EAU 2018: The Role of Lymphadenectomy in Urological Cancers

Copenhagen, Denmark (UroToday.com) Dr. Heidenreich presented a summary of the role of lymphadenectomy in prostate cancer. Below is a summary of his main points below. However, unlike in other urothelial cancers, the role of lymphadenectomy is less clear in prostate cancer.

Rationale for Lymphadenectomy

To identify micrometastatic spread to locoregional lymph nodes
To assess for future progression
To decide on best individual approach – surveillance vs. adjuvant therapy
To improve oncologic outcome

Lymphatic drainage of the Prostate

Cranial prostate drains to external iliac nodes
Posterolateral prostate drains to internal iliac and obturator nodes
Posterior prostate drains to external iliac, internal iliac and obturator nodes
Hence to adequately capture lymphatic drainage for prostate cancer, must complete an extended node dissection to include all three of these areas! Obturator nodes insufficient!
Liebner et al 1980 – of 54 surgically treated prostate cancers, 29 had internal iliac nodes, 21 had external iliac nodes, and 4 had common iliac nodes.

Who should undergo an ePLND?

Do NOT perform in a low-risk PCa patient – arguably, they shouldn’t undergo prostatectomy at all
Perform ePLND in intermediate risk if LN risk > 5% by nomograms
Perform ePLND in all high-risk patients

Extended vs. standard LND

Heidenreich et al JUrol 2002 – 103 patients in each group. Patients who underwent ePLND had more nodes identified (28 vs. 11) and more importantly, more positive nodes identified (26% vs. 12%)
Heidenreich et al EU 2007 – Looking at nodal distribution again, they noted that patients undergoing limited node dissection (external iliac only) would have missed 50% of positive nodes (29% in internal iliac, 22% in obturator)
Bivalacqua et al Urology 2013 – compared single-surgeon experiences (one doing ePLND and one doing sPLND) over 10 year follow-up period and found that ePLND patients had better RFS and MFS
Indeed, removal of limited nodal disease (oligometastatic disease) may be curative in a subset of patients (Seiler JUrol 2014) – 1 node positive patients tend to do quite well.
Abdollah et al EU 2016 – more extended node dissection (>14 nodes removed) patients do better
Choo MS Annals Surg Oncol 2017 – systematic review of ePLND vs. sPLND. Found oncologic benefit of ePLND in terms of BCR. Recommended for moderate to high risk PCa. However, negative impact on functional outcomes cannot be excluded.

There is currently an institutional RCT being conducted by Dr. Heidenreich in this field. 950 Intermediate/high risk PCa patients are being randomized 1:1 to ePLND and sPLND – 500 have been accrued so far. Powered to find an 8% overall survival benefit over 10 years. CSS, MFS and RFS are all being assessed.

However, the clinical reality in everyday practice is that there is significant variations in practices – even for doing a LND at the time of RP for intermediate and high risk patients. Despite the evidence, there is little standardization in practice.

Presented by: A. Heidenreich, MD, Cologne, Germany

Written by: Thenappan Chandrasekar, MD Clinical Fellow, University of Toronto, twitter: @tchandra_uromd at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark

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