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272 Radiation Oncology, Biology. Physics Volume 32, Supplement 1 2019 RADIATION THERAPY ALONE IS NOT SUCCESSFUL AS SALVAGE TREATMENT FOR LOCALLY RECURRENT PROSTATE CANCER AFTER RADICAl, PROSTATECTOMY Lute G. Oas, M.D.Gunar K. Zagars. MD., Alan Pollack, M D., PhD Department of Radiotherapy, The Univer,.ity of Texa:., M.D Andep, on Cancer ('enter, Houston, Texas PurposedObjectives: To evaluate radiolherap.v (XRT) as potential salvage treatment for patients with locally recurrent prostate cancer after redical prostatectomy {RPI Materials and Methods: Twenty-four consecutive patients with adenocarcinoma of the prostate who received definitive XRT between 198"] and 1993 for biopsy-proven (n=181 or for prostate-specfic antigen (PSA) - producing (n=6) recurrent disease following RP were evaluated. No patient had clinically or radiographically evident distant disease. Biopsies of suspicious nodules or ultrasound findings in the prostatic fossa were positive in lg and negative in 3. Three patients had no focal abnormalities and had no biopsy. The time between RP and XRT varied from 6 to 277 months (mean 52 monthsi. XRT doses to the prostatic fossa ranged from 60 to 70 Gy (median, 66 Gy). Outcome was analyzed relative to local control, metastatic disease and PSA status. Persistently undetectable PSA was required to define freedom from disease. Results: Pre-XRT PSA levels ranged front 07 to 2¢,.g ng/ml (mean 7.3 ng/ml, median 2.5 ng/ml). Although PSA fell post-XRT in all but 3 patients and 10 (52%) achieved undetectable levels, the outcome at a median follow-up of 42 months (range t3-90 months) was poor, with 15 patients (63%) developing persistent/progressive disease. The patterns of progressmn in these 15 were: local 3, metastatic 3. persistent PSA 9. All patients whose PSA was persistently detectable developed a rising PSA profile. The actuarial incidence of freedom from disease at 1, 2, 3 and 4 years was 75%. 43%, 36% and 2?% respectively. The only factor correlating to outcome was the pre-XRT PSA level. The 9 patients who remain free of disease had a mean PSA level of 3.6 ng/ml compared to a mean level of 9.6 ng/ml among the 15 who failed (p<0.01). All patients with a pre-XRT level >2.5 ng/mI developed disease relapse, whereas the 4-year freedom from disease in those with levels _<25 ng/ml was 52%. Eleven of the 15 patients whose disease relapsed after XRT received androgen ablation. Although the majority of patients relapsed, survival at 5 years after XRT was 85°4 - no different from the expected survival for age-matched men in the general population. Conclusion: Using PSA as a disease endpoint, reveals that radiation therapy rarely salvages patients with apparently localized relapse after radical prostatectomy for adenocarcinoma of the prostate Patients with indications for XRT after RP are better treated immediately rather than waiting for recurrence. 2020 TRUS AND MRI SHOULD NOT BE USED TO STAGE PA~flENTS WITH PROSTATE CANCER: AN OUTCOME BASED ANALYSIS W. H Pinover l)tL A. L. Hanlon MS, E. J. Kaplan MD, W. R. Lee MD, G. E. Hanks MD Fox Chase Cancer Center, Philadelphia, Pennsylvania Purpose/Objective: The AJCC staging ot prostate cancer relies upon DRE findings, but suggests using all available information, including prostate imaging studies, prior to definitive treatment of prostate cancer. We have examined whether imaging upstaged patients have a different outcome from those n{~t upstaged after treatment with external beam radiation therapy. Methods & Materials: The records of 348 patients ~xith clinically localized adenocarcinoma of the prostate treated with definitive external beam irradiation alone from 1 / 86 12/'43 were reviewed All patients had at least one of the following pretreatment imaging modalities performed - transrectal ultrasound (TRUS), pelvic, endorectal, or Helmholtz MRI. Patients were assigned two clinical stage one based only on palpation criteria and the second allowing for any up.staging by imaging abnormalities. The Kaplan-Meier method was used to estimate bNED sur~ ira[ where a failure is defined as a PS,,\ .- 1.:~ and rising. Differences in outcome were evaluated by th. log-rank test. Results: Overall upstaging by TRUS or M RI to any higher stage occurred in 115 of 312 (37'!.) palpation Tlc-T2c patients There was no significant difference in bNED survival tor tlr~se upstaged compared to those not upstaged. Twenty one of 244 (9%) Tlc-T2b patients were upstaged to T2c (bi]obar disease). No .',ignificant difference in bNED survival was noted for those upstaged to bilobar disease compared to those not upstaged (see table). Upstaging to T3 occurred in 32 ot 312 (10%) palpation Tlc-T2c patients (T3a-5%, T3b-<1%, T3c-5%). No significant difference m bNED survival was noted for those upstaged to T3 compared to those not upstaged (see table). Comparison of palpation T3 patients with imaging upstaged T3 patients demonstrated a significant difference in bNED survival (p=.01 see table). Controlling for pretreatment PSA, this difference remained significant (p-0.01). PALPATION STAGE IMAGING STAGE T1 c-T2ab upstage to T2c 66% not upstaged to T2c , 75% Tic- f2c upstaged to T3 i 84% not upstaged to T3 i 71% Imaging upstaged to T3 Palpation stage T3 36 month bNED p Value p = .64 p=.40 Conclusions: Using the endpoint of biochemical NED survival, upstaging by TRUS/MRI does not separate patients into groups with different prognoses. The AJCC staging system should consider eliminating the recommendation to include imaging in staging. If stage is used as a prognostic indicator in comparing results this should be restricted to palpation stage and further emphasizes the need for a biochemical PSA level based staging system. Diagnostic imaging for staging localized prostate disease is not indicated and it's elimination would result in significant savings in healthcare costs. 84% p=.O1 50%

2019 Radiation therapy alone is not successful as salvage treatment for locally recurrent prostate cancer after radical, prostatectomy

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272 Radiation Oncology, Biology. Physics Volume 32, Supplement 1

2019

RADIATION T H E R A P Y ALONE IS NOT SUCCESSFUL AS SALVAGE T R E A T M E N T FOR L O C A L L Y RECURRENT PROSTATE CANCER AFTER RADICAl, PROSTATECTOMY

Lute G. Oas, M.D.Gunar K. Zagars. MD., Alan Pollack, M D., PhD

Department of Radiotherapy, The Univer,.ity of Texa:., M.D Andep, on Cancer ('enter, Houston, Texas

PurposedObjectives: To evaluate radiolherap.v (XRT) as potential salvage treatment for patients with locally recurrent prostate cancer after redical prostatectomy {RPI

Materials and Methods: Twenty-four consecutive patients with adenocarcinoma of the prostate who received definitive XRT between 198"] and 1993 for biopsy-proven (n=181 or for prostate-specfic antigen (PSA) - producing (n=6) recurrent disease following RP were evaluated. No patient had clinically or radiographically evident distant disease. Biopsies of suspicious nodules or ultrasound findings in the prostatic fossa were positive in lg and negative in 3. Three patients had no focal abnormalities and had no biopsy. The time between RP and XRT varied from 6 to 277 months (mean 52 monthsi. XRT doses to the prostatic fossa ranged from 60 to 70 Gy (median, 66 Gy). Outcome was analyzed relative to local control, metastatic disease and PSA status. Persistently undetectable PSA was required to define freedom from disease.

Results: Pre-XRT PSA levels ranged front 07 to 2¢,.g ng/ml (mean 7.3 ng/ml, median 2.5 ng/ml). Although PSA fell post-XRT in all but 3 patients and 10 (52%) achieved undetectable levels, the outcome at a median follow-up of 42 months (range t3-90 months) was poor, with 15 patients (63%) developing persistent/progressive disease. The patterns of progressmn in these 15 were: local 3, metastatic 3. persistent PSA 9. All patients whose PSA was persistently detectable developed a rising PSA profile. The actuarial incidence of freedom from disease at 1, 2, 3 and 4 years was 75%. 43%, 36% and 2?% respectively. The only factor correlating to outcome was the pre-XRT PSA level. The 9 patients who remain free of disease had a mean PSA level of 3.6 ng/ml compared to a mean level of 9.6 ng/ml among the 15 who failed (p<0.01). All patients with a pre-XRT level >2.5 ng/mI developed disease relapse, whereas the 4-year freedom from disease in those with levels _<25 ng/ml was 52%. Eleven of the 15 patients whose disease relapsed after XRT received androgen ablation. Although the majority of patients relapsed, survival at 5 years after XRT was 85°4 - no different from the expected survival for age-matched men in the general population.

Conclusion: Using PSA as a disease endpoint, reveals that radiation therapy rarely salvages patients with apparently localized relapse after radical prostatectomy for adenocarcinoma of the prostate Patients with indications for XRT after RP are better treated immediately rather than waiting for recurrence.

2020

TRUS A N D MRI S H O U L D NOT BE USED TO STAGE PA~flENTS WITH PROSTATE CANCER: AN O U T C O M E BASED ANALYSIS

W. H Pinover l ) tL A. L. Hanlon MS, E. J. Kaplan MD, W. R. Lee MD, G. E. Hanks MD Fox Chase Cancer Center, Phi ladelphia , Pennsylvania

Purpose /Objec t ive : The AJCC s taging ot prostate cancer relies upon DRE findings, but sugges t s using all avai lable information, inc lud ing prostate imag ing studies, prior to def ini t ive t rea tment of prostate cancer. We have examined whe ther imag ing ups taged pa t ients have a different outcome from those n{~t ups taged after t reatment wi th external beam radia t ion therapy.

Methods & Mater ia ls : The records of 348 pat ients ~x ith cl inically localized adenocarc inoma of the prostate t reated wi th defini t ive external beam irradiat ion alone from 1 / 86 12/'43 were r e v i e w e d All pat ients had at least one of the fo l lowing pre t rea tment imag ing modal i t ies performed - transrectal u l t rasound (TRUS), pelvic, endorectal , or Helmhol tz MRI. Patients were ass igned two clinical s tage one based only on palpat ion criteria and the second a l lowing for any up.staging by imaging abnormali t ies . The Kaplan-Meier method was used to es t imate bNED sur~ ira[ where a failure is def ined as a PS,,\ .- 1.:~ and rising. Differences in outcome were eva lua ted by th. log-rank test.

Resul ts : Overal l ups tag ing by TRUS or M RI to any higher stage occurred in 115 of 312 (37'!.) pa lpa t ion Tlc-T2c p a t i e n t s There was no s ignif icant difference in bNED surviva l tor tlr~se ups taged compared to those not upstaged. Twenty one of 244 (9%) Tlc-T2b pat ients were ups taged to T2c (bi]obar disease). No .',ignificant difference in bNED surv iva l was noted for those ups taged to bi lobar disease compared to those not ups taged (see table). Ups tag ing to T3 occurred in 32 ot 312 (10%) palpat ion Tlc-T2c pat ients (T3a-5%, T3b-<1%, T3c-5%). No significant difference m bNED surviva l was noted for those ups taged to T3 compared to those not ups taged (see table). Compar i son of pa lpa t ion T3 pat ients with imaging ups t aged T3 pat ients demons t ra ted a signif icant difference in bNED surv iva l (p=.01 see table). Contro l l ing for pre t rea tment PSA, this difference remained significant (p-0.01).

P A L P A T I O N STAGE I M A G I N G STAGE T1 c-T2ab ups tage to T2c 66%

not ups taged to T2c , 75% Tic- f2c ups taged to T3 i 84%

not ups taged to T3 i 71%

Imaging ups taged to T3 Palpat ion s tage T3

36 month bNED p Value

p = .64

p=.40

Conclusions: Using the endpoin t of biochemical NED survival , ups tag ing by TRUS/MRI does not separate pat ients into g roups wi th different prognoses. The AJCC s taging sys tem should consider e l imina t ing the r ecommenda t ion to include imag ing in staging. If s tage is used as a prognost ic indicator in compar ing results this should be restricted to pa lpat ion s tage and further emphas izes the need for a b iochemical PSA level based s taging system. Diagnost ic imag ing for s taging localized prostate d isease is not indicated and it's e l iminat ion would result in s ignif icant sav ings in heal thcare costs.

84% p=.O1 50%