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High-Risk Prostate Cancer: Treatments Following Radical Prostatectomy

Opinion
Video

Paul M. Yonover, MD, FACS, reviews treatment options available for patients with high-risk prostate cancer following radical prostatectomy.

Case #1: A 66-Year-Old-Man with Prostate Cancer

Initial Presentation (June 2022)

  • A 66-year-old man reported mild urinary frequency to his primary care physician

Clinical workup

  • After an elevated serum PSA 22 ng/mL is noted, patient presents to his urologist
  • Family history of breast cancer (patient’s mother diagnosed at age 82)
  • Digital rectal exam (DRE) unremarkable, overall physical exam unremarkable
  • MRI revealed a 40 gm prostate; no extra-prostatic extension, no nodal involvement; 1 ROI, PIRADS-5
  • Transperineal (TP) MRI fusion biopsy demonstrated prostate adenocarcinoma andGleason score 8/Grade Group 4 in 9 of 12 tissue samples and Gleason score 9/Grade Group 5 in the region of interest
  • Germline genetic testing revealed no actionable mutations; CT and bone scan revealed no extra-prostatic involvement.

Initial Treatment (starting July 2022)

  • Patient underwent robotic assisted lap radical prostatectomy (RALP) + PLND; no surgical complications
  • Pathology confirmed GG5 prostate disease with pT3bN1R1 designation
    • Positive surgical margins; 1 of 12 obturator lymph nodes were positive

12-week Follow-up Notes (October 2022)

  • Post-surgical PSA is undetectable at 12 weeks
  • Minimal GSI (<1 pad/day)

This is a synopsis of a Case-Based Peer Perspectives series featuring Paul M. Yonover, MD, FACS, of Uropartners/SolarisHealth Partners.

Dr. Paul Yonover summarized considerations for adjuvant or salvage therapy after prostatectomy in the very high risk prostate cancer patient. Factors that impact decisions include adverse pathologic features like Gleason grade group 4 or 5, seminal vesicle invasion, positive margins, or lymph node metastases, as well as the post-operative prostate-specific antigen (PSA) nadir response.

If high risk features are present but lymph nodes were negative, options include adjuvant external beam radiation therapy with or without short-term androgen deprivation therapy (ADT). However, Dr. Yonover has moved away from routine adjuvant therapy in node-negative patients given recent literature, instead opting for close monitoring and early salvage radiotherapy when PSA rises above 0.1 ng/mL on repeat measurements. This achieves similar cure rates.

In contrast, if lymph node metastases are present, even if the post-operative PSA nadirs, Dr. Yonover encourages seeing radiation oncology to discuss adjuvant external beam radiation plus ADT, which has the best outcomes data for node-positive cases. Some node-positive patients get systemic ADT alone. Regardless, he refers the majority of node-positive patients for consideration of adjuvant radiotherapy and ADT after prostatectomy, particularly those with other high-risk features like Gleason grade group 4 or 5, or T3b disease. His practice follows NCCN guideline recommendations for post-prostatectomy adjuvant and salvage decisions based on pathologic risk factors.

*Video synopsis is AI-generated and reviewed by Urology Times editorial staff.

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