prostate - specific antigen ( psa ) screening has resulted in a down - staging of prostate cancer , with the incidence of nodal metastases decreasing from 20% to 40% in the 1980s to 5% to 10% more recently . the extent of lymph node dissection and the patient selection criteria might be other causes of these differences . lymph node metastasis is generally regarded to be a poor prognostic indicator in patients with prostate cancer . in patients with nodal metastases , nodal progression develops at a median of 18 to 24 months after radical prostatectomy ( rp ) , with a 5 year overall survival ( os ) rate of 39.5% . although androgen - deprivation therapy ( adt ) has been shown to benefit patients with high - risk , localized disease who are undergoing radiotherapy [ 9 - 11 ] , its role in patients with nodal metastases after rp is unclear . although immediate adjuvant adt in patients with nodal metastasis after rp has been found to improve os and progression - free survival ( pfs ) , controversy remains about the treatment effect of adjuvant adt on survival . in addition , because long - term adt has the potential for serious side effects , including osteoporosis , cardiovascular disease , diabetes , and mood disorder , the initiation and maintenance of adt should be considered carefully . we therefore assessed the role of adjuvant adt for 2 years on disease progression after rp for node - positive prostate cancer . of 937 patients who underwent rp performed by a single surgeon between 1990 and 2008 , we identified 40 ( 4.2% ) who had lymph node metastasis . of these 40 patients , 18 received adjuvant adt for 2 years ( adt group ) , whereas the remaining 22 were followed without therapy ( observation group ) . forms of adt included bilateral orchiectomy in 2 patients and maximal androgen blockade including lhrh agonist injection and oral antiandrogens in the remaining 16 patients . postoperatively , psa was measured every 3 months for the first 2 years , and every 6 months thereafter , unless recurrence was suspected . in all patients , psa was undetectable at the first hospital visit except in 3 patients in the observation group with psa levels of 13.6 ng / ml , 23.4 ng / ml , and 20.6 ng / ml . radiographic evaluation included abdominopelvis computed tomography ( ct ) or pelvic magnetic resonance ( mr ) and radionuclide bone scans , which were performed every 6 months and when clinically indicated . biochemical recurrence ( bcr ) after rp was defined as two consecutive serum psa concentrations > 0.2 ng / ml , and clinical progression was defined as local recurrence or distant metastasis on imaging study . after clinical progression was detected , two patients ( 2/6 ) in the adt group and three patients ( 3/9 ) in the observation group received radiotherapy . clinicopathological factors and 5 year pfs , cancer - specific survival ( css ) , and os rates were compared in the two groups by using chi - squared tests , kaplan - meier analysis , and the log rank test . chicago , il , usa ) was used for all statistical analyses , with a p - value 0.05 considered statistically significant . in the adt group , predictive factors of clinical progression were evaluated ; in the observation group , the incidence and predictive factors of bcr were analyzed . none of the patients in the adt group experienced severe complications requiring discontinuation of therapy . at the time of rp , the mean patient age was 64.0 years and the mean serum psa concentration was 34.8 ng / ml . of the 40 patients , 31 ( 77.5% ) had surgical gleason scores 8 and 27 ( 67.5% ) had tumors of pathological stage t3b . there were no significant differences between the adt group and the observation group in age , preoperative psa , surgical gleason score , pathological stage , number of positive lymph nodes , or percentage with positive surgical margins ( table 1 ) . the clinical 5 year pfs , css , and os rates of the entire patient cohort were 75.0% , 85.0% , and 72.5% , respectively . six ( 33% ) patients in the adt group experienced clinical progression at a median 42.7 months . in this group , five patients died , three due to prostate cancer , making the 5 year pfs , css , and os rates of this group 72.2% , 83.3% , and 72.2% , respectively . in the observation group , 14 ( 63.6% ) patients received salvage hormonal therapy owing to bcr , which was observed at a median 22.9 months after rp . the remaining eight ( 36.4% ) patients did not experience bcr during a median follow - up of 32.3 months . nine patients ( 9/22 , 40.9% ) in the observation group experienced clinical progression at a median 43.4 months after rp and a median 20.5 months after salvage hormonal therapy . in this group , six patients died , three due to prostate cancer , making the 5 year pfs , css , and os rates 77.2% , 86.4% , and 72.8% , respectively . there were no significant differences between the groups in clinical progression or survival ( figs . 1 , 2 ) . the pattern of clinical progression in the adt group included three patients with bone metastases , two with lymph node metastases , and one with metastasis at the local prostatectomy site ; the mean psa level of these patients was 19.1 ng / ml ( range , 1.1 to 81.0 ng / ml ) . in the observation group , five patients had bone metastases , three had lymph node metastases , and one had lung metastasis ; the mean psa level was 42.7 ng / ml ( range , 0.04 to 341 ng / ml ) . age , preoperative psa , surgical gleason score , number of positive lymph nodes , and positive surgical margin were not prognostic for clinical progression in the adt group or for bcr in the observation group . in the observation group , however , bcr developed in 12 of 13 patients ( 92.3% ) with pt3b tumors and in 2 of 9 patients ( 22.2% ) pt3a or less ( table 2 ) . of the 14 patients with pt3b disease in the adt group , 6 had clinical progression at a median 42.2 months after rp . of 13 patients in the observation group with pt3b disease , 12 received salvage hormonal therapy due to bcr at a median 20.6 months after rp and 6 had clinical progression at a median 22.5 months after salvage therapy . the benefits of adjuvant adt for patients with node - positive prostate cancer after rp are still unclear . we found that 6 of 18 ( 33.3% ) adt - treated patients experienced clinical progression at a median 42.7 months , compared with 9 of 22 ( 40.9% ) patients in the observation group , who experienced clinical progression at a median 43.4 months , indicating that adjuvant adt in patients with node - positive prostate cancer did not reduce or delay disease progression . moreover , there were no between - group differences in the 5 year css and os rates . in contrast , messing et al reported that immediate adjuvant adt improved pfs , css , and os in 47 patients who received immediate adt after rp and in 51 patients who were observed , with adt to be started after detection of distant metastases or symptomatic recurrences . the discrepancy between these studies may be due to the clinicopathological characteristics of the patients included in the retrospective analyses . that is , although the percentages of patients with pt3b disease and positive surgical margins did not differ , 77.5% of our patients had a gleason score 8 compared with 12.2% in the previous study . thus , our patients were at higher risk of recurrence although they received adt , which may have resulted in more developed clinical progression than in the previous study . in addition , the timing and duration of adt were not mentioned in the previous study , whereas we initiated adt at a mean 4.2 months after rp and continued treatment for 2 years . these differences in timing and duration of adt may be associated with disease progression . of the 22 patients in the observation group , 8 ( 36.3% ) although nodal metastases after rp represent a poor pathologic characteristic , not all patients are at the same risk of bcr and cancer - specific death . the proportion of patients without any adjuvant therapy not experiencing bcr was reported to be 15% in a previous study . in the current study , we were unable to identify differentiating prognostic factors between the patients developing bcr and those who did not , other than the pathological t stage . because bcr did not develop in 36.4% of patients in the observation group and patients with pt3a disease or less had a significantly lower risk of bcr , stage pt3a or less may indicate observation rather than initiation of adt , thus reducing the adverse effects of long - term adt . in regard to the initiation of adjuvant adt in patients with pt3bn+ disease after rp , we found no significant difference in clinical progression between patients with pt3b disease who received adjuvant adt or salvage hormonal therapy . in patients with pt2 - 4 prostate cancer , including 64.3% with pt3b disease , and lymph node metastasis , the combination of adjuvant adt and radiotherapy improved css and os . similarly , adjuvant adt plus radiotherapy in patients with node - positive prostate cancer , 60.8% with pt3b disease , improved recurrence - free survival and css . in patients with pt3bn+ , the combination of adjuvant adt and radiotherapy may improve disease control compared with adjuvant adt alone . because adjuvant adt failed to demonstrate survival differences or delay clinical progression , the timing of salvage adt may also be questioned . in failing patients , hormonal manipulation did not seem to extinguish the cancer in the entire population . in this regard , adt could be reserved until a measurable lesion is formed or clinical symptoms ensue . this study had several limitations , including its retrospective design and inclusion of a relatively small number of patients with node - positive prostate cancer , thus reducing the power of statistical analysis . moreover , multivariate analysis of factors affecting bcr in the observation group could not be done because of the small sample size . the effect of duration of adjuvant adt may have affected disease progression and patient survival . therefore , additional studies are needed to clarify the effects of long - term adt . adjuvant adt in patients with node - positive prostate cancer did not reduce or delay disease progression or improve survival . because a substantial number of untreated patients with pt3a or less did not develop recurrence after rp , administration of adt should be initiated carefully in these patients . however , in patients with pt3b disease , adjuvant adt and radiotherapy could be considered .
purposethe survival benefits of adjuvant androgen - deprivation therapy ( adt ) in prostate cancer and lymph node metastasis remain unclear . 
 we assessed the role of adt in disease progression after radical prostatectomy ( rp).materials and methodsof 937 patients who underwent rp , we identified 40 ( 4.2% ) who had lymph node metastasis . 
 a total of 18 received adjuvant adt ( adt group ) and 22 were observed ( observation group ) . clinical progression - free survival ( pfs ) , cancer- specific survival ( css ) , and overall survival ( os ) were compared in the 2 groups . 
 prognostic factors for clinical progression and biochemical recurrence ( bcr ) were analyzed.resultsthe 5-year pfs , css , and os of the entire cohort were 75.0% , 85.0% , and 72.5% , respectively . in the adt group , 
 6 patients ( 33.3% ) showed clinical progression at a median 42.7 months . 
 the 5-year pfs , css , and os rates of this group were 72.2% , 83.3% , and 72.2% , respectively . in the observation group , 14 patients ( 63.6% ) received salvage therapy owing to bcr . 
 nine patients ( 40.9% ) with bcr in the observation group showed clinical progression at a median 43.4 months after rp . 
 the 5-year pfs , css , and os rates of this group were 77.2% , 86.4% , and 72.8% , respectively . in the observation group , 
 the bcr rate was lower in patients with pt3a or less disease than in those with pt3b disease.conclusionsadjuvant adt in node - positive prostate cancer did not reduce or delay disease progression or improve survival . because a substantial number of untreated patients with pt3a or less disease did not experience recurrence , administration of adt should be initiated carefully . 
 however , in patients with pt3b disease , adjuvant adt and radiotherapy could be considered .