Presentation Authors: Stephen Ryan*, Fady Ghali, San Diego, CA, Moritz Hansen, Matthew Hayn, Jesse Sammon, Portland, ME, Reith Sarkar, James Don Murphy, A. Karim Kader, Brent Rose, San Diego, CA
Introduction: A prostate cancer (PCa) patient with non-metastatic but clinical positive lymph nodes (cN+) represents a difficult clinical scenario. Advocates for radical prostatectomy (RP) cite the high false positive rate of imaging (pN-) and overall survival (OS) benefit in men with a â‰¤2 positive lymph nodes (pN+). While others consider cN+ an omen of metastatic disease and advocate for systemic treatment without curative intent therapy. We compared OS after RP in cN- (High Risk), cN+/pN- (Discordant), and cN+/pN+ (Concordant).
Methods: The National Cancer Database was queried for all PCa patients from 2004-2013. Inclusion criteria were known age and PSA at diagnosis, biopsy Gleason score, TNM staging (cT1-3B, cN0/1, M0/X), margin, nodal status and primary treatment modality. cN+ was separated into two cohorts: pN- (Discordant) and pN+ (Concordant). RPs for High Risk PCa (cT3a/b or GS >=8 or PSA >20) with cN- was used as a comparison. OS was analyzed with Kaplan Meier (KMA) and Cox proportional hazard model combing demographic, clinical, and pathological factors.
Results: 4944 cN+ men were identified (21.7% RP, 27.5% systemic therapy only). 794 RPs had completed records. Discordant and Concordant represented 18.8% and 81.2% with median follow-up 48 and 48.9 months, and 13 and 97 deaths, respectively. KMA pairwise OS of High Risk (n=35,502) verses Discordant was not significant (p=0.28) but was significant verses Concordant (p < 0.001). There was no difference in OS on KMA between Discordant and Concordant (p=0.11). OS on Cox proportional hazard model, High Risk and Discordant had no observable difference (p=1.22). Concordant pathology had much worsened OS (HR 1.829, p < 0.001), as well as Medicaid/Medicare patients (HR 1.344, p < 0.001), biopsy Gleason score â‰¥8 (HR 1.350, p=0.0019), pathologic T stage (pT3a HR 1.567, pT3b 2.396, p < 0.001), and positive surgical margin (HR 1.257, p < 0.001).
Conclusions: In a large cohort of nonmetastatic PCa patients with cN+ disease, >27% were treated with systemic therapy based on clinical staging, but 18.8% of cN+ RPs were incorrectly staged. There was no difference in OS between cN- High Risk patients and pathologic Discordant (cN+/pN-) men, and the much worse OS in men with pN+. Study is needed for a more accurate clinical staging tool to identify the pathologically discordant population.