What is the treatment for metastatic adenocarcinoma of the prostate with retroperitoneal lymph node (lymph node) enlargement?

From the Guidelines

The treatment of metastatic adenocarcinoma of the prostate with retroperitoneum lymph node enlargement should involve androgen deprivation therapy (ADT) with treatment intensification, as recommended by the NCCN guidelines 1. The recommended first-line approach is ADT combined with either docetaxel chemotherapy or a novel hormonal agent such as abiraterone acetate, apalutamide, or enzalutamide.

• The use of ADT monotherapy in this setting is discouraged unless there are clear contraindications to combination therapy 1.
• Treatment intensification options include doublet therapy of ADT with abiraterone, apalutamide, or enzalutamide; triplet therapy of ADT with docetaxel and abiraterone or darolutamide; or ADT with external beam radiation therapy (EBRT) to the primary tumor for low-metastatic burden 1. For patients with high-volume disease or visceral metastases, the combination of ADT with docetaxel or an androgen receptor pathway inhibitor is particularly beneficial.
• ADT can be achieved through either surgical castration (bilateral orchiectomy) or medical castration using LHRH agonists (such as leuprolide) or LHRH antagonists (such as degarelix) 1.
• Bone-targeted agents like zoledronic acid or denosumab should be added for patients with bone metastases to reduce skeletal-related events. The European Urology guidelines also support the use of ADT with treatment intensification, including the combination of ADT with docetaxel or an androgen receptor pathway inhibitor 1.
• The guidelines recommend offering patients IMRT/VMAT plus IGRT in combination with long-term ADT, and considering the addition of abiraterone for patients with high-risk factors 1.

From the FDA Drug Label

1.3 Prostate Cancer Docetaxel Injection in combination with prednisone is indicated for the treatment of patients with metastatic castration-resistant prostate cancer.

The treatment for metastatic adenocarcinoma of the prostate with retroperitoneum lymph node enlargement is Docetaxel Injection in combination with prednisone.

• The recommended dose of Docetaxel Injection is 75 mg/m2 every 3 weeks as a 1 hour intravenous infusion.
• Prednisone 5 mg orally twice daily is administered continuously 2.

From the Research

Treatment Options for Metastatic Adenocarcinoma of Prostate with Retroperitoneum Lymph Node Enlargement

• The standard treatment for metastatic prostate cancer has been androgen deprivation therapy (ADT) alone, but new treatment options have emerged in recent years, including combination therapies of ADT, androgen receptor signaling inhibitors (ARSI), and chemotherapy 3, 4.
• For patients with metastatic hormone-sensitive prostate cancer, combination therapies of two or three agents of ADT, ARSI, and chemotherapy have been established and led to a significant benefit in overall survival 3.
• In patients with metastatic castration-resistant prostate cancer, new therapeutic approaches include ARSI, PARP inhibitors, and Lu-PSMA radioligand therapy, which have improved survival after progression under chemotherapy 3.
• The use of a bispecific T-cell engager (BiTE) is a new promising therapeutic approach, but it has not been established as standard of care yet 3.
• Immunotherapy also plays a role in prostate cancer treatment, but its use is still under investigation 3.

Role of Androgen Deprivation Therapy

• Androgen deprivation therapy (ADT) has been a treatment of choice for prostate cancer in almost all phases, particularly in the locally advanced, metastatic setting in both hormone-sensitive and castration-resistant disease 5.
• Different ways of administering ADT include surgical or chemical castration with the use of gonadotropin-releasing hormone (GnRH-agonists) being the foremost way of delivering ADT 5.
• The choice of ADT hinges upon cost, availability, ease of administration, and preference amongst physicians and patients alike 5.

Treatment of the Primary Tumor

• The standard treatment in metastatic prostate cancer is systemic, based on androgen deprivation therapy recommended in different forms, alone or combined with abiraterone acetate or docetaxel 6.
• Multimodal treatments offer the best chance for survival for these patients, but the optimal strategy lacks consensus 6.
• Local therapies, such as radical prostatectomy or radiotherapy, can achieve local control of disease and avoid potential complications and further surgical interventions 6.

Evolution of Treatment Options

• Over the past 7 decades, androgen-deprivation therapy (ADT) has been the cornerstone of treatment for metastatic non-castrate prostate cancer (NCPC) 7.
• Despite treatment with ADT, most men will progress to castrate-resistant prostate cancer (CRPC), and new treatment options have emerged for CRPC, which could also have a meaningful role earlier in NCPC 7.