And we're going to be talking about a counterpoint that they had at the meeting discussing the role of pelvic lymphadenectomy for prostate cancer. Gentlemen, thank you both for joining us during your busy congress.
Juan Carlos Vélez Román: Thank you, sir
Fernando Pablo Secin: No, thank you for the invitation.
Zachary Klaassen: So Juan, maybe just take our listeners, this is an age-old question, this is always a hot topic, should we perform lymph node dissection? What's the extent? Why are we still having this discussion in 2025?
Juan Carlos Vélez Román: Okay. The lymphadenectomy is really, in this moment, the role is the stratification and the controversy is the benefit in the oncological results as controversial and unclear to role in the same time the radical prostatectomy. And with Fernando, discuss about the role of the lymphadenectomy.
In this moment, the lymphadenectomy decreased in the world, like in UK, in patient high risk only or less the third patients do the lymphadenectomy in the same moment the radical prostatectomy, it's not clear for this. Maybe for the results, the study published the Memorial Group in the extended and limited lymphadenectomy, no clear benefit in the oncological results. Maybe this is produced on a decrease in the do the lymphadenectomy. And in this moment, they improve the stratification with the PSMA PET. Maybe change the role, the stratification in the lymphadenectomy.
Zachary Klaassen: Yeah, that's a great introduction. So Fernando, you were tasked with arguing for lymphadenectomy. What's the argument for still doing a lymphadenectomy, maybe extended in certain patients?
Fernando Pablo Secin: Well, there is a historical data from all these huge databases of the biggest institutions in the US, showing that around 20 to 25% of patients in whom lymphadenectomy was done they were free of biochemical recurrence, or secondary therapy 10, 15 years after surgery.
And those data were also found in Europe in the studies from Studer. And if we look at more updated data, I mean more up-to-date series of patients like the, I don't know, the group of Peter Carroll, they published like 1,500 patients, around a third of these patients were still with doubt, biochemical recurrence.
Zachary Klaassen: Essentially cured from a good surgery?
Fernando Pablo Secin: I would say, yes. Because also postponing secondary therapy is a benefit.
Zachary Klaassen: Absolutely.
Fernando Pablo Secin: I agree with Juan Carlos, that at least the two randomized trials out there, they didn't show a benefit in biochemical recurrence. The randomized trial done at Memorial showed improvement in the regional and the distant metastasis free rate. But I'm not sure those tests are really answering what we are looking for because those tests compare limited versus extended lymph node dissection.
Of course, we all would have liked to see a controlled group without lymphadenectomy. So I think that is the test perhaps that would answer the real question. But we all have patients in whom we did lymphadenectomy with let's say a relatively low lymph node density, less than 15 or 20%. And these patients do well for a long time, especially after, for example, in the setting of salvage prostatectomy, after radiation therapy.
I had a patient, I actually contacted this patient a month ago, and this patient, he had two positive lymph nodes status post-salvage prostatectomy, he had prior radiation. And the patient has been a decade without biochemical recurrence.
Zachary Klaassen: Wow.
Fernando Pablo Secin: So there is a niche, there's a group of patients who definitely benefit.
Zachary Klaassen: Sure.
Fernando Pablo Secin: The challenge is to identify them better so we do not over-treat the patients who don't need it, and at the same time, avoid the potential side effects of complications associated with extended lymph node dissection.
Zachary Klaassen: Yeah, well said. And I think you alluded to it, the disease biology, understanding who needs it, who doesn't, and PSMA PET, and you mentioned that, Juan Carlos, earlier too. So maybe an argument for being a little judicious on who we perform lymphadenectomy for.
Juan Carlos Vélez Román: Okay. Lymphadenectomy, in my opinion, for the high risk, is the best group do improve the oncological results. And in the intermediate risk, maybe avoid the lymphadenectomy with the PSMA PET. Maybe is safety, avoid lymphadenectomy in this group.
And the most evidence is retrospective for oncological benefit. And recently published the Furrer study in improve in the intermediate risk and high risk, really oncological benefit in the metastatic-free survival in this moment. In my opinion, high risk if the principal group benefit the lymphadenectomy in this moment.
Zachary Klaassen: Excellent. So when we counsel patients, this is what it comes down to, we're talking to maybe intermediate high risk, and I like how you broke that down, I'll start with Fernando, how should we counsel patients on why we're doing a lymphadenectomy, why we're doing extended or not extended?
Fernando Pablo Secin: Yes, there is no doubt that the benefit has to do with the prognosis and stratification, but at the same time, we understand that there are a need, there is a subgroup of patients that may potentially benefit. And if we go by the NCCN guidelines, for example, they say consider lymphadenectomy in intermediate favorable disease, but they recommend it still in any patient with had a higher risk than that.
And I sit down with the patient, I discuss the benefits. It is actually funny, because in the debate that followed us, we were discussing the benefits of the potential curative of patients with more advanced disease, with oligometastatic disease.
So if we are able to potentially cure patients with oligometastatic disease with radiation, whatever, why not give lymphadenectomy a chance? Especially considering that the data is very clear, some patients will definitely benefit from it.
Then the NCCN guidelines also offer the possibility of using the nomograms, MSKCC, Brigantis nomogram. That's a little bit more up to the individual urologists. But if I was the patient, please, clean as much as you've got, and then let biology decide the rest.
Zachary Klaassen: Yeah. And I think you made a good point earlier too, Fernando, that the toxicity of hormonal therapy, if we can delay that or completely avoid it, is definitely worth it for the patients as well.
Fernando Pablo Secin: Absolutely, yes.
Zachary Klaassen: Juan Carlos, how do you counsel patients when we're talking about lymphadenectomy in your practice?
Juan Carlos Vélez Román: We use the Briganti's nomogram for choose the lymphadenectomy in our patients. The new nomogram, the Briganti nomogram included the diameter deletion in MRI, include the number, the course in with cancer in the low grade, the PSA. In these firms, you avoid a lot of lymphadenectomies necessary to do. It's the principal forum. It is concordant with the high risk and very high risk.
Zachary Klaassen: And I think too, the nomograms give the patients numbers that they can put their head around too, right? I think that's very helpful for counseling.
Gentlemen, thank you for recreating this debate on UroToday. Really appreciate your time during the busy congress joining us on UroToday.
Juan Carlos Vélez Román: Thank you.
Fernando Pablo Secin: Thank you. Thank you for having us.