What's the best evidence supporting adding XRT to hormones, when positive node(s) were found in the prostatectomy specimens? Thanks
This is the one I was taughtWhat's the best evidence supporting adding XRT to hormones, when positive node(s) were found in the prostatectomy specimens? Thanks
It’s always an interesting question when you see someone who unexpectedly ended up pN+ but has a negative post op PSA. Do you treat or watch the PSA? I’m not quite sure we know yet. If they have a lot of high risk factors I typically do but I’ve become more comfortable watching people too if it is their preference.I wonder if this situation should be looked at more critically, "in the modern era". These patients are often being pushed into RT despite double-whammy of postop injury and leuprolide
We treat based on the Abdollah criteria, as referenced above.It’s always an interesting question when you see someone who unexpectedly ended up pN+ but has a negative post op PSA. Do you treat or watch the PSA?
It’s always an interesting question when you see someone who unexpectedly ended up pN+ but has a negative post op PSA. Do you treat or watch the PSA? I’m not quite sure we know yet. If they have a lot of high risk factors I typically do but I’ve become more comfortable watching people too if it is their preference.
Don’t get wrong, I practice the same as you both. Only admitting it’s a fair question as to whether or not concepts regarding adjuvant vs salvage apply to any patients with undetectable PSA and occult N+ disease. Good residents always ask about the nuances here.As Palex said, doesn't necessarily have to be ALL pN+ getting immediate adjuvant.
I think some break to allow for recovery of continence not unreasonable.
Don’t get wrong, I practice the same as you both. Only admitting it’s a fair question as to whether or not concepts regarding adjuvant vs salvage apply to any patients with undetectable PSA and occult N+ disease. Good residents always ask about the nuances here.
If you are going to give ADT for N+, then you should treat with RT too.Once hormones have started, close PSA follow up is obviously not feasible. So we always treat
If you are going to give ADT for N+, then you should treat with RT too.
However, with STAMPEDE data now showing benefit in N+ M0 with more intensive systemic treatment, the benefit of RT may shrink if these patients will be receiving ADT + further systemic treatment (so far we only have Abiraterone-data, but it's highly likely that these patients will also benefit from Enzalutamide, Apalutamide, Daralutamide).
great, look forward to losing another indication.If you are going to give ADT for N+, then you should treat with RT too.
However, with STAMPEDE data now showing benefit in N+ M0 with more intensive systemic treatment, the benefit of RT may shrink if these patients will be receiving ADT + further systemic treatment (so far we only have Abiraterone-data, but it's highly likely that these patients will also benefit from Enzalutamide, Apalutamide, Daralutamide).
There was still a pretty decent ffs benefit in that population I believe. As with breast, maybe worth wondering if 2 years of abi or whatever, is better or worse that 6 weeks of rt.great, look forward to losing another indication.
If you are going to give ADT for N+, then you should treat with RT too.
However, with STAMPEDE data now showing benefit in N+ M0 with more intensive systemic treatment, the benefit of RT may shrink if these patients will be receiving ADT + further systemic treatment (so far we only have Abiraterone-data, but it's highly likely that these patients will also benefit from Enzalutamide, Apalutamide, Daralutamide).
30% surgical cure is a gross overestimation. See RTOG 8531 above, etcWould have to dive into their definitions of N+ again, but there may be a big difference between cN+ and pN+ patients, presumably who where cN0 on imaging.
Not looking at XRT, but with respect to immediate vs. delayed ADT we have the old messing trial. DEFINE_ME
Despite this trial showing an OS advantage, standard of care never seemed to budge. The vast majority of Uros don't give ADT on node positive disease. There are a lot of issues with the trial, ranging from small cohorts, to the fact that "progression" was generally symptomatically based, when pretty much anyone these days would use PSA kinetics and start treatment earlier.
It's a mixed bag and is/should be patient centered. Up to 30% of patients with pN+ disease on RALP will never recur. So lifelong ADT +/- XRT is overtreating a big chunk of patients. As mentioned, we have no data on salvage vs. adjuvant in node positive setting. Personally If PSA undetectable I observe. If PSA detectable in the past would refer to salvage, now I'd get a PSMA pet and go from there.
30% for all comers with positive nodes on a prostatectomy may be an overestimate. 25-30% for cN0 pN1 limited nodal disease is probably accurate30% surgical cure is a gross overestimation. See RTOG 8531 above, etc