Radiation Oncology/Prostate/Node Positive

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Front Page: Radiation Oncology | RTOG Trials | Randomized Trials

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Prostate: Main Page | Prostate Overview | Screening and Prevention | Workup | Natural History | External Beam RT | IMRT | Androgen Suppression Therapy | Brachytherapy | Protons | Prostatectomy | Adjuvant RT after Prostatectomy | Salvage RT | Chemotherapy | Localized prostate cancer | Node Positive | Advanced disease | Recurrence after RT | Cryotherapy | RTOG Prostate Trials | Randomized Evidence

Contents

[edit] Long-term outcomes

  • RTOG 75-06 - PMID 9531359 — Ten-year outcomes for pathologic node-positive patients treated in RTOG 75-06. (Hanks GE, IJRBOP 1998).
    • Conclusion: A small fraction of node-positive patients are cured at 10-year follow-up by radiation therapy (2 of 90 with PSA +3 of 90 by clinical endpoints). Innovative treatment programs should be directed at node-positive patients in an effort to improve the fraction cured.

[edit] Prostatectomy vs Radiotherapy

  • Ulm, Germany / U. Michigan PMID 15356680 -- Comparison of external radiation therapy vs radical prostatectomy in lymph node positive prostate cancer patients. (2004 Kuefer, Prostate Cancer Prostatic Dis. 2004;7(4):343-9.)
    • Retrospective. 102 pts RPX, 44 pts ERT. Adjuvant androgen ablation was given in 76 of 102 RPX, 21 of 44 ERT.
    • Conclusion: "In case of positive lymph nodes, RPX and ERT might be considered and need to be explained to the patient. For future treatment decisions, the presented findings and a potential survival benefit need to be evaluated in a larger prospective setting."

[edit] Radiotherapy alone

Dose for positive nodes:

  • From Fletcher, Texbook of Radiotherapy, 3rd ed. (1980) - For lymphangiogram positive pelvic nodes, extend field to L4-L5 interspace, 45 Gy to pelvis + boost positive nodes to a total of 55-60 Gy.

[edit] Hormonal therapy after prostatectomy

  • Messing, 1999 (1988 - 93) - PMID 10588962 Full text — "Immediate hormonal therapy compared with observation after radical prostatectomy and pelvic lymphadenectomy in men with node-positive prostate cancer." Messing EM et al. N Engl J Med. 1999 Dec 9;341(24):1781-8.
    • 98 pts. Pts were found to have node-positive disease after radical prostatectomy + pelvic lymphadenectomy. Randomized to adjuvant goserelin (or bilateral orchiectomy) vs observation until disease progression.
    • Median 7.1 yrs f/u. 77% (antiandrogen) vs 18% (obs) were alive with no evidence of recurrent disease and undetectable PSA. Death from any cause in 7 of 47 men (antiandrogen) vs 18 of 51 (obs), S.S.
    • Conclusion: survival benefit for immediate hormonal therapy. RT not used.

[edit] Hormonal therapy and radiotherapy

  • MD Anderson, 2001 (1984-1998) PMID 11489709 — "Addition of radiation therapy to androgen ablation improves outcome for subclinically node-positive prostate cancer." Zagars GK, Pollack A, von Eschenbach AC. Urology. 2001 Aug;58(2):233-9.
    • Retrospective. 255 pts N+ found on lymphadenectomy treated with early androgen ablation alone (n=188) or with 70 Gy EBRT (n=72). Median F/U 9.4 years for ablation alone, 6.2 years for ablation + RT
    • 10 year outcome: Adding EBRT improved OS from 46 to 67%. Freedom from relapse improved from 25% to 80%
    • Conclusion: Early androgen ablation alone not helpful. Addition of RT offers substantial and significant improvement
  • RTOG 85-31: Subset Analysis, PMID 15681524 — "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." Lawton CA et al. J Clin Oncol. 2005 Feb 1;23(4):800-7.
    • Updated analysis of pN+ pts (median f/u on all pts (6.5 yrs) and all living pts (9.5 yrs))
    • 98 pts XRT + immediate adjuvant goserelin, 75 pts XRT alone w/ delayed goserelin @ time of failure.
    • Conclusion: Multivariant analysis shows XRT + immediate adj goserelin have SS benefit in all four end points analyzed-- biochem control, met failure, DSF, absolute survival. Need prospective randomized trial to confirm, but until then, pN+ pts should be considered for XRT + immediate hormonal manipulation rather than XRT alone with hormone manipulation at the time of relapse.
  • (closed due to poor accrual ) RTOG 96-08 (1997-98)
    • Randomized node-positive pts to indefinite total androgen ablation vs total androgen ablation plus RT to the pelvis + prostate. 50.4 Gy to the pelvis (to L4/5 interspace) with boost to 68.4 - 70.2 Gy.
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