Abstract
Background
Performing an extended pelvic lymph node dissection (PLND) on all men with intermediate- and high-risk prostate cancer at the time of a radical prostatectomy (RP) remains controversial. The majority of patients PLND histology is benign, and the long-term cancer-free progression in men with positive lymph node metastasis is low. The objective is to investigate the probability of long-term biochemical freedom from recurrent disease (bNED) in men with lymph node metastasis identified at the time of radical prostatectomy (RP).
Subjects and methods
A retrospective review of the pathology of 1184 pelvic lymph node dissections performed at the time of a radical prostatectomy by multiple surgeons referred to a single uro-pathology laboratory between 2008 and 2014 identified 61 men with node-positive prostate cancer. Of the men with positive nodes, 24 had a standard PLND and 37 an extended PLND (ePLND). bNED was defined as a post-operative serum PSA < 0.2 ng/ml.
Results
The median follow-up is 4 years (2–8). The median lymph node count was 7 (range 2–16) for PLND and 22 (range 6–46) for the ePLND. A single lymph node metastasis was identified in 56% of the 61 men. Only 10% of men with a positive lymph node metastasis remained free of biochemical recurrence of disease, and only 5% had undetectable serum PSA. There was no difference in bNED outcome between a PLND and ePLND. The number of men needed to be treated with a PLND at the time of RP (NNT) to result in an undetectable post-operative PSA at a median follow-up of 4 years is 395.
Conclusions
In men with lymph node metastasis, the probability of long-term bNED is low and the NNT for cure is high. With emerging improved radiological imaging techniques increasing the detection of lymph node metastasis outside the extended lymph node dissection templates, more scientific investigation is required to evaluate which men will benefit from a PLND and which men can avoid an unnecessary PLND procedure.
Similar content being viewed by others
References
Mottet N, Bellmunt J, Bolla M, Briers E, Cumerbatch M, Santis M, European Association of Urology Guidelines-EAU-ESTRO-SIOS et al (2017) Guidelines on prostate cancer part 1: screening, diagnosis and local treatment with curative intent. Eur Urol 71(4):618–629
Jemal A, Seigel R, Ward E, Hao Y, Xu J, Thun MJ (2009) Cancer statistics 2009. CA Cancer J Clin 59:225–249
Cagiannos I, Karakiewicz P, Eastham JA et al (2003) A pre-operative nomogram identifying disease risk of positive pelvic nodes in patients with prostate cancer. J Urol 170(5):1798–1803
Yaxley JW, Coughlin GD, Chambers SK et al (2016) Robot-assisted laparoscopic prostatectomy versus open radical prostatectomy: early outcomes from a randomised controlled phase 3 study. Lancet 388(10049):1057–1066
Briganti A, Chun FK-H, Salonia A et al (2006) Complications and other surgical outcomes associated with extended pelvic lymphadenectomy in men with localized prostate. Cancer 50:1006–1013
Fossati N, Willemse PM, van den Broeck, van den Bergh RCN et al (2017) The benefits and harms of different extents of lymph node dissection during radical prostatectomy for prostate cancer—a systematic review. Eur Urol 72(1):84–109. https://doi.org/10.1016/j.eururo.2016.12.003
Fortuin AS, Smeenk RJ, Meijer HJ, Witjes AJ, Barentsz JO (2014) Lymphotropic nanoparticle-enhanced MRI in prostate cancer: value and therapeutic potential. Curr Urol Rep 15:389. https://doi.org/10.1007/s11934-013-0389-7
Perry-Keene J, Ferguson P, Samaratunga H et al (2014) Total submission of pelvic lymphadenectomy tissues removed during radical prostatectomy for prostate cancer increases yield and detection of micrometastasis. Histopathology 64:399–404
Tuoijer KA, Mazzalo CR, Sjoberg DD, Scardino PT, Eastham JA (2014) Long term outcomes of patients with lymph node metastasis treated with radical prostatectomy without adjuvant androgen deprivation therapy. Eur Urol 65:20–25
Seiler R, Studer U, Tschan K, Bader P, Burkhard FC (2014) Removal of limited nodal disease in patients undergoing radical prostatectomy: long term results confirm a chance for cure. J Urol 191:1280–1285
Pierorazio PM, Gorin MA, Ross AE et al (2013) Pathological and oncological outcomes for men with positive lymph nodes at radical prostatectomy: the Johns Hopkins 30 year experience. Prostate 73:1673–1680
Afhar-Oromieh A, Zechmann CM, Malcher A et al (2014) Comparison of PET imaging with (68) Ga—labelled PSMA ligand and (18) F-choline-based PET/CT for the diagnosis of recurrent prostate cancer. Eur J Nucl Med Mol Imaging 41:11–20
Perera M, Papa N, Christidid D et al (2016) Sensitivity, specificity and predictors of positive 68Ga-prostate specific membrane antigen positron emission tomography in advanced prostate cancer: a systematic review and meta-analysis. Eur Urol 70:926–937
Maurer T, Gschwend JE, Rauscher I et al (2016) Diagnostic efficacy of Gallium-PSMA positron emission tomography compared to conventional imaging in lymph node staging of 130 consecutive patients with intermediate to high risk prostate cancer. J Urol 195:1436–1443
Meredith G, Wong D, Yaxley J et al (2016) The use of 68Ga-PSMA PET/CT in men with biochemical recurrence after definitive treatment of acinar prostate cancer. BJU Int 118:49–55
Birkháuser FD, Studer UE, Froehlich JM et al (2013) Combined supraparamagnetic particles of iron oxide enhanced and diffusion weighted MRI facilitates detection of metastasis in normal sized lymph nodes in bladder and prostate cancer. Eur Urol 64:953–960
Mattei A, Fuechsel F, Dhar N et al (2008) The template of primary lymphatic landing sites of the prostate should be revisited: results of multimodality mapping study. Eur Urol 53:118–125
Alemozaffar M, Sandra M, Yecles D et al (2015) Benchmarks for operative outcomes of robotic and open radical prostatectomy: results from the health professionals follow up study. Eur Urol 67(3):432–438
Osmonov DV, Askenov AV, Jilig CA et al (2016) Salvage lymphadenectomy in patients with prostate cancer recurrence. Urol A 55:208–217
Suarti N, Gandaglia G, Gallina A et al (2015) Long term outcomes of salvage pelvic lymph node dissection for clinically recurrent prostate cancer: results of a single-institution series with a minimum follow-up of 5 years. Eur Urol 67:299–309
Siriwardana A, Thompson J, van Leeuwen PJ, Doig S, Kalsbeek A, Emmett L et al (2017) Robot assisted salvage lymphadenectomy: acceptable safety profile but oncological benefit appears limited. BJUI. https://doi.org/10.1111/bju13919
van Leeuwen PJ, Emmett L, Ho B et al (2017) Prospective evaluation of Gallium-prostate specific membrane antigen positron emission tomography/computerized tomography for preoperative lymph node staging in prostate cancer. BJU Int 119:209–215
Budaus L, Leyh-Bannurah S, Salomon G et al (2016) Initial experience of (68)Ga-PSMA PET/CT imaging in high risk prostate cancer patients prior to radical prostatectomy. Eur Urol 69(3):393–396
Hong MKH, Macintyre G, Wedge DC et al (2015) Tracking the origins and drivers of subclonal metastatic expansion in prostate cancer. Nat Comm 6:6605. https://doi.org/10.1038/ncomms7605
Wit EMK, Acar C, Grivas N et al (2017) Sentinel node procedure in prostate cancer. A systematic review to assess diagnostic accuracy. Eur Urol 71(4):576–605. https://doi.org/10.1016/jeuro.2016.09.007 (Epub ahead of print)
Gakis G, Boorjiah SA, Briganti A et al (2014) The role of radical prostatectomy and lymph node dissection in lymph node-positive prostate cancer: a systematic review of the literature. Eur Urol 66(2):191–199
Acknowledgements
We would like to thank John Ricardo Maldonado of Power Stats for performing the statistical analysis for this manuscript.
Author information
Authors and Affiliations
Contributions
JWY contributed to protocol/project development, data collection, data analysis and manuscript writing. JD contributed to data collection and manuscript editing. BD contributed to manuscript writing/editing. LE contributed to manuscript writing/editing. JS contributed to manuscript editing. HS contributed to protocol development, data collection, data analysis and manuscript editing
Corresponding author
Ethics declarations
There was no financial funding for this manuscript. For this type of retrospective study formal consent is not required. No identifying patient information is contained in this study. Ethics approval was provided by Aquesta Institutional Ethics Committee. This article does not contain studies with animals by any author. The authors have no potential conflict of interest to declare in this article.
Conflict of interest
The authors have nil to declare.
Rights and permissions
About this article
Cite this article
Yaxley, J.W., Dagher, J., Delahunt, B. et al. Reconsidering the role of pelvic lymph node dissection with radical prostatectomy for prostate cancer in an era of improving radiological staging techniques. World J Urol 36, 15–20 (2018). https://doi.org/10.1007/s00345-017-2119-0
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00345-017-2119-0