What are the indications for adjuvant Androgen Deprivation Therapy (ADT) after radical prostatectomy in patients with pT3 disease and a Gleason score of 7?

Adjuvant ADT After Radical Prostatectomy for pT3 Gleason 7 Disease

Adjuvant ADT is NOT routinely indicated for pT3 Gleason 7 disease after radical prostatectomy unless positive lymph nodes are found. 1

Primary Indication: Lymph Node Positive Disease Only

The role of adjuvant ADT after radical prostatectomy is restricted to cases where positive pelvic lymph nodes are discovered, as neoadjuvant or adjuvant ADT generally confers no added benefit in men who have undergone radical prostatectomy without nodal involvement. 1

• For patients with positive lymph nodes found during or after radical prostatectomy, ADT is a category 1 option (highest level recommendation). 1
• The Messing trial demonstrated that immediate ADT in node-positive patients improved overall survival at 11.9 years median follow-up (HR 1.84; 95% CI 1.01-3.35). 1

What to Do Instead for pT3 Node-Negative Disease

For your patient with pT3 Gleason 7 disease without positive lymph nodes, the evidence-based approach is:

Adjuvant Radiation Therapy - The Preferred Option

Adjuvant radiotherapy (not ADT) is the appropriate adjuvant treatment for pT3 disease with adverse pathologic features. 1, 2

• Adjuvant RT should be delivered within 1 year after surgery for patients with:

  • Extracapsular extension (which defines pT3a) 1, 2
  • Seminal vesicle invasion (pT3b) 1, 2
  • Positive surgical margins, especially if diffuse (>10mm or ≥3 sites) 1, 2
  • Short PSA doubling time (<9 months) 1, 2

• The German trial by Wiegel et al specifically studied pT3 disease with undetectable PSA after radical prostatectomy and found adjuvant radiation improved 5-year biochemical progression-free survival (72% vs 54%; HR 0.53). 1, 2

• SWOG 8794 demonstrated improved 10-year biochemical failure-free survival for high-risk patients with seminal vesicle invasion receiving adjuvant radiation (36% vs 12% for observation; P=.001). 1, 2

Observation is Also Acceptable

Observation after radical prostatectomy remains appropriate, particularly if:

• PSA remains undetectable 1
• Surgical margins are negative 1
• No seminal vesicle invasion 1

Critical Distinction: ADT with Radiation vs ADT Alone

If you choose adjuvant radiation therapy, adding short-term ADT (4-6 months) may be considered for intermediate-risk features (Gleason 7), though this is primarily supported by data in the primary radiation setting, not post-prostatectomy. 1

However, ADT alone without radiation has no role in the adjuvant post-prostatectomy setting for node-negative disease. 1

Special Consideration: Very High-Risk Features

If your patient has additional very high-risk features beyond just pT3 and Gleason 7, such as:

• Gleason 8-10 (not your case) 2
• Multiple adverse factors 1
• Persistent detectable PSA post-operatively 1

Then consider adjuvant radiation with concurrent and adjuvant ADT for 12-24 months, as longer ADT duration (≥12 months) with post-prostatectomy radiation is associated with improved outcomes in high-risk disease. 3

Common Pitfall to Avoid

Do not initiate ADT monotherapy based solely on pT3 staging and Gleason 7. This represents a common misapplication of guidelines that recommend ADT with primary radiation therapy for high-risk disease. 1 The post-prostatectomy setting is fundamentally different, and ADT alone does not improve survival in node-negative patients. 1