Abstract
Patients diagnosed with clinically node-positive prostate cancer represent a population that has historically been thought to harbor systemic disease. Increasing evidence supports the role of local therapies in advanced disease, but few studies have focused on this particular population. In this review we discuss the limited role for conventional cross sectional imaging for accurate nodal staging and how molecular imaging, although early results are promising, is still far from widespread clinical utilization. To date, evidence regarding the role of radical prostatectomy and pelvic lymph node dissection in clinically node-positive disease comes from retrospective studies; overall surgery appears to be a reasonable option in selected patients, with improved oncological outcomes that could be attributed to both to its potential curative role in disease localized to the pelvis and to the improved staging to help guide subsequent multimodal treatment. The role of surgery in clinically node-positive disease needs higher-level evidence but meanwhile, radical prostatectomy with extended pelvic lymph-node dissection can be offered as a part of a multimodality approach with the patient.
Highlights
In 2018 it was reported that 12–13% of prostate cancer (PCa) patients presented with regional tumor involvement at the time of diagnosis [1] and this number is likely to increase in the coming years due to novel and more accurate imaging techniques
In this review we aim to summarize the evidence reporting the effect of radical prostatectomy (RP) in clinically node positive (cN1) population, after considering two relevant questions: can we rely on current clinical staging to exclude surgery as a possible primary treatment? Are patients with localized nodal metastasis a unique population?
Non-regional lymph node metastases are classified as M1a disease [2], in particular common iliac and retroperitoneal nodes are included in this classification
Summary
In 2018 it was reported that 12–13% of PCa patients presented with regional tumor involvement at the time of diagnosis [1] and this number is likely to increase in the coming years due to novel and more accurate imaging techniques. Following the America Joint Committee on Cancer (AJCC) Staging System, the “N” refers to regional lymph nodes, namely: pelvic, hypogastric, obturator, iliac, and sacral groups. Tumor of any “T” stage, negative for distant metastasis but with positive regional nodes involvement is referred as stage IVa [2]. This considerable proportion of PCa patients has historically been treated with the assumption that the presence of lymph node metastasis indicates systemic spread of disease, guidelines recommend ADT as the gold standard treatment [3, 4]. To date no randomized clinical trial exists evaluating the best treatment modality for these patients
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