Post-Radical Prostatectomy Management Options For The Positive Surgical Margin
Dr. Judd Moul, Duke University presented the "Argument for Observation". He stated that randomized controlled trials do not support treatment. The EORTC "Bolla" study does not support that adjuvant XRT results in improved cancer specific survival. The SWOG "Thompson" trial does not show an improvement in overall survival. The Duke data showed an increase in the positive SM rate from 19% to 31% over the past 20 years. This likely reflects operating on higher risk patients. The PSA recurrence rates were 70-79% and most occurred in the first two years. Giving salvage XRT resulted in similar outcomes to observation in their database.
Dr. Joseph Chin, University of Western Ontario presented the "Argument for Adjuvant Radiotherapy". He stated that the progression free status was worse in the face of positive SMs. He argued that the PFS was better with adjuvant XRT and overall survival was "close" to significant. The lack of reduction in metatstatic disease and overall survival was in large part due to the low number of events, he said. The argument for salvage XRT is not as good, according to a study showing that a lower PSA at treatment had better outcome. Other tumors such as breast and colon have shown adjuvant XRT to be of benefit.
Dr. Celestia Higano, University of Washington presented the "Argument for Androgen Deprivation Therapy and Chemotherapy". All positive margins are clearly not the same. She viewed a positive SM as high-risk localized disease. Her concern is systemic relapse and should be administered soon after RP when disease burden is at its lowest. The desired endpoint is delayed time to relapse and improved survival. The assumption that some patients who are treated were already cured and not in need of the treatment is acceptable to medical oncologists. What therapy to use is based upon using drugs that demonstrate evidence of effectiveness in advanced disease. ADT is lacking clinical evidence in this setting. She cited the Messing paper as demonstrating that patients receiving immediate ADT clearly did better. Chemotherapy with Docetaxel benefits AICaP and thus has some precedent for adjuvant treatment. Phase III adjuvant trials are ongoing and she encouraged the audience to enroll patients in these studies. Other high-risk features in addition to a positive SM should be considered.
A case of a 64yo man was presented. Although low risk, he had pT2 with a capsular incision, which is a breach in surgical disease. This would not warrant adjuvant XRT according to Dr. Chin or Dr. Moul.
Reported by UroToday.com Contributing Editor Christopher P. Evans, MD, FACS
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