title: The outcome and prognostic factors for lymph node recurrence after node-sparing definitive external beam radiotherapy for localized prostate cancer.
abstract: BACKGROUND
  The prognostic factors for the recurrence of lymph node (LN) metastasis after dose-escalated radiotherapy (RT) in prostate cancer patients have not been well investigated. We report the prognostic factors and outcomes in patients receiving salvage treatment for LN recurrence after high-dose intensity-modulated RT (IMRT).
  
  
  METHODS
  We studied a cohort of 419 patients with localized prostate adenocarcinoma undergoing definitive IMRT (78 Gy). LN recurrence was diagnosed by size criteria using computed tomography (CT) or magnetic resonance imaging, or abnormal uptake of (18)F-fluorocholine by LNs on positron emission tomography/CT. Overall survival and LN recurrence-free survival (LNRFS) were calculated, and prognostic factors were evaluated.
  
  
  RESULTS
  With a median follow-up of 60 months, 18 patients (4.3 %) had LN recurrence and a significantly lower 5-year overall survival rate (60 vs. 90 %, p = 0.003). Univariate analysis showed that T3/T4 stage (p = 0.003), Gleason score >7 (p < 0.001), and estimated risk of pelvic LN involvement of >30 % by the Roach formula (p = 0.029) were associated with significantly lower LNRFS. On multivariate analysis, high Gleason score (hazard ratio = 5.99, p = 0.007) was the only independent factor. The 1/2-year overall survivals after LN recurrence were 67/54 %. Patients with isolated LN recurrence (p = 0.003), prostate-specific antigen (PSA) doubling time >5 months (p = 0.009), interval between PSA nadir and biochemical failure >12 months (p = 0.035), and PSA <10 ng/ml at LN recurrence (p = 0.003) had significantly better survival. Patients with isolated LN recurrence had significantly better survival when treated with combined RT and hormones than when treated with hormones alone (p = 0.011).
  
  
  CONCLUSIONS
  Gleason score of >7 may predict LN recurrence in prostate cancer patients treated with definitive IMRT. Small number of patients limits the extrapolation of this risk with the primary treatment strategy. Combined RT and hormones may prolong survival in patients with isolated LN recurrence.
authors.affiliation: Department of Radiation Oncology, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan. 14294@s.tmu.edu.tw.
authors.forename: Yu-Jen
authors.initials: YJ
authors.lastname: Wang
authors.affiliation: Departments of Urology, College of Medicine and Hospital, National Taiwan University, No. 7 Chung-Shan South Road, Taipei, 10002, Taiwan. cyhuang0909@ntu.edu.tw.
authors.forename: Chao-Yuan
authors.initials: CY
authors.lastname: Huang
authors.affiliation: Division of Radiation Oncology, College of Medicine and Hospital, National Taiwan University, No. 7 Chung-Shan South Road, Taipei, 10002, Taiwan. houtommy@gmail.com.
authors.forename: Wei-Hsien
authors.initials: WH
authors.lastname: Hou
authors.affiliation: Division of Radiation Oncology, College of Medicine and Hospital, National Taiwan University, No. 7 Chung-Shan South Road, Taipei, 10002, Taiwan. chiachun@gmail.com.
authors.forename: Chia-Chun
authors.initials: CC
authors.lastname: Wang
authors.affiliation: Division of Radiation Oncology, College of Medicine and Hospital, National Taiwan University, No. 7 Chung-Shan South Road, Taipei, 10002, Taiwan. KENGHSUEH.LAN@gmail.com.
authors.forename: Keng-Hsueh
authors.initials: KH
authors.lastname: Lan
authors.affiliation: Departments of Urology, College of Medicine and Hospital, National Taiwan University, No. 7 Chung-Shan South Road, Taipei, 10002, Taiwan. mufasachen@gmail.com.
authors.forename: Chung-Hsin
authors.initials: CH
authors.lastname: Chen
authors.affiliation: Departments of Urology, College of Medicine and Hospital, National Taiwan University, No. 7 Chung-Shan South Road, Taipei, 10002, Taiwan. yhj5251@mtu.edu.tw.
authors.forename: Hong-Jen
authors.initials: HJ
authors.lastname: Yu
authors.affiliation: Departments of Urology, College of Medicine and Hospital, National Taiwan University, No. 7 Chung-Shan South Road, Taipei, 10002, Taiwan. mingkuen2002@gmail.com.
authors.forename: Ming-Kuen
authors.initials: MK
authors.lastname: Lai
authors.affiliation: Departments of Oncology, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan. alcheng@ntu.edu.tw.|Graduate Institutes of Oncology, College of Medicine, National Taiwan University, Taipei, Taiwan. alcheng@ntu.edu.tw.
authors.forename: Ann-Lii
authors.initials: AL
authors.lastname: Cheng
authors.affiliation: Departments of Urology, College of Medicine and Hospital, National Taiwan University, No. 7 Chung-Shan South Road, Taipei, 10002, Taiwan. spliu@mtuh.gov.tw.
authors.forename: Shihh-Ping
authors.initials: SP
authors.lastname: Liu
authors.affiliation: Departments of Urology, College of Medicine and Hospital, National Taiwan University, No. 7 Chung-Shan South Road, Taipei, 10002, Taiwan. yspu@ntu.edu.tw.
authors.forename: Yeong-Shiau
authors.initials: YS
authors.lastname: Pu
authors.affiliation: Division of Radiation Oncology, College of Medicine and Hospital, National Taiwan University, No. 7 Chung-Shan South Road, Taipei, 10002, Taiwan. jasoncheng@ntu.edu.tw.|Graduate Institutes of Oncology, College of Medicine, National Taiwan University, Taipei, Taiwan. jasoncheng@ntu.edu.tw.|Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan. jasoncheng@ntu.edu.tw.
authors.forename: Jason Chia-Hsien
authors.initials: JC
authors.lastname: Cheng
mesh_terms: D000230:Adenocarcinoma / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy*; D000368:Aged; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D060787:Neoplasm Grading; D009364:Neoplasm Recurrence, Local / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy*; D009367:Neoplasm Staging; D011379:Prognosis; D011471:Prostatic Neoplasms / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy*; D050397:Radiotherapy, Intensity-Modulated / Q000401:mortality*; D016879:Salvage Therapy / Q000401:mortality*; D015996:Survival Rate