EAU 2018: Variation in Pelvic Lymph Node Dissection Among Prostate Cancer Patients in The Netherlands: Are We Using a Double Standard for Radical Prostatectomy and Radiotherapy Patients?

Copenhagen, Denmark (UroToday.com) The Dutch guidelines advice to consider a pelvic node dissection (PLND) for all patients scheduled for curative intent intervention with a risk of node involvement. Apparently, this applies to both patients undergoing a radical prostatectomy and radiation therapy. The European and American guidelines do not advise nor condemn the use of diagnostic PLND in patients undergoing radiation treatment. However, the practice is not common in the US. The authors aim to assess variations in the use of PLND between patients undergoing radical prostatectomy (RP) and radiation therapy (RT) and assess how it impacts subsequent interventions.

The study queried a national database (Netherlands Cancer Registry) for all patients with localized prostate cancer (cT1–cT3N0M0) between Oct 2015 and Apr 2016 at risk of LNI>10% (based on MSKCC nomogram) treated with RP or EBRT. The proportion of patients undergoing PLND was calculated for individual hospitals. Multivariable logistic regression analyses were performed to examine the effect of patient, tumor and hospital-related factors on the performance of a PLND.

A total of 985 patients were included in the analysis. Of these 377 underwent RP, of which 87.5% underwent a PLND. Performance of PLND varied mildly between hospitals with a performance rate ranging from 70% to 100%. High PSA level and higher Gleason score were determinants of PLND receipt among those undergoing a PLND. Performance of a PLND did not affect the subsequent management of the patient as most patients were followed with serial PSAs and a minority given adjuvant treatments (proportion not reported).

In regard to RT, 608 patients underwent treatment with EBRT, with 20% of the patients receiving a diagnostic PLND. Significant variation was noted in the receipt of PLND between hospitals ranging from 0% to 80%. On multivariate analyses, younger patients and those with a higher EAU risk score were more likely to receive a PLND. Interestingly, those treated in a community hospital or those who did not receive a PET/CT were more likely to receive a PLND. Patients who received a PLND were more likely to receive whole pelvic radiation if found to have nodal disease.

In summary, high-risk prostate cancer patients treated with a PLND are more likely to receive a PLND than those treated with RT. It is unclear what is the motivation of a diagnostic PLND in patients treated with PLND: avoidance of hormonal therapy, risk stratification for whole pelvic radiation or due to lack of diagnostic resources. On discussion with the presenter, the data registry does have the granularity to answer these questions which is a major limitation of the study.

Speaker: Jansen H, Netherlands Comprehensive Cancer Organization, Dept. of Research, Utrecht, Netherlands

Written by: Andres F. Correa, MD, Urologic Oncology Fellow, Fox Chase Cancer Center, Philadelphia, PA, at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark
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