EAU 2020 Treatment of Recurrent Lymph Node Metastatic Prostate Cancer - Surgery Is the Best Option

(UroToday.com) Dr. Steven Joniau discussed the role of surgery as the best option for men with treatment of recurrent lymph node metastatic prostate cancer at the 2020 European Association of Urology (EAU) Virtual Meeting. Dr. Joniau notes that the location of relapse is important in relation to treatments received. Lymph node recurrence may be highly variable, with recent data suggesting that 44% of recurrences are distal to the common iliac bifurcation, 28.5% in the retroperitoneum, 15.5% in the common iliac/pre-sacral region, and 3% perirectal.

Dr. Joniau’s group has also assessed the approach to salvage lymph node dissection in a recently published report.1 This study included 60 patients undergoing open salvage lymph node dissection between 2010-2016 and 30 patients undergoing robot-assisted salvage lymph node dissection between 2016 and 2018. Robotic salvage lymph node dissection was associated with reduced blood loss (median 100 vs. 275cc, p < 0.0001) and shorter length of stay (median two vs. seven days, p < 0.0001) compared to open salvage lymph node dissection. Postoperative complications within 30 days after surgery were more prevalent in the open salvage lymph node dissection group compared to the robotic group (41.6% vs. 20%, p = 0.04). Importantly, there were no significant differences in lymph node yield, biochemical recurrence-free survival, and clinical recurrence-free survival between both groups.

In a study of 121 patients with recurrent prostate cancer as defined by PSMA-ligand PET, 99% of patients could have metastatic tissue removed.2 Impressively, a complete biochemical response was achieved in 77 patients (66%), and the chance of complete biochemical response was highest in patients with both low preoperative PSA and a single lesion (84%). The median biochemical free survival was 6.4 months in the whole patient cohort and 19.8 months for patients with a complete biochemical response.

prostate cancer PSMA ligand PET

However, Dr. Joniau notes that perhaps outcomes of salvage lymph node dissection are not as good as expected. In a study published earlier this month, Bravi and colleagues3 investigated the long-term oncological outcomes after salvage lymph node dissection among 189 patients. After salvage lymph node dissection, 145 patients received androgen deprivation therapy (ADT), with a median time to ADT of 41 months. At a median follow-up for survivors of 87 months (IQR 51-104), 48 patients died of which 45 died of prostate cancer. Overall, the probabilities of freedom from cancer-specific death at 10 years was 66% and 64% for all-cause death. As such approximately one-third of men treated with salvage lymph node dissection for PET-detected nodal recurrence died of prostate cancer after long-term follow-up. However, Dr. Joniau notes that these patients may not have been the best-selected patients with many having poor prognostic factors, including retroperitoneal involvement (10%) or both retroperitoneal and pelvic (14%) on PET/CT, ≥ 3 lesions on PET-CT (20%), and ongoing ADT at the time of PET/CT (18%).

Dr. Joniau concluded with several take-home messages from his presentation:

  • Prostate cancer recurrence is most often a pelvic nodal disease
  • The pelvic nodes can be easily reached by surgery
  • The robotic approach is associated with shorter hospital stay and fewer complications
  • A unilateral extended template is possible in patients with a single, unilateral pelvic PSMA PET/CT positive lesion
  • However, in all other situations, a bilateral extended template should be performed
  • Tc-99m-PSMA-guided surgery is promising but needs further study
  • The gain for the patient most likely likes in an approach with repeated multidisciplinary therapy in a multidisciplinary setting

Presented by: Steven Joniau, MD, PhD, Katholieke Universiteit Leuven, Leuven, Belgium

Written by: Zachary Klaassen, MD, MSc, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, Augusta, Georgia, Twitter: @zklaassen_md at the Virtual 2020 EAU Annual Meeting #EAU20, July 17-19, 2020


1. Devos, Gaëtan, Tim Muilwijk, Yannic Raskin, Victor Calderon, Lisa Moris, Thomas Van den Broeck, Charlien Berghen et al. "Comparison of Peri-operative and Early Oncological Outcomes of Robot-Assisted vs. Open Salvage Lymph Node Dissection in Recurrent Prostate Cancer." Frontiers in oncology 9 (2019): 781.

2. Horn, Thomas, Markus Krönke, Isabel Rauscher, Bernhard Haller, Stephanie Robu, Hans-Jürgen Wester, Margret Schottelius et al. "Single lesion on prostate-specific membrane antigen-ligand positron emission tomography and low prostate-specific antigen are prognostic factors for a favorable biochemical response to prostate-specific membrane antigen-targeted radioguided surgery in recurrent prostate cancer." European urology 76, no. 4 (2019): 517-523.

3. Bravi, Carlo A., Nicola Fossati, Giorgio Gandaglia, Nazareno Suardi, Elio Mazzone, Daniele Robesti, Daniar Osmonov et al. "Long-term Outcomes of Salvage Lymph Node Dissection for Nodal Recurrence of Prostate Cancer After Radical Prostatectomy: Not as Good as Previously Thought." European Urology (2020).
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