Introduction & Objectives: To compare BCR-free survival (BCR-FS), metastasis-free survival (MFS), and overall survival (OS) rates between radical prostatectomy (RP) vs. radiotherapy (EBRT) as primary radical treatment in clinical node positive (cN1) prostate cancer (PCa) patients. Materials & Methods: We relied on a multicentric database of 402 consecutive cN1 patients (according to either RECIST1.1 or PROMISE criteria) from 16 Academic institutions, of whom 66 (16%) vs. 336 (84%) were treated with primary EBRT and RP, respectively. Logistic regression models assessed PSA persistence after RP vs EBRT. Kaplan-Meier plots and Cox regression models tested the effect of RP vs EBRT on BCR-FS, MFS, and OS. All analyses were adjusted for age, D’Amico risk group, subsequent treatment with adjuvant or salvage EBRT, and administration of androgen deprivation therapy (ADT). Results: Overall, RT patients were older (73 vs 67 years) and presented with more adverse D’Amico criteria (high-risk 88% vs 69%,intermediate- risk 12% vs 25%, low-risk 0% vs 6%), as compared to their RP counterparts. After logistic regression analyses, we did not record differences in PSA persistence in RP vs EBRT (OR 1.81, 95% CI 0.81-4.17, p=0.15). 5-year BCR-FS, MFS, and OM were respectively 86 vs 76% (p=0.15), 97% vs 83% (p=0.051), and 87 vs 97% (p<0.001) in EBRT vs RP groups. These rates did not translate into statistically significant hazard ratios (HRs) in favor of one treatment for early oncological outcomes. Specifically, compared to EBRT, RP yielded an HR of 0.66 (95% CI 0.18-2.45, p=0.5) for BCR-FS, and 1.07 (95% CI 0.20-5.65, p=0.9) for MSF. However, OS rates translated into an HR of 0.08 (95% CI 0.01-0.46, p=0.005) in favor of RP, after adjustment for age, D’Amico risk, subsequent treatment with adjuvant / salvage EBRT, and administration of ADT. Conclusions: Our study suggests that RP and EBRT have similar early oncological outcomes, but RP might hold an OS advance in the treatment of cN1 PCa, even after adjustment for age, adverse clinical features, and subsequent adjuvant or salvage treatments.
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