Natural History of Clinical Recurrence Patterns of Lymph Node-Positive Prostate Cancer after Radical Prostatectomy

Background Patients with lymph node (LN)-positive prostate cancer (PCA) at radical prostatectomy (RP) face a high risk of cancer recurrence. Nevertheless, recurrence patterns of LN-positive PCA and their prognostic significance remain understudied in the literature. Objective To analyze a large single-institution series with long-term follow-up to elucidate the various clinical recurrence patterns of LN-positive PCA and their association with oncologic outcomes. Design, setting, and participants Years 1987-2012 of a prospectively maintained institutional RP registry were queried for men with LN-positive PCA at RP. Clinical recurrences were categorized as local, nodal, skeletal, or visceral. Outcome measurements and statistical analysis In addition to descriptive statistics and Kaplan-Meier analysis, univariable and multivariable Cox proportional hazards models were constructed to predict recurrence and to quantify the impact of recurrence patterns on cancer-specific mortality (CSM). Results and limitations Data from 1011 men with LN-positive PCA at RP were analyzed with 17.6 yr of median follow-up. The 15-yr clinical recurrence rate was 33% (95% confidence interval [CI], 31-35%) for all patients and 52.2% (95% CI, 47.3-57.1%) for patients with biochemical recurrence. The solitary locations were skeletal (n = 94, 55%), nodal (n = 59, 34%), local soft tissue (n = 29, 17%), and visceral (n = 8, 5%). Significant multivariable predictors of recurrence were Gleason score 8-10, number of positive nodes, pathologic Gleason score, and more recent year of surgery. The 15-yr CSM after clinical recurrence was 80%, with a mean overall survival of 30 mo after recurrence. On multivariable analysis, recurrences after 5 yr from RP (hazard ratio [HR]: 0.05), multiple recurrences (HR: 1.97), skeletal (HR: 3.13), and visceral metastases (HR: 7.43) were independently associated with CSM (all p < 0.05). Conclusions Recurrences after RP for LN-positive PCA are heterogeneous in terms of time from RP, location, and number of concomitant lesions. Patient summary We found that impact of recurrence patterns on cancer-specific mortality varies significantly and allows these patients to be stratified for purposes of prognostication, follow-up, and therapy.