EURURO Vol. 73 No. 1

140 148

Re: Impact of Radical Prostatectomy on Long-term
Oncologic Outcomes in a Matched Cohort of Men with
Pathological Node Positive Prostate Cancer Managed by
Castration
Bhindi B, Rangel LJ, Mason RJ, et al
J Urol 2017;198:86–91
Experts’ summary:
We read with interest the scientific paper by Bhindi et al [1]
from the Mayo Clinic entitled, “Impact of Radical Prostatec-
tomy on Long-term Oncologic Outcomes in a Matched Cohort
of Men with Pathological Node Positive Prostate Cancer Man-
aged by Castration.” The paper evaluated the long-term (20 yr)
oncologic outcomes of surgical castration plus radical prosta-
tectomy (RP) compared with surgical castration alone in the
treatment of pathological node positive prostate cancer (PCa)
using a retrospective matched cohort analysis. One hundred
and fifty[5_TD$DIFF] eight men (79 in each group) from a cohort treated
between[6_TD$DIFF] 1966 and 1995 were included and crucially over 90%
were followed to death. Patients were matched to age, cT
stage, number of positive nodes, and pre-op prostate-specific
antigen (PSA) where available (57% were pre-PSA era). No
patients had prostatic bed radiotherapy or systemic hormonal
treatment.
The mean age was 65 yr, median PSAwas 51.4 ng/ml, and
59% had three or more positive nodes. In the surgical
castration alone group, 76 of 79 men died during follow-up
with 60 dying of PCa in comparison to the RP plus surgical
castration group where 70 of 79 men died with only
28 dying of PCa. There was a statistically significantly lower
20-yr cancer specific survival (CSS) and overall survival (OS)
for the surgical castration alone group in comparison to the
RP plus surgical castration group (18% vs 59% 20-yr CSS,
p < 0.001 and 9% vs 22% 20-yr OS, p < 0.001).
Experts’ comments:
This paper provides data supporting the use of loco-regional
treatment of advanced/metastatic PCa in addition to systemic
therapy in comparison to standard systemic therapy alone, in
the form of surgical castration[2_TD$DIFF]. A major strength of the study is
the excellent long-term follow-up to death, whilst the issue of
unmeasured bias was addressed adequately using sensitivity
analysis. Unfortunately, quality of life comparisons were out of
the scope of this study but clearly would be of interest. This
study complements the data from population-based studies[3_TD$DIFF]
showing that aggressive loco-regional treatment of advanced
PCa leads to improved CSS and OS [2,3].
The landscape in PCa management is rapidly changing.
There is now high quality, long-term randomized controlled
trial (RCT) evidence showing the lack of benefit of RP in
low-risk PCa Whilst no RCTevidence is available, there is
increasingly high-quality evidence [2,3,5] that RP and
extended pelvic node dissection, in addition to systemic
treatment, confer long-term oncological and survival
benefit in both locally advanced and metastatic (node
positive and oligometastatic disease) that are superior to
the approach of systemic treatment alone that is currently
standard practice for many. Although it is not standard
practice yet due to lack of level 1 evidence, when we look at
the dramatic survival benefit of the emerging evidence as
seen in this study, it seems that it will not be long before this
becomes[7_TD$DIFF] part of the standard treatment paradigm. The
challenge for us is in ensuring that our patients receive
optimal state of the art care, whilst RCT evidence in a
disease with such a long natural history is difficult to accrue,
although studies such as the STAMPEDE study[8_TD$DIFF] (“M1jRT
comparison”) in the UK seek to address this currently.
Conflicts of interest: The authors have nothing to disclose.
References
[1]
.
[2]
.
[3]
.
[4]
.
[5]
.
Daniel W. Gooda,b, Alan S. McNeilla
[1_TD$DIFF]
b, *[4_TD$DIFF]
a Department of Urology, Western General Hospital, NHS Lothian, Edinburgh,
Scotland, UK
bEdinburgh Urological Cancer Group, University of Edinburgh, Edinburgh,
Scotland, UK
*Corresponding author. NHS Lothian, Crewe Road South, Edinburgh EH2
4XU, Scotland, UK.
E-mail address: (A.S. McNeilla
[1_TD$DIFF]* [4_TD$DIFF]).
© 2017 European Association of Urology.
Published by Elsevier B.V. All rights reserved.
Re: Salvage High-intensity Focused Ultrasound (HIFU)
for Locally Recurrent Prostate Cancer After Failed
Radiation Therapy: Multi-institutional Analysis of
418 Patients
Crouzet S, Blana A, Murat FJ, et al
BJU Int 2017;119:896– 904
Expert's summary:
Crouzet et al analysed data from a 4-yr dedicated registry
including 418 patients undergoing whole-gland salvage
high-intensity focused ultrasound (HIFU) treatment
(Ablatherm device). All patients had biochemical recurrence,
a positive postradiation biopsy, and a negative metastatic
E U R O P E A N U R O L O GY 7 3 ( 2 0 18 ) 13 9 – 14 4 140