JCU - January 2022 - 27

Gilliland et al.
27
Table 1. Pathological high-risk prostate cancer cohort
demographics.
Variable
Number of patients
Median age at surgery (years)
Median diagnostic prostatespecific
antigen (ng/ml)
Median follow-up (months)
pT2a
pT2b
pT2c
pT3a
pT3b
pT4
N1 (any)
Gleason 6
Gleason 7
Gleason 8−10
Gleason not applicable due to
preop ADT
ADT: androgen deprivation therapy.
patient developed a pulmonary embolus requiring HDU
admission. Twelve patients (1.8%) experienced a delayed
complication. These included one bladder neck stenosis,
four submeatal strictures, four urethral strictures and two
incisional hernias.
Information on functional outcomes was prospectively
collected in our patients. The present data mirrors the original
complex British Association of Urological Surgeons
(BAUS) dataset audit fields and includes information on
continence and erectile function. The details are shown in
Table 2. Data were available from 532 patients (79.5%),
with 243 patients (45.6%) described as continent, 182
patients (34.2%) with minor stress leakage and 50 patients
(9.4%) were using one pad per day; 7.5% (40 patients)
were using more than one pad per day, 3.2% (17) were
using an appliance and three patients (0.4%) had a subsequent
artificial urinary sphincter inserted. Information on
erectile function was available for 533 patients (79.6%).
452 patients (85%) described full erectile dysfunction
(ED), 65 patients (12.2%) reported partial ED and 16
patients (3%) were recorded as potent.
OS was 94.3% (631 patients), CSS was 98.7% (660
patients) and BCR-free survival was 45.6% (305 patients).
Figure 1(a) illustrates Kaplan-Meier curves for OS and
Number
669
65 (44−78)
11 (1.2−118)
66 (8−129)
1
1
6
410
249
2
76
35
500
113
11
CSS. Figure 1(b) shows Kaplan-Meier curves for BCR
according to pathological stage. This includes a Cox regression
analysis which indicates that pathological stage
P=0.003, any positive margin P=0.005 and age of the patient
P=0.026 are the significant predictors of BCR, an observation
also reflected in the hazard ratios. Figure 2 (a)/(b)
shows similar curves for BCR according to pathological
stage and postoperative Gleason score. The log-rank analysis
demonstrates that patients with N1 disease and Gleason
8 and 9 are most likely to experience a BCR.
Overall, 363 patients (54.2%) experienced a BCR and
328 went on to have one or more salvage treatments, with
an overall salvage treatment rate of 90.3% in patients with
BCR. Patients with BCR were divided into immediate (⩽6
months), and delayed (>6 months), to represent distant
and local recurrence, respectively. Patients undergoing salvage
treatments were analysed as having prostate bed radiotherapy
of any duration or fractions, prostate bed
radiotherapy and ADT of any duration or type, ADT alone
of any duration or type, and any other (chemotherapy with
or without radiotherapy with or without ADT), and those
treated conservatively with observation only.
The average PSA in the immediate BCR subgroup (163
patients) was 1.63 (0.03-40.5), with 89.6% (146 patients)
receiving subsequent salvage treatment.
Figure 3(b) illustrates the effects of salvage treatments
on subsequent BCR using Kaplan-Meier graphs. Visually,
the curve for radiotherapy alone to the prostate bed differs
significantly
from the other treatments. This is
reflected in the log-rank analyses comparing RT plus
ADT vs RT alone, ADT vs RT alone and RT alone vs
other, with calculated P values of P<0.0001, P<0.0001
and P=0.010, respectively. None of the 78 patients in the
immediate BCR group who received prostate bed radiotherapy
experienced a durable response. All went on to
have a subsequent BCR, with 45 (57.6%) receiving subsequent
systemic salvage treatments, and 31 (39.7%)
patients subsequently observed.
In the delayed BCR subgroup (197 patients), 73
patients (37.1%) were simply observed with PSA surveillance
and received no further salvage treatment.
Sixty patients (30.4%) received prostate bed radiotherapy,
with 35 of these patients (43.2%) experiencing a
durable response. The median time to BCR from surgery
for these patients was 32.5 months (7-90 months) with
an average PSA of 0.41 at the time of treatment (range
0.06-5). Of the remaining patients, 25 received prostate
bed radiotherapy plus ADT, 16 received ADT, three had
chemotherapy with or without ADT with or without
radiotherapy.
Figure 3(c) illustrates the Kaplan-Meier graphs for salvage
treatments and further subsequent failure in the
delayed BCR group. The log-rank analyses revealed no
significant difference between subsequent failure between
the salvage treatments.

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