San Diego, CA USA (UroToday.com) In this session, Dr. Eastham addressed some of the aspects of performing lymphadenectomy at the time of radical prostatectomy (RP). He noted that lymphadenectomy at RP provides both diagnostic and staging information, but the therapeutic benefit is less clear. Nonetheless, interest in both extending the limit of the node dissection and in new settings such as salvage lymph node dissection remain.
From a diagnosis and staging standpoint, Dr. Eastham referenced Dr. Studer’s pelvic lymph node mapping studies, which clearly demonstrate the majority of positive nodes occurring below the obturator nerve, along the hypogastric chain, and up to the common ileac lymph nodes. As such, the EAU guidelines for surgery in prostate cancer state that a pelvic lymph node dissection must be done in clinically localized intermediate and high risk disease and that it should be extended given the limitations of current preoperative imaging techniques in the diagnosis of oligometastatic nodal disease. Similarly, the NCCN guidelines state that an extended pelvic lymphadenectomy will discover metastatic disease approximately twice as often as limited pelvic lymphadenectomy. Extended pelvic lymphadenectomy provides a more complete assessment and should be performed in patients with > 2% predicted probability of nodal metastases based on predictive nomograms.
The therapeutic benefit of pelvic lymphadenectomy in patients with positive nodal metastases is less clear. So is more better in this setting? If we look at other cancers, the answer may simply be “no.” Randomized, controlled trials in gastric, non-small cell lung, and breast cancers have demonstrated no benefit to additional nodal resection relative to limited sampling (for diagnosis).
In conclusion, Dr. Eastham noted that an extended lymphadenectomy is recommended in intermediate and high-risk prostate cancer as it provides diagnostic and prognostic information. It may additionally help to select patients for clinical trials and systemic therapy. It may also improve outcomes, but the jury is still out here and RCTs are needed to answer these questions more definitively.
Presented By: James A. Eastham, MD
Written By: Benjamin T. Ristau, MD; Fox Chase Cancer Center, Philadelphia, PA at the 2016 AUA Annual Meeting - May 6 - 10, 2016 – San Diego, California, USA
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