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| Cytoreductive radical prostatectomy after chemohormonal therapy in patients with primary metastatic prostate cancer |
Christa Babsta,Thomas Amiela,Tobias Maurerb,Sophie Knipperb,Lukas Lungera,Robert Taubera,Margitta Retza,Kathleen Herkommera,Matthias Eibera,Gunhild von Amsbergb,Markus Graefenb,Juergen Gschwenda,Thomas Steuberb,Matthias Hecka,*( )
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a Department of Urology, Technical University of Munich, Rechts der Isar Medical Center, Munich, Germany
b Martini-Klinik Prostate Cancer Center, Hamburg, Germany |
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Abstract Objective: Cytoreductive radical prostatectomy (cRP) has been proposed as local treatment option in metastatic hormone-sensitive prostate cancer (mHSPC) to prevent local complications and potentially improve oncological outcomes. In this study, we examined the feasibility of a multimodal concept with primary chemohormonal therapy followed by cRP and analyzed prostate size reduction under systemic treatment, postoperative complication rates, as well as early postoperative continence.
Methods: In this retrospective study, 38 patients with mHSPC underwent cRP after primary chemohormonal therapy (3-monthly luteinising hormone-releasing hormone-analogue + six cycles 3-weekly docetaxel 75 mg/m2) at two centers between September 2015 and December 2018.
Results: Overall, 10 (26%) patients had high volume and 28 (74%) patients had low volume disease at diagnosis, according to CHAARTED definition. Median prostate-specific antigen (PSA) decreased from 65 ng/mL (interquartile range [IQR] 35.0-124.5 ng/mL) pre-chemotherapy to 1 ng/mL (IQR 0.3-1.7 ng/mL) post-chemotherapy. Prostate gland volume was significantly reduced by a median of 50% (IQR 29%-56%) under chemohormonal therapy (p = 0.003). Postoperative histopathology showed seminal vesicle invasion in 33 (87%) patients and negative surgical margins in 17 (45%) patients. Severe complications (Grade 3 according to Clavien-Dindo) were observed in 4 (11%) patients within 30 days. Continence was reached in 87% of patients after 1 month and in 92% of patients after 6 months. Median time to castration-resistance from begin of chemohormonal therapy was 41.1 months and from cRP was 35.9 months. Postoperative PSA-nadir ≤1 ng/mL versus >1 ng/mL was a significant predictor of time to castration-resistance after cRP (median not reached versus 5.3 months; p<0.0001).
Conclusion: We observed a reduction of prostate volume under chemohormonal therapy going along with a low postoperative complication and high early continence rate. However, the oncologic benefit from cRP is still under evaluation.
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Received: 30 May 2020
Available online: 20 January 2022
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Corresponding Authors:
Matthias Heck
E-mail: matthias.heck@tum.de
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| Characteristic | Value | | Age, median (IQR), year | 57 (54-64) | | Number of patients, n (%) | | ≥65 years | 9 (23) | | <65 years | 29 (77) | | ASA score, median (IQR) | 2 (2-2) | | PSA, median (IQR), ng/mL | | At diagnosis | 65 (35.0-124.5) | | Pre-surgery | 1.0 (0.3-1.7) | | Gleason score, n | | 6 | 1 | | 7a | 2 | | 7b | 2 | | 8 | 9 | | 9 | 21 | | 10 | 3 | | Median (IQR) | 9 (8-9) | | CHAARTED criteria, n (%) | | Low volume disease | 28 (74) | | High volume disease | 10 (26) | | Metastases status at diagnosis, n (%) | | Lymph node | 33 (87) | | Bone | 23 (61) | | Visceral | 2 (5) | | Time from diagnosis to chemotherapy, median (IQR), day | 53 (32-74) | | Time from diagnosis to surgery, median (IQR), day | 250 (222-281) | | Time from end of chemotherapy to surgery, median (IQR), day | 61 (47-82) | | Prostate volume, median (IQR), mL | | Pre-docetaxel | 50 (35-64) | | Pre-surgery | 25 (15-31) | | Prostate volume reduction, median (IQR), mL | 25 (10-35) | | Prostate volume reduction, median (IQR), % | 50 (29-56) | | Hemoglobin, median (IQR), g/dL | | Pre-surgery | 13.7 (13.0-14.1) | | Post-surgery (Day 1 after surgery) | 10.7 (10.2-12.1) | | Hemoglobin loss, median (IQR), g/dL | 2.9 (1.9-3.4) | | Operation time, median (IQR), min | 196 (157-233) | | Hospital length of stay, median (IQR), day | 9 (6-10) | | Postoperative T stage, n (%) | | pT2c | 2 (5) | | pT3a | 3 (8) | | pT3b | 33 (87) | | Postoperative N stage, n (%) | | pN0 | 4 (11) | | pN1 | 34 (89) | | Lymph nodes removed, median (IQR), n | 18.5 (12-24) | | Positive lymph nodes, median (IQR), n | 3 (1-6) | | Margin status, n (%) | | R0 | 17 (45) | | R1 | 21 (55) |
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Descriptive characteristics of 38 patients treated with cytoreductive radical prostatectomy after chemohormonal therapy.
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Kaplan-Meier curve showing the time from begin of chemohormonal therapy to development of castration resistance. NA, not available; CI, confidence interval.
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Kaplan-Meier curve showing the time from cytoreductive prostatectomy to development of castration resistance. CI, confidence interval; NA, not available.
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Kaplan-Meier curve showing the time from cytoreductive prostatectomy to development of castration resistance stratified by postoperative PSA-nadir ≤1 ng/mL versus >1 ng/mL.CI, confidence interval.
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| Pad use | Postoperative continence after 1 month (n=31a), n (%) | Postoperative continence after 6 months (n=25b), n (%) | Postoperative continence after 12 months (n=26c), n (%) | | 0 pad | 2 (6) | 15 (60) | 18 (69) | | 1 pad (for security) | 25 (81) | 8 (32) | 5 (19) | | 1 wet pad (mild incontinence) | 1 (3) | 1 (4) | 1 (4) | | 2 wet pads (moderate incontinence) | 3 (10) | 1 (4) | 2 (8) | | ≥3 pads (severe incontinence) | 0 | 0 | 0 |
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Continence and pad use.
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