localised high risk prostate cancer: oncological and functional … · 2013-07-20 · localised...
TRANSCRIPT
S. Machtens
Director of the
Department of Urology and Paediatric Urology
Academic Teaching Hospital
Marien-Hospital Bergisch Gladbach
Prostate Brachytherapy UK & Ireland Conference 2013
Localised High Risk Prostate Cancer: Oncological and functional outcomes (PSA +20ng/ml; Gleason:8-10; T2c+)
Radical Surgery
Disclosures
• Payed Lectures: Sanofi-‐Aven6s;Amgen; Novar6s;BARD; Bebig; Janssen-‐Cilag;
Pfizer;Astra-‐Zeneca; Astellas • Advisory Board Ac6vi6es: Sanofi-‐Aven6s; BARD; Pfizer; Amgen, Bebig • Scien6fic grants: BARD There do not exist any Ownership Interests.
0%5%
10%15%20%25%30%35%40%45%50%
1989-1992 1993-1995 1996-1999 2000-2002
High RiskIntermediate RiskLow Risk
Cooperberg MR et al.; J Urol 2003 Dec:170(6Pt2):S21-25
Changes in Risk Stratification in the PSA Era 1989-2002: CaPSURE
20-35% of patients with newly diagnosed PCa are still classified as high risk, based on either PSA>20ng/ml,
Gleason score >8 or an advanced clinical stage
Patients classified with high-risk Pca are at an increased Risk of:
PSA failure
Need for secondary therapy Metastatic Progression
Death from PCa
NEJM Mai 2011
NEJM Mai 2011
Gleason 8-10
EAU Guidelines 2012
Organ-confined disease is 26-31%.
One third with biopsy Gleason ≥8 show a Gleason of ≤7 in final histopathology.
25% positive lymph nodes
N+ disease
Among patients with high-risk disease with N+ multiple series have demonstrated long-term cancer control after surgery
with 10-yr CSS of up to 85%
Tumorregistry Munich
4,44 M total
0,56 M Counties from 2007: 1,44 M Counties from 2002: 1,18 M Counties from 1978: 1,26 M Town of Munich
End of 70ies"
f / up in 96%"
since 1988 all 6 Departments in Munich"
Tumorregistry Munich
Since 1988 35.629 PCA cases registered 27.956 primary PCA 13.805 with information on LN status 1.413 with positive LN
957 N+ and rPx 456 N+ without rPx
pN+: rPx vs prostate left in place %
0
10
20
30
40
50
60
70
80
90
100
110
Jahre0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Gruppe
ohne PVEn=93
alle mit PVEn=544
mit PVE 5 Stichprobenje n=182
Tumor specific survival"
years
5 y survival
without rPx: 70% with rPx: 95%
Difference 5y: 25%
10 y survival
without rPx: 40% with rPx: 86%
Difference 10y: 46%
Prostate left in place (no rPx)
Prostate out (rPx)
pN+: rPx vs prostate left in place
Clear survival benefit for pN+ PCA when undergoing surgical removal of the
prostate
pN+: adjuvant radiation
pN+: adjuvant radiation
pN+: adjuvant radiation
further improvement of long-term survival in pN+ after
rPx by adjuvant radiotherapy
PSA > 20ng/ml
PSA-failure rates between 44% (5a) and 53% (10a).
PSA failure rate of 50% (5a).
PSA > 20ng/ml
CSS of 90% (10a) and 85% (15a).n=712
CSS of 80%, 85% and 91% (10a) in patients with PSA>100ng/ml; 50,1-100ng/ml; 20,1-50ng/ml
cT3a PCa
EAU Guidelines 2012
Around 30% of diagnosed PCas today are locally advanced.
Several studies have demonstrated advantage of EBRT + ADT against EBRT without ADT.
So far no study demonstrating
combined treatment being superior to RP
cT3a PCa
EAU Guidelines 2012
.
Positive margins are present in 33,5-66%.
Positive lymph nodes are found in 7,9-49%.
56-78% require adjuvant or salvage radiation.
but
Overstaging occurs in 13-27%.
cT3a PCa
EAU Guidelines 2012
Around 30% of diagnosed PCas today are locally advanced.
Several studies have demonstrated advantage of EBRT + ADT against EBRT without ADT.
So far no study demonstrating
combined treatment being superior to RP
High risk disease
EAU Guidelines 2012
.
Depending on definition of high risk disease CSS at 10 years varied beween 3-12%.
35-76% of patients remained free from
additional therapy at 10years.
High risk disease
.
CSS of 95% (10a) after RP with only 24% adjuvant ADT and 8% adjuvant RT.(n=1513)
CCS of 81% (15a) after RP.
Advantages of RP in High risk disease
.
Ability to obtain pathological staging, which may guide application of secondary therapies.
Patients with high-risk disease treated with radiation
were 3.5 times more likely to receive ADT than after RP.
55-60% will have organ-confined disease.
Advantages of RP in High risk disease
.
Patients treated initially with RP and then salvage RT were less likely to wear pads and less likely to experience ED
than patients treated with RT and then salvage RP .
Advantages of RP in High risk disease
.
Several studies have shown in a retrospective non-randomized series improved survival for RP plus ADT against ADT alone.
Functional Outcome after RP
.
EAU Guidelines 2012
Worse urinary control and sexual function with RP
Bowel dysfunction more common with radiation
Worse irritative and obstructive urinary function after radiation.
Boorjian et al.; Eur Urol, 2012
l Long-term morbidity rates for urinary, rectal and
erectile side effects is low. (LoE: III)
l Technical advances improve tumor control and lower toxicity.
Summary
EAU Guidelines 2012