ESOU 2019: Treatment of Positive Pelvic Lymph Nodes: Surgery

Prague, Czech Republic ( In the debate for the optimal treatment modality for patients with positive pelvic nodes, Dr. Alberto Briganti from Milan made the argument for surgery.

In a recently published article in European Urology, work from his group assessing outcomes of 162 patients with cN1 disease treated with radical prostatectomy and ePLND highlights the limitations of conventional imaging, noting that 21.6% of patients were pN0, leading to significant distant metastasis-free survival compared to pN1 patients1. Furthermore, citing unpublished data, Dr. Briganti notes that functional imaging is characterized by better concordance with final pathology only in men with a higher nodal burden.

Dr. Briganti highlighted several possible advantages of radical prostatectomy in cN+ disease relative to radiation therapy:

  • Accurate assessment of the real extent of nodal invasion, as performance characteristics of available imaging for lymph node invasion, are not optimal in the setting of an untreated prostate
  • More accurate pelvic nodal treatment when a meticulous and extended pelvic lymph node dissection is performed
  • Use of a “real” multimodal approach in a real individualized way (surgery first step of multimodal approach, but also the only step)
  • Tissue analysis for patient stratification
Work from the NCDB suggests that men receiving some form of local therapy +/- ADT had a significant overall mortality benefit compared to men receiving ADT alone2. However, when comparing radical prostatectomy +/- ADT vs radiotherapy +/- ADT, there was no difference in survival advantage between the two treatment modalities [2]. One way to further select cN+ patients for radical prostatectomy is biomarkers. In work from Dr. Briganti’s group, patients with at least 1% PD-L1+ tumor cells had shorter metastasis free-survival (HR 3.90, p=0.008) compared to those with no PD-L1 expression3. Based on this data and several other retrospective studies, Dr. Briganti states that cN+ status should not be an absolute contraindication to radical prostatectomy and ePLND for appropriately selected and well-informed surgical candidates. In fact, according to the EAU guidelines, there is strong evidence to “offer radical prostatectomy to highly selected patients with cT3b-T4 N0 or any T N1 disease only as part of multi-modal therapy.”

Selecting the appropriate patient for adjuvant radiation therapy (+ADT) in pN1 patients may be challenging. According to the landmark paper by Abdollah et al4 in 2014, patients with pT3b/pT4 or positive surgical margins in the setting of Gleason 7-10 disease OR patients with 3-4 positive lymph nodes derived a greater benefit from ADT + adjuvant radiation therapy.

Dr. Briganti concluded by suggesting that the future may be a combination of neoadjuvant/perioperative systemic therapy + surgery (+/- radiation therapy). However, he notes that currently there is not a single trial focusing on systemic treatment + surgery in cN1 only disease.

Presented by: Alberto Briganti, Deputy Director, Urological Research Institute, Head of Prostate cancer Unit, Associate professor, Università Vita Salute, IRCCS Ospedale San Raffaele, Milan, Italy

Written by: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, Twitter: @zklaassen_md, at the 16th Meeting of the European Section of Oncological Urology, #ESOU19, January 18-20, 2019, Prague, Czech Republic

1. Gandaglia G, Soligo M, Battaglia A, et al. Which patients with clinically node-positive prostate cancer should be considered for radical prostatectomy as part of multimodal treatment? The impact of nodal burden on long-term outcomes. Eur Urol 2018 Nov 5 [Epub ahead of print].
2. Seisen T, Vetterlein MW, Karabon P, et al. Efficacy of local treatment in prostate cancer patients with clinically pelvic lymph node-positive disease at initial diagnosis. Eur Urol 2017 Sep 7 [Epub ahead of print].
3. Petitprez F, Fossati N, Vano Y, et al. PD-L1 Expression and CD8+ T-cell Infiltrate are Associated with Clinical Progression in Patients with Node-Positive prostate cancer. Eur Urol Focus 2017 Jun 21 [Epub ahead of print].
4. Abdollah F, Karnes RJ, Suardi N, et al. Impact of adjuvant radiotherapy on survival of patients with node-positive prostate cancer. J Clin Oncol 2014 Dec 10;32(35):3939-3947.

Further Related Content:
Treatment of Positive Pelvic Lymph Nodes: Genomics
Treatment of Positive Pelvic Lymph Nodes: Systemic Treatments
Treatment of Positive Pelvic Lymph Nodes: Radio Hormonal Therapy