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