Twelve-year outcomes of prostate cancer after radical prostatectomy for T3 and/or positive margins managed with surveillance or salvage radiation therapy, based on risk groups()

BACKGROUND: To assess 12-year outcomes on radical prostatectomy with T3/positive margins, while categorizing patients into risk groups. METHODS: From 2004 to 2007, 862 radical prostatectomy patients had T3/positive margins. Management included surveillance (54.8%), salvage radiation therapy (SRT) (36.8%), and primary androgen deprivation therapy (ADT) (8.5%). Freedom from biochemical failure, metastasis-free-survival (MFS), prostate cancer–specific survival (PCSS) were estimated using Kaplan-Meier. Multivariable analysis established prognostic factors that affected PCSS, which were used to form risk groups. Subanalysis was performed on SRT patients. RESULTS: Median follow-up was 12.1 years. T3b, Gleason score (GS), and detectable postoperative PSA independently lowered PCSS. Very–low-risk (VLR) were GS 6. Low-risk (LR) were GS 3 + 4 with T3a or positive margins, but undetectable postoperative PSA <0.1. High-risk (HR) were T3b with GS 7-10, or any GS 7-10 with T3a/b and positive margins, but undetectable PSA. Ultra–high-risk (UHR) were detectable PSA with GS 7-10. Median time to first salvage treatment for VLR, LR, HR, and UHR were 11.1, 10.8, 5.3, and 0.6 years, p < 0.001. The 12-year freedom from biochemical failure for VLR, LR, HR, UHR were 60.2%, 52.9%, 28.4%, and 0%, p < 0.001. For 12-year MFS, 99.1%, 97.8%, 88.6%, and 63.6%, p < 0.001. For 12-year PCSS, 99.5%, 99.4%, 93.5%, and 78.9%, p < 0.001. For subanalysis of 317 SRT patients, 10-year MFS were 100.0%, 97.0%, 88.2%, and 84.6%, p = 0.008. CONCLUSIONS: Outcomes of VLR/LR yields excellent results using surveillance or SRT as initial management, in which adjuvant radiation therapy or ADT plus SRT can be avoided. For HR, early SRT or adjuvant radiation therapy can be considered reasonable, and UHR patients may benefit from ADT plus immediate SRT.