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subsequent reduced screening measures, we might expect a

stable or even increasing fraction of PCa patients with lymph

node–positive disease


. In 2015, 12% of newly diagnosed

patients in the USA presented with regional lymph node



. The ECOG 3886 trial represents the only trial

conducted and published to date with level 1 evidence for

patients with any pT pN1M0 disease after RP


. In this

multicenter study, 98 patients with pN1 disease after RP

(treatment period 1988–1993) were randomized either to

receive immediate ADT (


= 47) or to be observed (


= 51),

with ADT provided when symptomatic recurrence or distant

metastasis occurred. After median follow-up of approximately

12 yr, men assigned to immediate ADT had a significant

improvement in OS (HR 1.84, 95% CI 1.01–3.35). It is ques-

tionable whether this patient pool randomized on average

25 yr ago reflects the tumor characteristics of patients diag-

nosed nowadays with lymph node–positive disease (partly

with just marginal lymph node involvement) and whether the

results reported can be transferred to current times consider-

ing the targeted treatment options now available. Besides the

study by Jegadeesh et al, there are further retrospective stud-

ies providing evidence of a survival benefit when patients are

treated with aggressive multimodal therapy including ART


. Despite these optimistic data, several questions remain:

(1) What target volume should be defined for ART and what

benefit results from additional radiation of lymphatic

drainage paths?

(2) What is the role of ART of the prostate bed for stage


(3) Can we—on the basis of postoperative PSA nadirs,

histopathologic and surgical criteria, and genomic

markers (which still need to be defined)—identify

pN1 patients for whom we can avoid any adjuvant


(4) To what extent can modern radiation techniques

and regimes involving image guidance, volumetric

modulated arc therapy, or intensity-modulated radia-

tion therapy improve oncologic safety and reduce

treatment-associated side effects?

(5) Is there an optimal systemic treatment partner for

combination with ART, and for what time periods

should medical treatment be administered?

The study by Jegadeesh et al represents a proper

retrospective evaluation that may guide clinical decision-

making, and it suggests that ART should be seriously

considered in this patient population. However, relevant

level 1 evidence is still lacking. In due consideration of

the questions above, increased efforts are required to design

a randomized controlled trial evaluating adjuvant locor-

egional treatment for lymph node–positive PCa after RP.

Conflicts of interest:

Sabine Brookman-May is employee of Janssen

Pharma Research and Development Oncology. There is no conflict of

interest with regard to the topic of this article. The remaining authors

have nothing to disclose.



Reese AC, Wessel SR, Fisher SG, Mydlo JH. Evidence of prostate cancer ‘‘reverse stage migration’’ toward more advanced disease at diagnosis: data from the Pennsylvania Cancer Registry. Urol Oncol 2016;34, 335.e21–e28.


Baker BR, Mohiuddin JJ, Chen RC. The role of radiotherapy in node- positive prostate cancer. Oncology 2015;29:108–14.


Messing EM, Manola J, Yao J, et al. Immediate versus deferred androgen deprivation treatment in patients with node-positive pros- tate cancer after radical prostatectomy and pelvic lymphadenectomy. Lancet Oncol 2006;7:472–9



Abdollah F, Karnes RJ, Suardi N, et al. Impact of adjuvant radiother- apy on survival of patients with node-positive prostate cancer. J Clin Oncol 2014;32:3939–47.

[5] Tilki D, Preisser F, Tennstedt P, et al. Adjuvant radiation therapy is

associated with better oncological outcome compared with salvage

radiation therapy in patients with pN1 prostate cancer treated with

radical prostatectomy. BJU Int. In press. bju.13679 .


Crehange G, Weinberg VK, Izaguirre A, et al. Disease-specific survival outcomes in lymph node-positive patients with prostate cancer treated with radiotherapy. J Clin Oncol 2011;29(7 Suppl):182


Matthias May


, Christian G. Stief


, Sabine D. Brookman-May




Department of Urology, Klinikum St. Elisabeth, Straubing, Germany


Department of Urology, Ludwig-Maximilians University Munich,

Munich, Germany


Janssen Research and Development, Los Angeles, CA, USA

*Corresponding author. Department of Urology, Ludwig-Maximilians

University Munich, Campus Grosshadern, Marchioninistraße 15,

81377 Munich, Germany.

E-mail address:

(S.D. Brookman-May).


2017 European Association of Urology.

Published by Elsevier B.V. All rights reserved.

Re: The Detection of Androgen Receptor Splice Variant

7 in Plasma-derived Exosomal RNA Strongly Predicts

Resistance to Hormonal Therapy in Metastatic Prostate

Cancer Patients

Del Re M, Biasco E, Crucitta S, et al

Eur Urol 2017;71:680–7

Expert’s summary:

A splice variant of the androgen receptor (AR-V7) lacks the

androgen-binding domain. Detection of this splice variant

may be linked to prostate cancer resistance to hormonal



. However, previous studies were based on

circulating tumor cells, which are cumbersome to collect

and may yield false-negative results. Del Re et al have estab-

lished a plasma-based


method for the detection of AR-V7.

E U R O P E A N U R O L O G Y 7 1 ( 2 0 1 7 ) 8 3 1 – 8 3 6