ESOU 2019: Salvage Radical Prostatectomy

Prague, Czech Republic (UroToday.com) Dr. Heidenreich presented on the indications for salvage radical prostatectomy – or rather, salvage radical surgery. As an established, well-known urologic oncologist, he provides insight into his experience with salvage surgery for prostate cancer – though, his experience may not be translatable to the general urologic community. Salvage surgery should be done in expert hands.

In his experience, salvage surgery is reserved for 3 clinical scenarios:

Intrapelvic anatomically unexpected recurrences following radical prostatectomy
Pelvic lymph node metastases following radical prostatectomy
Intraprostatic relapse following radiation therapy

He demonstrated each of these through clinical scenarios

The first patient underwent robotic radical prostatectomy and PLND at another institution for cT2N0 Gleason 4+4=8 PCa – found on final pathology to have pT3aN0 (0/3 nodes) R1 Gleason 4+3=7 prostate adenocarcinoma.

He notes that they had more of a node pluck than a true node dissection
The patient received salvage RT for BCR in 2008
In 2017, they again had BCR and PSA progression
PSMA PET imaging revealed a hot spot near the UVJ behind the bladder – not typical of a node

He made it very clear that this was likely a seminal vesicle that was not removed with the prostate. Given the options of management, including monitoring, salvage resection, salvage LDR-brachy, and ADT, he chose salvage resection. In his mind, this is not recurrence so much as it was insufficient primary therapy. Despite 2 primary treatments in the pelvis before, they were able to excise the remnant vas deferens and seminal vesicle. In their clinical experience, their series of patients undergoing salvage resection of remnant seminal vesicles had a 50% PFS benefit at 3 years – similar to patients undergoing salvage radical prostatectomy.

The second patient underwent radical prostatectomy for pT3bN0 (0/17 nodes) R0 Gleason 4+3=7 prostate cancer in 2013. He had salvage RT for PSA progression in 2015 and ultimately had BCR in 2016. PSA had risen to 1.3 by that time. PSMA PET imaging demonstrated a single large right common iliac node. Given options of ADT, cyberknife RT, IMRT to all pelvic nodes and salvage PLND, he opted for salvage PLND. His main take-home point for this case, though, was that all the nodes in the region should be cleaned out – not just the PET avid node. He found 4/9 nodes in that region that were positive, even though only one was PET avid.

In a study by Porres et al. (Prostate Cancer Prostate Diseases 2017), his group found that patients who have a complete response (PSA < 0.2 after sPLND) had excellent prognosis – 80% systemic therapy free survival and 70% BCR free survival. But only about 25% of patients achieve this.
Just this year (EU 2019), Fossati et al. published a nomogram to identify optimal candidates for sPLND and it provides a risk calculation of risk of clinical recurrence at 1 year. This can be discussed with the patient before coming to a decision about surgery. The variables included are:
- Gleason Grade Group
- Time from RP to rising PSA (months)
- ADT at time of PET/CT
- Retroperitoneal uptake PET/CT
- Number of Positive Spots at PET/CT
- PSA at SLND (ng/ml)

The last patient presented was one who was diagnosed with cT1 Gleason 6 PCa in 2004. He underwent EBRT with 2005, had BCR, had LDR brachytherapy for an intraprostatic recurrence in 2010, and unfortunately had a biochemical relapse in 2012. PSMA PET avidity noted only in the prostate and in the seminal vesicle. Biopsy demonstrated Gleason 4+4=8 PCa in the prostate (4/24 cores) and in the seminal vesicle. Despite having had two radiation treatments to the bladder, they proceeded with salvage open radical prostatectomy. Dr. Heidenreich and his institution have a long experience with open salvage RP’s and do approximately 50/year. In his experience hands, the patient did well – no nerve sparing was feasible, as expected. His pathology was ypT3b Gleason 8 PCa R0 with 6 days hospitalization. PSA was undetectable 6 weeks post-op.

At last years EAU, Heidenreich et al. presented the sRP experience of 2 centers with large volume experience – between the 2, they had 262 patients who underwent sRP. Median follow-up was 43-45 months. Patients who were pN0 had a 62 month PFS, and those were pN1 had a 31 month PFS.
With his own experience with >350 sRP’s, his selection criteria and evaluation for patients is as follows:

This talk, though unclear how well it can be translated to general practice, show difficult cases that should be handled at high volume centers with significant experience.

Presented by: Axel Heidenreich, MD, Professor, University Hospital Aachen, Department of Urology, Cologne, Germany

Written by: Thenappan Chandrasekar, MD. Clinical Instructor, Thomas Jefferson University, Twitter: @tchandra_uromd, @TjuUrology, at the 16th Meeting of the European Section of Oncological Urology, #ESOU19, January 18-20, 2019, Prague, Czech Republic

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