Pelvic Lymphadenectomy For Prostate Cancer Research Articles

Changing Patterns of Pelvic Lymphadenectomy for Prostate Cancer: Results From CaPSURE™

Widespread screening for prostate cancer in the United States has resulted in earlier tumor identification at lower stages. The fewer number of men with lymph node metastases at initial presentation has altered patterns of pelvic lymphadenectomy before definitive treatment. We characterized patterns of pelvic lymphadenectomy in conjunction with radical prostatectomy in a community based cohort. In the CaPSURE database we identified men undergoing radical prostatectomy. Patients were stratified into 3 clinical risk groups based on serum prostate specific antigen, T stage and pathological grade. We examined temporal trends of pelvic lymphadenectomy and predictors of pelvic lymphadenectomy. From 1992 to 2004 the proportion of men undergoing pelvic lymphadenectomy in conjunction with radical prostatectomy decreased from 94% to 80%. Overall positive lymph nodes were identified in 0.87%, 2.0% and 7.1% of men in the low, intermediate and high risk groups, respectively. While men with high risk disease continued to undergo pelvic lymphadenectomy at a high rate (greater than 90%), the fraction of men at low and intermediate risk undergoing pelvic lymphadenectomy steadily decreased. Prostate specific antigen, Gleason sum, clinical stage and income were factors associated with pelvic lymphadenectomy. A mean of 5.7 lymph nodes (median 5.0) were removed. The performance of pelvic lymphadenectomy has decreased in patients at low and intermediate risk, and remained stable in patients at high risk. Further investigation of the role of extended pelvic lymphadenectomy and the potential therapeutic benefits of pelvic lymphadenectomy would better define the contemporary role of pelvic lymphadenectomy and identify appropriate candidates.

800: Defining the Ideal Number of Nodes to Remove at Pelvic Lymphadenectomy for Prostate Cancer: Validation of a Nomogram for Intermediate to High Risk Patients

800: Defining the Ideal Number of Nodes to Remove at Pelvic Lymphadenectomy for Prostate Cancer: Validation of a Nomogram for Intermediate to High Risk Patients

The Association Between Total and Positive Lymph Node Counts, and Disease Progression in Clinically Localized Prostate Cancer

We examined the association between the number of LNs removed, the number of positive LNs and disease progression in patients undergoing pelvic lymph node dissection and radical retropubic prostatectomy for clinically localized prostate cancer. We analyzed 5,038 consecutive patients who underwent radical retropubic prostatectomy between 1983 and 2003. Clinicopathological parameters, including the administration of neoadjuvant hormonal therapy, preoperative prostate specific antigen, specimen Gleason score, surgeon and pathological stage, were collected prospectively in our prostate cancer database. We excluded men treated with radiation or chemotherapy before surgery. BCR was defined as 2 postoperative prostate specific antigen increases greater than 0.2 ng/ml. Cox models were used to determine whether the number of nodes removed or the number of positive nodes predicted freedom from BCR after adjustment for prognostic covariates. The 4,611 eligible patients had a median of 9 LNs (IQR 5 to 13) removed. Positive nodes were found in 175 patients (3.8%). Overall the number of LNs removed did not predict freedom from BCR (HR per additional 10 nodes removed 1.02, 95% CI 0.92 to 1.13, p = 0.7). Results were similar in patients receiving and not receiving neoadjuvant hormonal therapy. Finding any LN involvement was associated with a BCR HR of 5.2 (95% CI 4.2 to 6.4, p <0.0005). However, in men without nodal involvement an increased number of nodes removed correlated significantly with freedom from BCR (p = 0.01). Nodal disease increased the risk of progression. Extensive lymphadenectomy enhances the accuracy of surgical staging. However, we were unable to determine that removing more nodes improves freedom from BCR uniformly. Since the proportion of patients with prostate cancer with positive nodes is low, the value of extensive lymphadenectomy requires a multi-institutional, randomized clinical trial.

DETECTION OF EARLY LYMPH NODE METASTASES IN PROSTATE CANCER BY LAPAROSCOPIC RADIOISOTOPE GUIDED SENTINEL LYMPH NODE DISSECTION

Radioisotope guided sentinel lymph node (SLN) dissection (SLND) for prostate cancer has been shown to increase the sensitivity of detecting early metastases in open pelvic lymph node dissection. We developed a technique that allows SLND to be performed by laparoscopy in conjunction with laparoscopic radical prostatectomy. In 71 consecutive patients SLND was performed by 1 surgeon preceding laparoscopic radical prostatectomy. Mean preoperative prostate specific antigen was 8.88 ng/ml (range 2.1 to 25.4). At 24 hours prior to surgery 3 ml (200 MBq) Tc labeled human albumin colloid were injected into the prostate gland under transrectal ultrasound guidance. An especially designed laparoscopic gamma probe was used to measure radioactivity during surgery. SLNs were identified and removed. If frozen section analysis showed metastases, extended pelvic lymph node dissection was performed. Radioactivity was detected on 2, 1 and no sides in 50 (70.4%), 19 (26.7%) and 2 patients (2.8%), respectively. In 81 of the 142 pelvic side walls (54.7%) SLNs were exclusively outside of the obturator fossa. Histopathological examination showed metastases to SLNs in 9 patients (12.9%). Eight of the 11 detected metastases (72.7%) were outside of the obturator fossa. Lymph node metastases were exclusively found in Tc marked lymph nodes. Mean tumor size was 1.7 mm (range 0.2 to 3.9). SLND is feasible by laparoscopy. It detects micrometastases outside of the obturator fossa in a significant number of patients. We noted that the transperitoneal approach allowing wide exposure and a gamma probe with a 90-degree lateral energy window is the most important factor to enable successful laparoscopic SLND.

ROBOTIC ASSISTED, LAPAROSCOPIC PELVIC LYMPH NODE DISSECTION IN HUMANS

We evaluate the feasibility and efficacy of robotic assisted, laparoscopic pelvic lymph node dissection for locally advanced prostate cancer staging. Robotic assisted, laparoscopic pelvic lymph node dissection was performed in 10 consecutive patients with mainly T3 M0 prostatic carcinoma (robotic group). Operative, postoperative and pathological parameters were compared with the results of the last 10 patients undergoing conventional, laparoscopic pelvic lymph node dissection performed with similar indications by the same operator (laparoscopy group). All operations were performed according to the established protocol with no specific intraoperative or postoperative complications. No conversion was required, and no technical incidents were observed in the robotic group. Mean operating time plus or minus standard deviation for the robotic group was 125 +/- 57 minutes (range 75 to 215), significantly longer than that for the laparoscopy group, which was 60 +/- 15 minutes (p = 0.0013). In the robotic group 2 patients presented with postoperative lymphoceles revealed in 1 by deep venous thrombosis and in the second by obturator pain. In the laparoscopy group 1 patient presented with acute urinary retention. The histological results concerning the number of lymph nodes removed were similar in both groups (p = 0.5). We show the technical feasibility of robotic assisted, laparoscopic pelvic lymph node dissection in humans. Although the benefit of this technique has not yet been established, predictable technological improvements would suggest the development of telesurgery and an improved precision of surgical procedure.

VALIDATION OF PARTIN TABLES FOR PREDICTING PATHOLOGICAL STAGE OF CLINICALLY LOCALIZED PROSTATE CANCER

The accurate prediction of pathological stage of prostate cancer using preoperative factors is a critical aspect of treatment. In 1997 Partin et al published tables predicting pathological stage using clinical stage, Gleason score and prostate specific antigen (PSA). We tested the validity of the Partin tables. From 1990 to 1996 inclusively 5,780 patients underwent bilateral pelvic lymphadenectomy and radical prostatectomy for prostate cancer at the Mayo Clinic. However, only 2,475 of these patients met all inclusion criteria of no preoperative treatment, known biopsy Gleason score, available preoperative PSA done either before biopsy or more than 28 days after biopsy and clinical stage T1, T2 or T3a. Among the 2,475 patients 15 had positive lymph nodes and planned prostatectomy was abandoned. The receiver operating characteristics (ROC) curve area, observed and predicted Partin rates of each pathological stage, and positive and negative predictive values were used to compare the Mayo study to the Partin tables. The distribution of pathological stage was organ confined in 67% of Mayo cases versus 48% in the Partin study, extracapsular without seminal vesicle or node involvement in 18% versus 40%, seminal vesicle involvement without nodes in 9% versus 7% and were positive nodes in 6% versus 5%. Using the predicted probabilities of Partin et al the ROC curve area for predicted node positive disease was 0.84 for Mayo cases compared to an estimated 0. 82 in the Partin series. The ROC curve area for predicting organ confined cancer was 0.76 for the Mayo Clinic compared to an estimated 0.73 for the Partin series. The observed rates of node positive disease were similar to those predicted (Partin) based on clinical stage, PSA and Gleason score. For organ confined disease Mayo rates were consistently higher than those predicted from the Partin series using a cut point of 0.50 or greater. Positive and negative predictive values were 0.83 and 0.49 versus 0.63 and 0.70 for the Mayo Clinic and Partin series. Our study provides strong evidence that sensitivity and specificity of the Partin tables for external clinical sites are similar to what was reported.

Outcome for Surgically Staged Localized Prostate Cancer Treated With External Beam Radiation Therapy

Purpose A retrospective analysis was performed on patients with surgically staged localized prostate cancer treated with external beam radiation therapy for 10-year overall, cause specific and disease-free survivals based on lack of clinical recurrence and 2 separate prostate specific antigen criteria for cure. Materials and Methods We analyzed 145 patients who received external beam radiation therapy after a negative staging pelvic lymphadenectomy for prostate cancer. Followup data were available for 129 patients (90%). Disease was stage A in 29 patients (22.5%), stage B in 64 (49.6%), stage B2/C in 2 (17%) and stage C in 14 (10.9%). Average potential followup from date of diagnosis was 11.5 years (minimum 7.2). Of the patients 87 potentially can be followed for longer than 10 years. Disease-free survival was based on a normal digital rectal examination, lack of symptoms suspicious for metastasis and application of 2 separate prostate specific antigen criteria of 4 ng./ml. or less (group 1), or 1.5 ng./ml. or less (group 2). Survival was analyzed with the Kaplan-Meier actuarial method. Results Actuarial overall survival at 10 and 15 years was 63.7 and 49.6, respectively, and cause specific survival was 84.2 and 80%, respectively. Disease-free survival was 54.5 and 32.4%, respectively, for group 1, and 42.3 and 9.6%, respectively, for group 2. Conclusions The improved patient selection inherent in surgical staging before definitive external beam radiation therapy provides for improved overall and cause specific survival over that of patients without surgical staging. Biochemical disease-free survival also appears to be improved.

Anatomical Basis for Pelvic Lymphadenectomy in Prostate Cancer

Anatomical Basis for Pelvic Lymphadenectomy in Prostate Cancer

Anatomical Basis for Pelvic Lymphadenectomy in Prostate Cancer: Results of an Autopsy Study and Implications for the Clinic

Purpose Pelvic lymphadenectomy remains the most reliable method to prove lymph node metastases in prostate cancer. However, evaluation of lymphadenectomy to be complete and sufficient as judged by the number of removed lymph nodes is hampered by the fact that, in contrast to other malignancies (for example breast or gastric cancer), anatomical studies investigating the regular and average number of pelvic lymph nodes are missing. We established an anatomically based standard for pelvic lymphadenectomy. Materials and Methods Standard pelvic lymphadenectomy was performed on 30 human cadavers and 59 consecutive patients with clinically organ confined prostate cancer during radical retropubic prostatectomy. Number, size and topography of the lymph nodes were noted separately for each anatomical region of both iliac fossas. Results The mean number of lymph nodes removed in the autopsy series plus or minus standard deviation (22.7 plus/minus 10.2, range 8 to 56) was nearly identical to that from patients with prostate cancer (20.5 plus/minus 6.6, range 10 to 37) but striking interindividual differences were observed. Patients with prostate cancer demonstrated enlarged nodes regardless of whether they did or did not contain tumor. Interestingly, pelvic lymph node metastases were more common on the left side regardless of the primary tumor site. Conclusions Approximately 20 pelvic lymph nodes may serve as a guideline for a sufficient standard pelvic lymph node dissection. Lymphadenopathy in prostate cancer patients is not always a result of metastases but, rather, hyperplastic or regressive alterations. A preferential distribution of lymph node metastases along the left iliac vessels regardless of the primary tumor site in the prostate warrants further investigation.

Perioperative complications and quality of life after radical retropubic prostatectomy

— The Authors report their experience with perioperative complications in 128 patients after radical retropubic prostatectomy preceding bilateral pelvic lymphadenectomy for prostatic cancer. Patients were classified by anatomo-pathological stage; 25% were stage D1. Data relating to homologous transfusions (22%), intraoperative complications (1.6%), minor (16%) or major (7%) early complications and late complications (0.8%) are analysed. The latest group of patients has also been assessed from a sexual, psychological and social point of view. 84% of patients reported an erectile deficit, but only 4% suffered a psychological worsening reflecting on their social life.

Laparoscopic Management of Urologic Malignancies

Although current laparoscopic techniques are best applied to benign urologic conditions, certain neoplastic urologic conditions are amenable to laparoscopic techniques. These conditions include staging pelvic lymphadenectomy for prostate cancer and testis tumor. Laparoscopic ablative procedures such as nephrectomy and nephroureterectomy for renal cell cancer and upper tract transitional cell carcinomas have been reported. Laparoscopic bladdersparing procedures for selected bladder cancers are also possible.

Staging Pelvic Lymphadenectomy for Prostate Cancer: A Comparison of Laparoscopic and Open Techniques

The operative morbidity and convalescence of our initial 30 patients who underwent laparoscopic pelvic lymph node dissections were compared to those of 16 patients who underwent open surgical pelvic lymph node dissections performed at our institution for staging purposes between 1990 and 1992. The average time for laparoscopic pelvic lymph node dissection (199.4 minutes) was nearly twice that of surgical pelvic lymph node dissection (102.4 minutes). However, the blood loss in the former group was significantly less. Oral intake occurred after a mean of 0.63 days in the laparoscopic pelvic lymph node dissection group compared to 2.87 days in the surgical group. Also, laparoscopic pelvic lymph node dissection was superior to surgical pelvic lymph node dissection in terms of average postoperative analgesic use (1.55 versus 47mg. morphine sulfate), average hospital stay (1.7 versus 5.37 days), average return to normal daily activities (4.94 versus 42.9 days) and interval to full recovery (10.8 versus 65.5 days). However, the incidence of significant complications in the laparoscopic pelvic lymph node dissection group was 13%, with no complications seen in the surgical group. Interestingly, all significant problems in the bilateral laparoscopic pelvic lymph node dissection patients were confined to our initial 12 patients, indicating the steepness of the laparoscopic learning curve.

Significance of staging pelvic lymphadenectomy for prostatic cancer.

Staging pelvic lymphadenectomy in 31 cases in stages A2-C prostatic cancer was performed. In 15 of the cases (48%) lymph node invasion was found. Metastatic tendency strengthened with an increase in Gleason scores, although no metastases were found in 38% of the cases with Gleason scores of 8-10. Percutaneous fine-needle aspiration biopsy guided by lymphography was conducted in 14 cases and 17% were false-negative. Lymph node metastases were found in the common iliac lymph nodes in 47%, external iliac lymph nodes in 67% and internal iliac obturator lymph nodes in 100%. Prolonged lymph drainage in 4 cases (13%) and wound infection in 2 cases (3%) were found as postoperative complications, but they were all treated conservatively. So it was concluded that pelvic lymphadenectomy was a reasonable adjunct to total prostatectomy since it provided an accurate assessment of the anatomic distribution of disease, which could be of help in selecting treatment. Dissection of the lymph nodes of the internal iliac obturator was considered quite sufficient to establish the presence of any lymph node metastases.

Risk factors for the development of distant metastases in patients undergoing pelvic lymphadenectomy for prostatic cancer

Sixty-two patients with clinically localized prostatic cancer underwent pelvic lymphadenectomy between 1972 and 1975. Thirty-one patients had concomitant total prostatectomy. The objectives of this study included determination of the relation of findings at lymphadenectomy, with and without total prostatectomy, to subsequent clinical course, identification of histologic parameters related to the subsequent appearance of distant metastatic disease, and determination of the vital status of patients initially having a staging pelvic lymphadenectomy. Follow-up of at least 5 years was obtained for 52 patients, including 28 who had concomitant total prostatectomy. Ten patients were lost to follow-up. Fifty-four percent are alive without evidence of disease, 25 percent are alive with metastatic disease, 10 percent have died with metastatic cancer, and 12 percent have died without prostate cancer. Metastases have developed in 11 (37 percent) of 30 patients with negative pelvic lymph nodes, reflecting either seminal vesicle or transcapsular invasion. Minimal lymph node involvement (one or two pelvic nodes) alone may not be as poor a prognostic sign as originally thought. Metastases have developed in 22 percent of nine patients with tumor considered stage B 2. No recurrences or metastases were noted in the seven patients with stage b 1 disease. Patients with high grade lesions were at no increased risk for distant metastases, although they constituted a relatively small segment of our series. Thus the extent of local disease correlates with the subsequent development of distant metastasis. Adjuvant systemic treatment (endocrine manipulation, chemotherapy, or both) has a rational basis in patients with one or more of these identifiable risk factors

Complications of 125Iodine Implantation and Pelvic Lymphadenectomy for Prostatic Cancer with Special Reference to Patients Who Had Failed External Beam Therapy as Their Initial Mode of Therapy

The operative, postoperative and late complications of 125iodine implantation and pelvic lymphadenectomy in 36 patients with curable prostatic cancer are described. Of these patients 14 had undergone previously external beam therapy that failed, and it is in this group that the major morbidity occurred. The possible mechanism of these complications is discussed, as well as the criteria for case selection to prevent these complications.