Salvage Lymph Node Dissection in Patients with Prostate Cancer Treated with Radical Prostatectomy or Radiotherapy and Positive Choline - Beyond the Abstract

Oligometastatic prostate cancer is a unique and challenging scenario. Historically, distinctions were not made regarding the extent of the metastatic burden, as patients were all treated with Androgen deprivation therapy (ADT). However recent advances in imaging are identifying men with potentially isolated metastases and evidence suggests that durable control could be achieved with treatment targeting oligometastasis.

Patients with nodal recurrence show more favorable outcomes when compared to patients with bone or visceral metastasis. In addition, hormonal therapy is not a potentially curative treatment and many of these men will experience castration resistance.

Current clinical guidelines do not support the use of salvage lymphadenectomy (SLND) due to an unproven efficacy and impact on survival.

We decided to evaluate our results on salvage lymph node dissection in patients with nodal only recurrence after radical prostatectomy or radiotherapy. We found that the use of SLND could delay the use of ADT in 14.9 months. Most of the patients were treated with a laparoscopic approach with few severe complications (see table).

It is clear that the impact of SLND depends on patient selection. So far it has been done by clinical variables (PSA, Gleason score, PSA-DT, extent of nodal involvement, etc). In our study, we found no clinical predictor for response. In the subgroup of patients with PSA-DT <6 months, although it did not reach statistical significance, we found that these patients presented radiological recurrence 18.2 months earlier than their counterparts.

We believe that in order to select patients that would benefit the most of SLND the tumor biology should be studied. It is theorized that potentially curable oligometastatic prostate cancer is biologically different from aggressive metastatic prostate cancer, which probably should be treated with systemic therapy.

In conclusion, we think that SLND is feasible in expert centers with few complications. Patient selection should be better tailored in the future according to genomic classification.

Written by: Renan Otta Oshiro, MD, MD Anderson Cancer Center, Madrid, Spain

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