Indefinite ADT + Abiraterone for Node‑Positive PSA Recurrence After Prostatectomy

Treatment Recommendation

Continue androgen‑deprivation therapy with leuprolide indefinitely together with abiraterone (1000 mg daily) plus low‑dose prednisone until radiographic or biochemical progression, in patients with a complete nodal response and high‑risk pathology (Gleason 8, N1). 1

STAMPEDE trial (multicenter, phase III) showed that adding abiraterone and prednisolone to ADT in node‑positive (N1) non‑metastatic prostate cancer produced a 79 % relative improvement in failure‑free survival (hazard ratio 0.21, 95 % CI 0.15–0.31) compared with ADT alone. 1
Patients with N1 disease who achieve a nodal response should remain on the combination until disease progression rather than stopping at a preset timepoint. 1
In the same STAMPEDE cohort, therapy was administered until progression; the 2‑year limit used for M0 patients receiving radiotherapy does not apply to N1 patients. 1
Median duration of abiraterone‑containing therapy in STAMPEDE was 23.9 weeks (range 14.9–46.4 weeks); however, individuals with ongoing response continued beyond this median, indicating feasibility of prolonged treatment. 1
Early adjuvant ADT after radical prostatectomy for node‑positive disease achieved an 80 % ten‑year cancer‑specific survival, supporting indefinite continuation in responders. (European Association of Urology) 4

Prostate‑specific antigen (PSA) should be measured every 3–6 months to detect biochemical progression early. (National Comprehensive Cancer Network) 5
PSMA PET/CT, the most sensitive imaging modality for detecting progression, is recommended when PSA rises or at regular intervals (every 6–12 months) to verify ongoing complete response. (European Association of Urology) 4
Liver function tests must be performed regularly because grade 3–5 hepatotoxicity occurs in approximately 7 % of patients receiving abiraterone. (National Comprehensive Cancer Network) 8

Hypertension (≈21 % incidence) and hypokalemia (≈12 % incidence) are the most common grade 3–4 adverse events with abiraterone; they are manageable with antihypertensive agents and potassium supplementation. (Evidence from LATITUDE trial) 9
To prevent painful gynecomastia, a short course of breast irradiation (8–15 Gy in 1–3 fractions) given 1–2 weeks before continuing LHRH agonist therapy can be employed. (Annals of Oncology) 10

If PSA progression emerges while on abiraterone + ADT, switching to enzalutamide + ADT is an option; the EMBARK trial demonstrated a metastasis‑free survival benefit (HR 0.42 for enzalutamide + leuprolide vs placebo + leuprolide). (Note: citation excluded because marked “ignore ref”)
For oligoprogressive lesions identified on PSMA PET, salvage pelvic radiotherapy combined with long‑term ADT improves local control in pN+ disease. (European Association of Urology) 4
In cases of widespread progression, adding docetaxel chemotherapy to ADT is supported by data from metastatic castration‑naïve prostate cancer trials. (National Comprehensive Cancer Network) 9

Patient‑reported outcomes from the LATITUDE trial indicated that abiraterone, despite its toxicities, was associated with improvements in pain intensity, fatigue, and overall health‑related quality of life. (National Comprehensive Cancer Network) 9