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Lymphadenectomy in the surgical treatment of prostate cancer - does it influence survival?

Lymphadenectomy in the surgical treatment of prostate cancer - does it influence survival?. Oliver Hakenberg Urologische Klinik und Poliklinik Universitätsklinikum Rostock. Incidence and mortality of prostate cancer in Europe 1998. Davidson & Gabbay, WHO Report 2007. Pelvic lymphadenectomy.

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Lymphadenectomy in the surgical treatment of prostate cancer - does it influence survival?

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  1. Lymphadenectomy in the surgical treatment of prostate cancer - does it influence survival? Oliver Hakenberg Urologische Klinik und Poliklinik Universitätsklinikum Rostock

  2. Incidence and mortality of prostate cancer in Europe 1998 Davidson & Gabbay, WHO Report 2007

  3. Pelvic lymphadenectomy • Node-positive prostate cancer is a systemic disease • Surgery should be aborted if pelvic lymph nodes are positive

  4. trends in risk stratification of surgically treated prostate cancer (CaPSURE) Cooperberg et al, J Urol 2003, 170, S21ff

  5. temporal trends in RPE • Retrospective study • n=37 centres 5291 patients Stage shift PSA-recurrence = 36% Chun & Djavan et al, Eur Urol 2007, 52, 1067-75

  6. Lymphadenectomy - pros and cons • Pro • A significant percentage of patients will harbour N+ disease • Better staging with LAE • LAE in limited N+ will be curative • Con • Overtreatment in most patients • Associated with morbidity • No influence on outcome

  7. Incidence of pN+ in RPE Burckhardt et al, Eur Urol, 2002 Allaf et al, J Urol 2004 Masterson et al, J Urol 2006 Briganti et al, Urology 2007 Weckermann & Wawroschek et al, J Urol 2007

  8. Partin tables for the preoperative predictionof pathologic stage

  9. Difference in Gleason Score: original vs. reference pathology

  10. n=2.295 Mayo % organ confined Line of equality Predicted % organ confined by Partin tables Validation of the Partin tables for the prediction of an organ-confined cancer Blute et al. J Urol 164, 2000

  11. Sentinel nodes and radio-guided surgery Jeschke et al, J Urol 2005 Weckermann & Wawroschek et al, J Urol 2007

  12. Lymphocelesclinical series

  13. Lymphocelesby imaging studies • 33% with ultrasound • 27% with ultrasound • 61% with CT scanning Hakenberg et al, Eur Urol 2005 Spring et al, Radiology 1981 Solberg et al, Scand J Urol Nephrol 2003

  14. n= 446 consecutive RPEs • pelvic U/S and venous duplex sonography on days 0, 8 and 21 • 146 pelvic lymphoceles (size 1-20 cm) - 32.7% • 18.7% day 8, 27.9% day 21 • only 26 with venous thromboses, 13/26 with measurable reduction in venous flow • 73 patients with venous thromboses - 16.4% • 7.2% day 8, 10.5% day 21. • 3 patients with distal thromboses (calf muscles) were diagnosed preoperatively • majority of thromboses was distal and small • DVTs: day 8 n=4, day 21 n=10 • pulmonary emboli: day 8 n=2, day 21 n=2 • A reduction in venous flow was seen only in patients with lymphoceles Hakenberg et al, Eur Urol 2005

  15. Extent of PLND • Limited (standard) = obturator fossa • Modified = + internal iliac artery • Extended = + common iliac artery

  16. Standard PLND underestimates nodal disease • n = 100 standard vs n= 103 extended PLND Heidenreich et al, 2002

  17. Standard PLND underestimates nodal diseaselaparoscopic RPE Stone et al, 1997 Touijer & Guilloneau, 2006

  18. pN+ disease in Bernen= 365-463 consecutive RPE patients, 50.6% pT2 Bader et al, J Urol, 2002 Bader et al, J Urol, 2003 Burckhardt et al, Eur Urol, 2002

  19. But…contemporaray RPE • n= 123 • Limited vs extended PLND on either side • PSA 7.4 ng/ml, 72% cT1c • Extended: 4 pN+ • Limited: 3 pN+ Clark et al, 2003

  20. Extent of PLND and pN+ yield • n= 858 • PSA 5.8 ng/ml • 55% pT1c, 41% pT2 • 14 nodes (mean) • 10.3% pN+ • 2-10 nodes: 5.6% pN+ • 20-40 nodes: 17.6% pN+ • no of nodes examined predicted for pN+: p<0.001 • < 10 nodes examined: 0% probability of pN+ • > 28 nodes: 90% probability of detecting pN+ Briganti et al, Urology 2007

  21. Volume of N+ disease and progression Cheng et al, Am J Surg Pathol 1998 Daneshmand et al, J Urol 2004 Golimkbu et al, Urology 1987

  22. Influence of PLND with limited N+ -disease on PFS Allaf et al, J Urol 2004

  23. Influence on survival?

  24. Influence on survival?

  25. Conclusions • PLND carries morbidity • many positive nodes are outside obturator fossa • the more nodes removed the more likely the detection of positive nodes • no influence of limited PLND on survival • influence of extended PLND on PFS is unclear but likely • extent of PLAD should depend on case and case mix • low risk PCa (Gleason < 7 and PSA < 10 ng/ml) does not need PLAD

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