Pathology, Jefferson Medical College and Kimmel Cancer Center, Philadelphia, PennsylvaniaSearch for more papers by this authorBenjamin W. Corn M.D., Benjamin W. Corn M.D. Department of Radiation Oncology, Jefferson Medical College and Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PennsylvaniaSearch for more papers by this author First published: 31 October 2000 https://doi.org/10.1002/(SICI)1097-0142(19980515)82:10 3.0.CO;2-XCitations: 36 † Presented at a meeting of the American Radium Society, New York, New York, May 1997. AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Abstract BACKGROUND The authors evaluated the effect of postoperative radiation therapy on freedom from biochemical failure (bNED) in men with prostate carcinoma who had pathologic seminal vesicle invasion after radical prostatectomy and negative pelvic lymph node dissection (pT3cN0). METHODS Between 1989 and 1995, 375 men underwent radical prostatectomy at Thomas Jefferson University Hospital. Fifty-three men (13%) had pT3cN0 prostate carcinoma and were the subject of this analysis. Men in whom prostate specific antigen (PSA) could not be detected were deemed free of biochemical failure. RESULTS Of the 53 men with pT3cN0 prostate carcinoma, 18 had an elevated PSA immediately after surgery and received salvage radiation therapy (RT). The 3-year bNED rate for this group was only 38%. At 3 months, PSA could not be detected in the other 35 men. Fifteen of those 35 men underwent early adjuvant RT, and the other 20 were observed for biochemical failure. The 3-year bNED rate for the 15 patients treated with immediate adjuvant RT was 86%, compared with 48% for the 20 men who were observed (P = 0.01). CONCLUSIONS These data suggest that early adjuvant RT for men with pT3cN0 prostate carcinoma and no detectable PSA postoperatively reduces the likelihood of future biochemical failure. Men with pT3cN0 prostate carcinoma and a persistently elevated postoperative PSA level are less likely to benefit from RT and should be considered for systemic therapy. Cancer 1998;82:1909-14. © 1998 American Cancer Society. It is generally accepted that men with pathologic seminal vesicle invasion (SVI) by prostate carcinoma have a poor prognosis. SVI is often associated with large tumor volume, capsular penetration, poorly differentiated tumors, and lymph node metastases,1-5 factors predisposing patients to both local and distant recurrences. In addition, men with SVI are likely to have prostate specific antigen (PSA) failure months or years after a radical prostatectomy.6-9 Despite this ominous outlook, the potential role of adjuvant radiation therapy (RT) has yet to be defined. The emergence of PSA monitoring for patients with pathologic stage T3c adenocarcinoma of the prostate has provided a new means of evaluating the effect of adjuvant RT. Serial PSA levels are of great value in monitoring men after definitive treatment for prostate carcinoma.10 Many studies have demonstrated that PSA monitoring is a sensitive marker for recurrent cancer and predictive of treatment outcome.11-14 It has been shown that an elevated PSA level after a radical prostatectomy can precede clinical recurrence by months or years.11 In the current study, we evaluated the biochemical outcomes of men with pathologic SVI by prostate carcinoma and identified a group of men who may benefit from postoperative RT. MATERIALS AND METHODS Between 1988 and 1995, 375 men with adenocarcinoma of the prostate underwent radical prostatectomy at Thomas Jefferson University Hospital. This period represents the time during which the serum PSA assay was in routine use at our institution. Each man underwent pelvic lymph node dissection prior to radical prostatectomy. Fifty-six men were found to have pathologic SVI. Two men were excluded because of pelvic lymph node metastases, and one man was lost to follow-up. Thus, 53 men were found to have pathologic SVI in the absence of lymph node metastases (pT3cN0). The 1992 American Joint Commission on Cancer staging system was used.15 These men were the subject of this analysis. Preoperatively, men were evaluated with digital rectal exam, serum PSA value, serum prostatic acid phosphatase, chest X-ray, abdominopelvic computed tomography or magnetic resonance imaging, and radionuclide bone scan. Serum PSA level was determined by the Hybritech radioimmunoassay. The lower limit of detectability for this assay at our laboratory was 0.2 ng/mL. Surgical Specimens Radical prostatectomy specimens were received fresh in Surgical Pathology. After amputation of the seminal vesicles, the prostate was weighed and the anterior-posterior, transverse, and cephalocaudad dimensions recorded. After 48 hours of formalin fixation, the outside surface was inked and the entire prostate serially sectioned in a transverse plane at 3-mm intervals, beginning at the apex and continuing to the base. The first (apex) and the last (base) sections were further sectioned at 90° to the surgical margins. Each of the whole mount serial sections was submitted for microscopic review. Tumor grade (Gleason system), possible capsular penetration, SVI, and surgical margin status were recorded. The seminal vesicles were sectioned and submitted in their entirety for microscopic examination. SVI was defined as the presence of tumor cells in the muscular coat of the seminal vesicles. Radiation Therapy Thirty-three men received postoperative RT within 6 months after radical prostatectomy. Of these men, 18 had rising PSA values when irradiated. The majority of men were treated with 25 MV photons and received an initial dose of 45-50 gray (Gy) to the whole pelvis with a four-field box technique. A reduced field was used to boost the dose to the prostatic fossa and periprostatic tissues for an additional 10-15 Gy. The median radiation dose was 64.8 Gy. Treatments were divided into 1.8- or 2.0-Gy fractions. Hormonal Therapy Hormonal therapy included neoadjuvant hormonal therapy for six patients with locally advanced disease for the purpose of preoperative tumor downsizing. Ten patients received hormonal therapy for an increasing PSA level after failed salvage radiation therapy, and six received it as primary salvage treatment for an increasing PSA level that was initially undetectable postoperatively. No patient received hormonal therapy prior to RT after relapse. Follow-Up Postoperatively, patients were followed at 3- to 6-month intervals with history and physical examinations. Serum PSA level was obtained 4-6 weeks after radical prostatectomy and then at all subsequent follow-up visits thereafter. For a rising serum PSA level, workup for recurrent disease included digital rectal exam, blood chemistries, chest X-ray, computed tomography of the abdomen and pelvis, and a radionuclide bone scan. If the findings on digital rectal examination were suspicious for a prostatic bed recurrence, biopsy was performed. For the entire group of 53 men with pT3cN0 prostate carcinoma, the median follow-up from the date of surgery was 38 months, with a range of 5-89 months. The median follow-up from the completion of RT for the men irradiated for a persistently elevated serum PSA level was 41 months, with a range of 10-86 months. Statistical Analysis Biochemical failure was defined as a detectable PSA level (0.2 ng/mL or higher). Actuarial rates of freedom of biochemical failure (bNED) were estimated by the Kaplan-Meier method.16 Comparison of subgroups was carried out with the log rank test.17 Multivariate analysis was performed according to the method of Cox.18 RESULTS Patient Characteristics The characteristics of the patients are listed in Table 1. The clinical stages of the study population were T1c, T2, and T3 for 50%, 47%, and 3%, respectively. As previously stated, 53 men had pathologic involvement of the seminal vesicles. All of these men had lymph nodes that were free of metastatic adenocarcinoma on staging pelvic lymph node dissection. All but one man had capsular penetration. Determination of Gleason scores revealed that there were no men with scores of 2-4, 35 (66%) with scores of 5-7, and 18 (34%) with scores of 8-10. Surgical margins were free of tumor in 26 (49%) of the specimens and positive in 27 (51%). During the 3 months after radical prostatectomy, 35 men (66%) did not have detectable serum PSA levels, whereas 18 (34%) did have detectable levels. Pretreatment characteristics according to treatment subgroup are also listed. The pretreatment prognostic factors appeared well balanced between the adjuvant RT and observation groups, but the salvage RT group tended to have higher preoperative PSA levels and higher Gleason scores. Table 1. Characteristics of 53 Patients with pT3cN0 Prostate Carcinoma According to Treatment Group No. of patients (%) Characteristics Observation Early RT Salvage RT Total Gleason score 5-6 5 (25) 0 (0) 4 (22) 9 (17) 7 11 (55) 12 (80) 3 (17) 26 (49) 8-10 4 (20) 3 (20) 11 (61) 18 (34) Preoperative PSA <15 ng/mL 14 (70) 9 (60) 6 (33) 29 (54) ≥15 ng/mL 6 (30) 6 (40) 12 (67) 24 (46) Capsular penetration Present 19 (95) 15 (100) 18 (100) 51 (98) Absent 1 (5) 0 (0) 0 (0) 1 (2) Surgical margins Positive 5 (25) 12 (80) 10 (56) 27 (51) Negative 15 (75) 3 (20) 8 (44) 26 (49) PSA <3 mos after RP Detectable 0 (0) 0 (0) 18 (100) 18 (34)a Undetectable 20 (100) 15 (100) 0 (0) 35 (66) Hormonal therapy Yes 1 (5) 1 (7) 4 (22) 6 (11) No 19 (95) 13 (93) 14 (78) 47 (89) Total 20 (38) 15 (28) 18 (36) 53 (100) RT: radiation therapy; PSA: prostate specific antigen; RP: radical prostatectomy. a Median, 1.5 ng/mL; range, 0.4-36 ng/mL. Freedom from Biochemical Failure The 3-year bNED rate for all 53 men with SVI was 36%. Preoperative serum PSA strongly predicted biochemical outcome. Those men with a serum PSA level greater than or equal to 15 ng/mL fared less well than those with a level less than 15 ng/mL (22% vs. 48%, P = 0.007) (Fig. 1a (7K)). Men with Gleason scores of 8-10 tended to fare less well than men with Gleason scores of 5-7 (20% vs 43%, P = 0.09) (Fig. 1b (7K)). Age, clinical stage, and surgical margin status were not significant predictors of outcome. Figure 1Open in figure viewerPowerPoint (a) Actuarial freedom of biochemical failure (bNED) versus preoperative prostate specific antigen (PSA) level is shown. (b) Actuarial freedom of biochemical failure (bNED) versus Gleason score is shown. Adjuvant Radiation Therapy Thirty-five men had pT3cN0 prostate carcinoma and no detectable postoperative PSA at 3 months. Fifteen of the 35 men had early adjuvant RT and the other 20 were observed for biochemical failure. Of the 15 men irradiated, 2 had a biochemical relapse, compared with 14 of 20 treated with a radical prostatectomy alone. The actuarial bNED rates at 1, 2, and 3 years were 100%, 100%, and 86% for the men irradiated, compared with 80%, 48%, and 48%, respectively, for the men not irradiated (P = 0.01) (Fig. 2 (3K)). Figure 2Open in figure viewerPowerPoint Actuarial freedom of biochemical failure (bNED) is shown for men who did or did not receive early adjuvant radiation therapy (RT). Clinical Recurrence and Salvage Therapy PSA was determined in all men at each follow-up visit, and detectable increase prompted evaluation in all cases. Among the 15 men who were irradiated adjuvantly for pathologic SVI but did not have a detectable serum PSA level, 2 men had a biochemical failure at 24 and 72 months, respectively, after completing RT. To date they have had no other indication of failure. Of the 20 men who did not have detectable serum PSA levels postoperatively and were not irradiated adjuvantly, 14 subsequently developed a biochemical failure. Of these men, 4 have had clinical recurrences. Two men had local recurrences 25 and 28 months, respectively, after their PSA levels became elevated, and 2 developed distant metastases at 6 and 18 months, respectively. Only three men received salvage RT, one for a clinical local failure and two because of isolated biochemical relapse. Two of these three men have had their serum PSA levels return to an undetectable value at last follow-up. Hormonal therapy has so far been initiated for six men. For the remainder, it has been deferred until either clinical relapse or a more rapid rise in the PSA level. Eighteen men were treated with RT for persistently elevated PSA after radical prostatectomy. At initiation of RT, their PSA levels ranged from 0.4 to 39 ng/mL (median, 1.5 ng/mL). Thirteen men had an initial decrease in PSA, but only 36% were free of a second biochemical failure within 2 years of irradiation (Fig. 3 (3K)). The 24-month actuarial bNED rate was 44% for men with a PSA level less than 2.0 ng/mL compared with 22% for those with a PSA level 2.0 ng/mL or higher (P = 0.1). Of the 5 men who failed to respond to local salvage treatment, 4 men (22%) subsequently developed distant metastases (median time, 39 months). Two men died of their disease at 2 and 13 months after clinical recurrence. Figure 3Open in figure viewerPowerPoint Actuarial freedom of second biochemical failure (bNED) is shown for 18 men treated with radiation therapy for persistently elevated prostate specific antigen after radical prostatectomy. Complications RT resulted in mild or moderate self-limiting complications in the majority of patients (57%). Symptoms included radiation enteritis in 14 (40%), cystitis in 7 (20%), proctitis in 3 (9%), and moderate dermatitis in 1 (3%). There was one case of hemorrhagic cystitis. None of the irradiated patients developed leg or genital lymphedema. After radical prostatectomy, 44 (85%) had urinary continence that was maintained even after the completion of RT. The recording of sexual potency was incomplete, so a meaningful analysis was not possible. DISCUSSION The results of the current series indicate a higher probability of bNED for men with pT3cN0 prostate carcinoma and no detectable serum PSA level who are treated with adjuvant RT versus radical prostatectomy alone. The results were less favorable for the group of men who underwent salvage postoperative RT for a PSA elevation within 3 months of radical prostatectomy. Long term follow-up is necessary to determine whether improvement in bNED survival translates into improved disease specific and overall survival. Men with adenocarcinoma of the prostate with pathologic SVI after radical prostatectomy have a high risk of biochemical and clinical recurrence.7, 9, 19-21 Several investigators have reported that men predominantly fail distantly and that there is only a limited role for local adjuvant RT.21-23 These studies antedated the use of PSA monitoring and relied on local recurrence or distant metastases as endpoints of treatment failure. More recently, it has become unclear whether pathologic SVI is an independent predictor of overall poor prognosis or an elevation of postoperative PSA value is the overwhelming factor. Wu et al. correlated bNED with various potential prognostic factors, including pre-RT PSA, PSA doubling time, RT dose, Gleason score, capsular penetration, positive surgical margins, and SVI among 53 men who were irradiated for isolated elevation of postoperative PSA value.19 They found on multivariate analysis that pre-RT PSA value was the most important predictor of remaining bNED. SVI was not a significant prognostic factor. In contrast, Schild et al. were unable to show a significant improvement in bNED in men irradiated postoperatively for tumors involving the seminal vesicles.20 Few studies have evaluated the effect of adjuvant radiation therapy on bNED in men with pathologic SVI compared with radical prostatectomy alone. Morgan et al. found that, at 1 year postoperatively, 94% of prostate carcinoma patients with capsular penetration with or without SVI treated with adjuvant radiation had PSA levels of 0.2 ng/mL or lower, which was significantly different from the results for those not treated adjuvantly (P = 0.02).14 Schild et al. was also able to demonstrate a significant advantage for men receiving radiation postoperatively for tumors extending beyond the capsule without involvement of the seminal vesicle.20 Those investigators were unable to show a significant difference for men with SVI who were irradiated postoperatively, but did not exclude men with persistently elevated PSA levels. We found that postoperative RT resulted in a significant improvement for men with SVI who did not have lymph node metastases if the postoperative PSA level remained undetectable 3 months after prostatectomy. The bNED rate was 86% at 3 years for men who underwent prostatectomy and adjuvant RT versus 48% at 3 years for men who underwent prostatectomy only (P = 0.01). In several recent reports on SVI after radical prostatectomy, the inclusion of men at highest risk of having biochemical failure may have confounded the real efficacy of local adjuvant treatment.8, 20, 24 Zietman et al. analyzed the outcomes of 24 men with pathologic SVI but without lymph node metastases. They reported a 43% freedom from recurrence at 4 years after adjuvant RT.8 A greater benefit may have been observed if all men with persistently elevated postoperative PSA levels could have been identified and excluded from their analysis. Other studies have included men with Stage D1 disease and/or elevated postoperative PSA levels; the presence of subclinical distant metastases in these men may have yielded less favorable outcomes.6, 7, 19, 24 In agreement with these studies, we found that men with SVI who had a persistently elevated PSA level had poor prognoses: the 3- and 4-year bNED rates for these men were 36% and 20%, respectively. In the current study, of the 15 men irradiated adjuvantly for pT3cN0 prostate carcinoma who did not have detectable serum PSA, only 2 had biochemical failures. One man received RT to the prostatic bed to a total dose of 55 Gy, whereas the other men received doses of 64.8 Gy or greater. There was an insufficient number of men to evaluate the effect of higher radiation doses. Schild et al. found that radiation doses of 64 Gy or more to the prostatic bed were associated with better responses.6 Another study confirmed the presence of a dose-response relationship in men receiving postoperative RT for pT3 disease after radical prostatectomy.25 CONCLUSIONS Early adjuvant RT for men with pT3cN0 prostate carcinoma and no detectable PSA postoperatively decreases the likelihood of future biochemical failure. Whether this difference in biochemical failure will be reflected in disease specific and overall survival remains to be seen. Men with persistently elevated PSA levels after radical prostatectomy benefit less often from postoperative RT alone and ought to be considered for adjuvant systemic therapy, such as early androgen blockade. The Radiation Therapy Oncology Group is carrying out a prospective randomized study in which men with pathologic T3N0 prostate carcinoma and PSA elevation are randomized to radiation plus placebo or radiation plus adjuvant hormonal therapy. This study should determine whether there is a benefit to adjuvant hormonal therapy when added to salvage RT. Acknowledgements The authors thank Carla L. Jackson who assisted in the preparation of the manuscript. They also thank Yang Xie for providing data. REFERENCES 1 McNeal JE, Kindrachuk RA, Freiha FS, Bostwick DG, Redwine EA, Stamey TA. Patterns of progression in prostate cancer. Lancet 1986; 11: 60- 3. 2 Mukamel E, DeKernion JB, Hannah J, Smith RB, Skinner DG, Goodwin WE. The incidence and significance of seminal vesicle invasion in patients with adenocarcinoma of the prostate. Cancer 1987; 59: 1535- 8. 3 Epstein JI, Carmichael M, Walsh PC. 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Cancer 1994; 73: 384- 7. 25 Valicenti RK, Gomella LG, Ismail M, Mulholland SG, Petersen RO, Corn BW. Effect of higher radiation dose on biochemical control after radical prostatectomy for pT3N0 prostate cancer. Int J Radiat Oncol Biol Phys 1997; 39(Suppl 2): 222. Citing Literature Volume82, Issue1015 May 1998Pages 1909-1914 FiguresReferencesRelatedInformation