Matheus Ruggeri: It's a great pleasure to be here. My name is Matheus Ruggeri, and I'm a co-researcher of this very important study.
Jean Lestingi: And my name is Jean Lestingi. I'm the PI investigator of this randomized controlled trial.
Sam Chang: Yeah. So tell us what you found, Professor Lestingi.
Jean Lestingi: Because in 2021 we published the first randomized controlled trial comparing extended versus limited lymphoma dissection in localized prostate cancer patients. So now we are presenting actually the 10 years of follow-up. When we consider all the cohort patients, we did not find difference in oncological outcomes.
Sam Chang: Between the limited versus the extended?
Jean Lestingi: Yes. When we considered overall cohort. But when we looked at five years of follow-up and a specific subgroup of patients with biopsy ISUP 3 to 5 group grade, the patients who were allocated to extended dissection group had better biochemical recurrence-free survival. And now with 10 years of follow-up, we saw that this difference was maintained along the time, and the difference became early in the beginning, and this difference has maintained it suggesting that there is no lead-time bias.
Sam Chang: Sure. Okay.
Jean Lestingi: And when we analyzed other oncological outcomes in five years of follow up, there was no difference regarding metastasis-free survival. But now with long-term follow-up, we showed that this specifically high-grade disease patients, now we demonstrated better metastasis-free survival.
Sam Chang: And so with your practice with higher-risk disease, higher grade disease, grade group three, four, five, your practice now then is to do an extended lymph node dissection. Is that correct? Based upon this, this was a randomized trial.
Jean Lestingi: Yes.
Sam Chang: So now do you do an extended lymph node dissection for these patients?
Jean Lestingi: Yes.
Sam Chang: And then with that, tell me the boundaries of your extended lymph node dissection.
Jean Lestingi: The caudal limited is the circumflex vein and deep femoral canal. The cranial limited is the ureter crossing over the common iliac.
Sam Chang: So pretty high up.
Jean Lestingi: Yes.
Sam Chang: And this was done open robotic or both?
Jean Lestingi: We designed the trial in 2011.
Sam Chang: Oh, so this is your-
Jean Lestingi: There was no robots.
Sam Chang: There was no robot at that time.
Jean Lestingi: Yes.
Sam Chang: Yeah, absolutely.
Jean Lestingi: And the latter boundaries are genitofemoral nerve and the medial boundary is vesical pouch.
Sam Chang: And did you see a difference in the complication rates between your limited versus your extended?
Jean Lestingi: Yes. There is an increase in complications, but minor complications. Just [inaudible 00:04:47] one and two, and only temporary only in the first 90 days. And maybe there was a specific complication that was symptomatic lymphocele that was 4% of patients in the extended group and there was no symptomatic lymphocele in the-
Sam Chang: In the limited group. And so I tell you, we were talking earlier with the advent now of nuclear medicine scanning, specifically PSMA PET scans being fairly good, although some data says maybe not so good with micrometastatic disease. Tell me how you will be integrating the PET scan data with whether or not we should be doing extended lymph nodes.
Matheus Ruggeri: I think it's important to realize that once we found there's actually cancer difference between the patient that were submitted to different kind of lymphadenectomies, we are giving them at least after 10 years, better oncological outcomes that we couldn't actually omit lymphadenectomy even if the PET PSMA is negative, that is the idea that is pretty been discussed nowadays. So this data goes against it.
Sam Chang: Right. And so when you look at the, because this was randomized.
Matheus Ruggeri: Yes.
Sam Chang: When you look at the patients that had the extended versus the limited, and this was by definition localized, you must have found more patients with microscopic metastatic disease or no? Is there differences in rates?
Jean Lestingi: Yes. When we did the extended dissection group, we found five times more [inaudible 00:06:51] metastasis in the extended group than limited one. And this difference was significant in intermediate-risk and high-risk patients. We consider the low sensitivity of PET PSMA to detect micrometastasis and consider when with higher risk of lymph node invasion and the [inaudible 00:07:34] negative value of PET PSMA decreases a lot. I think we should consider this data, this long-term followup of our study to integrate with PET PSMA.
Sam Chang: Right. No, the reason why I think this is so important is because honestly in the US we've really deemphasized the lymph node dissection for different reasons. But this data and some other recent data from the US also as well as Europe suggested we are missing the micrometastatic disease with the PSMA PET scan. So showing this difference in oncologic efficacy with your extended lymph node dissection, showing the fact that you're better able to stage upfront metastatic disease versus not with extended really I think is food for thought for all surgeons when they're operating on higher-risk disease to really consider doing an extended lymph node dissection. Not just a lymph node dissection, but an extended one.
Jean Lestingi: Yes.
Sam Chang: So I think it's very important, and I applaud you to be able to do a randomized trial and with 10 year follow up, it's unbelievable. I think it's very, very important and really sets the bar very high because many of our studies just look at complications or just look at the initial metastatic rate that we find, but to see that difference at 10 years and for it to go from five and continue at 10 years to show a benefit I think is really, really important. I think we struggle with the extended and limited lymph node dissection. If you look at bladder cancer, some are positive, some are negative, but there are different reasons why they may be positive/negative. I think making that decision due to lymph node dissection, I think committed to a more extended one only makes more sense at the possible cost of increased complications and things that we can obviously explain to the patient.
Jean Lestingi: Yes.
Sam Chang: So the AUA is quite fortunate to have leaders like yourself, like I said, from all over the world to come. We really appreciate you spending some time on UroToday to go over your study, and we look forward to even other studies as well very much. Thank you so much for being with us.
Matheus Ruggeri: Perfect. Thank you for the invitation.
Jean Lestingi: Thanks so much. We appreciate being here.