More Extensive Pelvic Lymph Node Dissection Improves Survival in Patients with Node-positive Prostate Cancer

Positive node burden rather than the number of removed nodes impacts survival in patients with node-positive prostate cancer

BACKGROUND

The value of pelvic lymphadenectomy during radical prostatectomy (RP) remains controversial. This study aims to test the effects of the number of removed lymph nodes (RLN), positive nodes (pLN), and pLN ratio (pLNR) on cancer-specific survival (CSS) in patients with node-positive prostate cancer (PCa).

METHODS

A total of 2458 patients with a greater than 5% probability of lymph node invasion according to the updated Briganti nomogram who harboured pathologically confirmed positive nodes in the Surveillance, Epidemiology, and End Results database between 2004 and 2015 were identified. Multivariable Cox regression with forward stepwise selection was performed to identify independent risk factors for CSS. Maximally selected rank statistics were used to determine the most informative cut-off value for pLN and pLNR.

RESULTS

The median pLN counts and RLN in the study were two (interquartile range [IQR] 1- 3) and 18 (IQR 15-23), respectively. The RLN counts could not predict CSS, while the higher pLN and pLNR were associated with worse CSS (hazard ratio [HR], 1.11; p < 0.001 and HR, 1.01; p < 0.001, respectively). Patients with ≤ 2 pLN or pLNR ≤ 20% had significantly better CSS than those with pLN > 2 or pLNR > 20% (HR, 1.38 (1.08-1.77); p = 0.009; HR, 1.77 (1.41-2.22); p < 0.001, respectively).

CONCLUSIONS

In patients with node-positive PCa, pelvic lymphadenectomy provides important information for staging, prognosis, and guiding after RP therapy; however, it does not play a therapeutic role. The pLN counts and pLNR were independent predictors of CSS.

The significance of De Ritis ratio in patients with radiation-recurrent prostate cancer undergoing salvage radical prostatectomy

Objective

To evaluate the clinical prognostic value of preoperative serum De Ritis ratio (DRR; aspartate aminotransferase/alanine aminotransferase) on postoperative survival outcomes in patients with radiation-recurrent prostate cancer (PCa) who underwent salvage radical prostatectomy (SRP).

Patients and methods

A retrospective review was conducted of patients with radiation-recurrent PCa who underwent SRP in five tertiary referral centres from 2007 to 2015. An increased preoperative serum DRR was defined as ≥1.35. The association between DRR and postoperative outcomes was tested. Multivariate Cox analyses were performed to identify the independent predictors of biochemical recurrence (BCR), metastases-free survival (MFS), overall survival (OS), and cancer-specific survival (CSS).

Results

Overall 214 patients underwent SRP, of them 98 (45.8%) with a high serum DRR were included in the study. In a multivariate analysis high DRR was an independent predictor of BCR [hazard ratio (HR) 1.79, 95% confidence interval (CI) 1.16–2.78; P = 0.009]. No significant association was found between preoperative DRR and MFS (HR 1.32, 95% CI 0.53–3.30; P = 0.55), OS (HR 2.35, 95% CI 0.84–6.57; P = 0.10), and CSS (HR 3.36, 95% CI 0.65–17.35; P = 0.15).

Conclusion

Increased preoperative serum DRR is associated with the development of BCR in patients with radiation-recurrent PCa who underwent SRP. DRR might serve as an early indicator of BCR, which may facilitate recognition of potential relapse and could translate into more intense follow-up and even salvage therapy in selected patients.

Abbreviations

ADT: androgen-deprivation therapy; BCR, biochemical recurrence; BCRFS: BCR-free survival; CSS: cancer-specific survival; DRR: De Ritis ratio; HR: hazard ratio; MFS: metastasis-free survival; PCa: Prostate Cancer; OS: overall survival; PLND: pelvic lymph node dissection; (EB)RT: (external beam) radiotherapy; SRP: salvage radical prostatectomy

Small-volume lymph node involvement and biochemical recurrence after robot-assisted radical prostatectomy with extended lymph node dissection in prostate cancer

BACKGROUND

We investigated prognostic factors for biochemical recurrence (BCR) after robot-assisted radical prostatectomy (RARP) with extended pelvic lymph node (LN) dissection.

METHODS

We included 173 patients who underwent RARP with extended pelvic LN dissection without neoadjuvant therapy at our hospital between October 2010 and April 2018. BCR was defined as prostate serum antigen (PSA) levels ≥ 0.2 ng/mL; BCR-free survival rates were determined using Kaplan-Meier analysis. We used Cox regression analysis to evaluate effects of PSA and pathologic variables on BCR.

RESULTS

Median follow-up was 27.9 (range 6.1-86.9) months. Five-year BCR-free survival was 89.5%. In multivariate analysis, positive LNs (HR 7.117; 95% CI 2.826-17.925; P < 0.001) and Gleason score (GS) ≥ 8 (HR 2.612; 95% CI 1.051-6.489; P = 0.039) were significant predictors of BCR. Patients with 1 or 2 positive LNs (n = 10) had significantly higher BCR-free survival rates than patients with ≥ 3 positive LNs (n = 5). We, therefore, stratified the patients as low-risk (GS < 8 and no positive LNs), intermediate-risk: (either GS ≥ 8 or positive LNs) and high-risk (both GS ≥ 8 and positive LNs). Their 1-year BCR-free survival rates were low-risk: 94.6%, intermediate-risk: 88.5%, and high-risk: 33.3% (P < 0.05).

CONCLUSIONS

Patients with 1-2 positive LNs and GS < 8 have low risk for BCR; close observation without immediate adjuvant hormonal therapy can be considered for these patients.

Distribution of prostate cancer recurrences on gallium-68 prostate-specific membrane antigen (68 Ga-PSMA) positron-emission/computed tomography after radical prostatectomy with pathological node-positive extended lymph node dissection

Objectives

To examine the anatomical distribution of prostate cancer (PCa) recurrence on gallium‐68 prostate‐specific membrane antigen (⁶⁸Ga‐PSMA) positron‐emission tomography (PET)/computed tomography (CT) in patients with biochemical recurrence (BCR) after undergoing radical prostatectomy (RP) with pathological lymph node metastasis (pN1) in their extended pelvic lymph node dissection (ePLND), and to compare the location of PCa recurrence with the location of the initial lymph node metastasis at ePLND.

Materials and Methods

We retrospectively reviewed 100 patients with BCR (PSA 0.05–5.00 ng/mL) after RP with pN1 ePLND who underwent ⁶⁸Ga‐PSMA PET/CT to guide salvage therapy. Clinical and pathological features and anatomical locations of PCa recurrence on ⁶⁸Ga‐PSMA PET/CT were obtained, and management impact was recorded.

Results

In all, 68 patients (68%) had a positive and 32 patients (32%) had a negative ⁶⁸Ga‐PSMA PET/CT result. Of the 68 patients with a positive ⁶⁸Ga‐PSMA PET/CT, 44 (65%) showed abnormal uptake only in the pelvic area, seven (10%) only outside the pelvic area, and 17 (25%) both within and outside the pelvic area. ⁶⁸Ga‐PSMA PET/CT‐positive pelvic lymph nodes were often (84%) detected on the same side as the lymph node metastasis diagnosed at ePLND. Based on the outcomes of the ⁶⁸Ga‐PSMA PET/CT, change of management was noted in 68% of the patients.

Conclusion

Recurrence of PCa on ⁶⁸Ga‐PSMA PET/CT was limited to the pelvis in the majority of patients with BCR after RP with pN1 ePLND. Moreover, recurrence was often detected on the same side as the lymph node metastasis at ePLND. The results confirm the diagnostic value of ⁶⁸Ga‐PSMA PET/CT in patients with BCR after RP with pN1 ePLND. Prospective studies are needed to support the long‐term benefit of ⁶⁸Ga‐PSMA PET/CT‐dictated management changes.

Standardized and Simplified Robot-assisted Superextended Pelvic Lymph Node Dissection for Prostate Cancer: The Monoblock Technique

BACKGROUND

Extended pelvic lymph node dissection (ePLND) remains the most accurate procedure for lymph node staging in intermediate- and high-risk prostate cancer (PCa) patients undergoing radical prostatectomy (RP). A superextended pelvic lymph node dissection (sePLND) can be considered in selected very-high-risk PCa patients.

OBJECTIVE

To demonstrate a reproducible robot-assisted technique for sePLND at the time of RP for PCa.

DESIGN, SETTING, AND PARTICIPANTS

From June 2016 to August 2019, 41 consecutive patients with localized PCa and very high risk for lymph node invasion (LNI) received a robot-assisted RP and a standardized 10-step monoblock ePLND, followed by a 5-step monoblock sePLND. Very high risk for LNI was defined as ≥30% risk for LNI, as calculated by the Briganti 2017 nomogram.

SURGICAL PROCEDURE

After performing the ePLND template resection (harvesting lymph nodes from the obturator region, external and internal iliac vessels, and common iliac vessels up to the ureter crossing), the 5-step monoblock sePLND approach was performed. The sePLND template was tailored to the common iliac vessels up to the aortic and caval bifurcation as well as the presacral region.

MEASUREMENTS

Lymph node yield, perioperative complications.

RESULTS AND LIMITATIONS

Overall, 41 patients received sePLND, reporting a median (interquartile range [IQR]) number of nodes removed of 23 (19-29). Median operative time (including RP, ePLND, and sePLND) was 256 min. Median preoperative prostate-specific antigen was 12 ng/mL (IQR 6.45-17.6). Disease stage pT <3 was found in 10 (24.4%) patients, pT3a in nine (22%) patients, pT3b in 21 (51.2%) patients, and pT4 in one (2.4%) patient. Of the treated patients, 54% revealed LNI: five (4.9%) in a solitary node, five (4.9%) in two to five nodes, and 12 (29.3%) in more than five nodes. Considering perioperative complications, three (7.3%) patients experienced Clavien I-II and four (9.7%) experienced Clavien ≥ III complications. Median hospital stay was 6 d. No patient underwent postoperative blood transfusion.

CONCLUSIONS

The 5-step sePLND approach is a reproducible and feasible technique for PCa patients at a very high risk of LNI.

PATIENT SUMMARY

In our study, we aimed to provide surgeons with a step-by-step technique for lymph node dissection, which aims to collect possibly metastatic lymph nodes of prostate cancer in an even more extended version ("superextended") than a standard ("extended") lymph node dissection.

Applied anatomy of pelvic lymph nodes and its clinical significance for prostate cancer:a single-center cadaveric study

Background

Pelvic lymph node dissection (PLND) is one of the most important steps in radical prostatectomy (RP). Not only can PLND provide accurate clinical staging to guide treatment after prostatectomy but PLND can also improve the prognosis of patients by eradicating micro-metastases. However, reports of the number of pelvic lymph nodes have generally come from incomplete dissection during surgery, there is no anatomic study that assesses the number and variability of lymph nodes. Our objective is to assess the utility of adopting the lymph node count as a metric of surgical quality for the extent of lymph node dissection during RP for prostate cancer by conducting a dissection study of pelvic lymph nodes in adult male cadavers.

Methods

All 30 adult male cadavers underwent pelvic lymph node dissection (PLND), and the lymph nodes in each of the 9 dissection zones were enumerated and analyzed.

Results

A total of 1267 lymph nodes were obtained. The number of lymph nodes obtained by limited PLND was 4–22 (14.1 ± 4.5), the number obtained by standard PLND was 16–35 (25.9 ± 5.6), the number obtained by extended PLND was 17–44 (30.0 ± 7.0), and the number obtained by super-extended PLDN was 24–60 (42.2 ± 9.7).

Conclusions

There are substantial inter-individual differences in the number of lymph nodes in the pelvic cavity. These results have demonstrated the rationality and feasibility of adopting lymph node count as a surrogate for evaluating the utility of PLND in radical prostatectomy, but these results need to be further explored.

Combined Long-Term Androgen Deprivation and Pelvic Radiotherapy in the Post-operative Management of Pathologically Defined High-Risk Prostate Cancer Patients: Results of the Prospective Phase II McGill 0913 Study

Purpose: Following radical prostatectomy, prostate bed radiotherapy (PBRT) has been combined with either long-term androgen deprivation therapy (LT-ADT) or short-term ADT with pelvic lymph node radiotherapy (PLNRT) to provide an oncological benefit in randomized trials. McGill 0913 was designed to characterize the efficacy of combining PBRT, PLNRT, and LT-ADT. It is the first study to do so prospectively.

Methods: In a single arm phase II trial conduced from 2010 to 2016, 46 post-prostatectomy prostate cancer patients at a high-risk for relapse (pathological Gleason 8+ or T3) were assessed for treatment with combined LT-ADT (24 months), PBRT, and PLNRT. Patients received PLNRT and PBRT (44 Gy in 22 fractions) followed by a PBRT boost (22 Gy in 11 fractions). The primary endpoint was progression-free survival (PFS). Toxicity and quality of life (QoL) were evaluated using CTCAE V3.0 and EQ-5D-3L questionnaires, respectively.

Results: Among the 43 patients were treated as per protocol, median PSA was 0.30 μg/L. On surgical pathology, 51% had positive margins, 40% had Gleason 8+ disease, 42% had seminal vesicle involvement, and 19% had lymph node involvement. At a median follow-up of 5.2 years, there were no deaths or clinical progression. At 5 years, PFS was 78.0% (95% Confidence Interval 63.7–95.5%). Not including erectile dysfunction, patients experienced: 14% grade 2 endocrine toxicity while on ADT, one incident of long-term gynecomastia, 5% grade 2 acute urinary toxicity, 5% grade 2 late Urinary toxicity, and 24% long-term hypogonadism. No comparison between the average or minimum self-reported QoL at baseline, during ADT, nor after ADT demonstrated a statistically significant difference.

Conclusions: Combining PBRT, PLNRT, and LT-ADT had an acceptable PFS in patients with significant post-operative risk factors for recurrence. While therapy was well-tolerated, long-term hypogonadism was a substantial risk. Further investigations are needed to determine if this combination is beneficial.

Trial registration: NCT01255891.

Results from extended lymphadenectomies with [111In]PSMA-617 for intraoperative detection of PSMA-PET/CT-positive nodal metastatic prostate cancer

Purpose

Identification of suspicious PSMA-PET/CT-positive lymph node (LN) metastases (LNM) from prostate cancer (PCa) during lymphadenectomy (LA) is challenging. We evaluated an ¹¹¹In-labelled PSMA ligand (DKFZ-617, referred to as [¹¹¹In]PSMA-617) as a γ-emitting tracer for intraoperative γ-probe application for resected tissue samples in PCa patients. Forty-eight hours prior to LA, [¹¹¹In]PSMA-617 was administered intravenously in 23 patients with suspected LNM on PSMA-PET/CT (n = 21 with biochemical relapse, n = 2 at primary therapy). Resected tissue samples (LN, LNM and fibrofatty tissue) were measured ex situ by a γ-probe expressed as counts per second (CPS_norm). [¹¹¹In]PSMA-617 tissue sample uptake was measured by a germanium detector for verification and calculated as %IA_lbm (percent injected activity per kilogram lean body mass at time of surgery). Based on a clinical requirement for a specificity > 95%, thresholds for both ex situ measurements were chosen accordingly. Correlation of the results from PET/CT, γ-probe and germanium detector with histopathology was done.

Results

Eight hundred sixty-four LNs (197 LNM) were removed from 275 subregions in 23 patients, on average 8.6 ± 14.9 LNM per patient. One hundred four of 275 tissue samples showed cancer. Median γ-probe and germanium detector results were significantly different between tumour-affected (33.5 CPS_norm, 0.71 %IA_lbm) and tumour-free subregions (3.0 CPS_norm, 0.03 %IA_lbm) (each p value < 0.0001). For the chosen γ-probe cut-off (CPS_norm > 23) and germanium detector cut-off (%IA_lbm > 0.27), 64 and 74 true-positive and 158 true-negative samples for both measurements were identified. Thirty-nine and 30 false-negative and 6 and 5 false-positive tissue samples were identified by γ-probe and germanium detector measurements.

Conclusion

[¹¹¹In]PSMA-617 application for LA is feasible in terms of an intraoperative real-time measurement with a γ-probe for detection of tumour-affected tissue samples. γ-probe results can be confirmed by precise germanium detector measurements and were significantly different between tumour-affected and tumour-free samples.

Prognostic Value of Gleason Score at Positive Surgical Margin in Prostate Cancer: A Systematic Review and Meta-analysis

The individual clinical significance of a positive surgical margin (PSM) after radical prostatectomy has remained controversial. Studies have suggested that the Gleason grade (GG) at the PSM could improve predictive accuracy and decision making. Our objective was to systematically review the reported data to determine the effect of the GG at the PSM on the prognosis after radical prostatectomy. A systematic review was conducted by searching MEDLINE/PubMed for studies reported by June 2019 in accordance with the Preferred Reporting Items for Systematic Review statement. The keywords used included prostate cancer, radical prostatectomy, positive surgical margin, Gleason score, and/or Gleason grade. After a systematic literature review, 10 studies were included, comprising 14,108 patients, of whom 2454 (17.4%) had a PSM and 428 (14%) eventually experienced biochemical recurrence (BCR) within a median follow-up of 18 to 156 months. Data on neoadjuvant or adjuvant therapy were not estimable. In a meta-analysis, GG4 at PSM was significantly associated with BCR compared with GG3 (pooled hazard ratio, 1.87; 95% confidence interval, 1.53-2.28; z = 6.16). The Cochrane Q test (χ² = 5.88; P = .318) and I² test (I² = 15.0%) showed that no significant heterogeneity was present. GG4 at a PSM is a feature of biologically and clinically aggressive prostate cancer that is associated with a significant increase risk of BCR. GG at PSM should be recorded in each pathological report. Given this adverse prognostic value patients with GG4 at the PSM should be considered for multimodal therapy such as radiotherapy.

Management of Patients with Advanced Prostate Cancer: Report of the Advanced Prostate Cancer Consensus Conference 2019

BACKGROUND

Innovations in treatments, imaging, and molecular characterisation in advanced prostate cancer have improved outcomes, but there are still many aspects of management that lack high-level evidence to inform clinical practice. The Advanced Prostate Cancer Consensus Conference (APCCC) 2019 addressed some of these topics to supplement guidelines that are based on level 1 evidence.

OBJECTIVE

To present the results from the APCCC 2019.

DESIGN, SETTING, AND PARTICIPANTS

Similar to prior conferences, experts identified 10 important areas of controversy regarding the management of advanced prostate cancer: locally advanced disease, biochemical recurrence after local therapy, treating the primary tumour in the metastatic setting, metastatic hormone-sensitive/naïve prostate cancer, nonmetastatic castration-resistant prostate cancer, metastatic castration-resistant prostate cancer, bone health and bone metastases, molecular characterisation of tissue and blood, inter- and intrapatient heterogeneity, and adverse effects of hormonal therapy and their management. A panel of 72 international prostate cancer experts developed the programme and the consensus questions.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The panel voted publicly but anonymously on 123 predefined questions, which were developed by both voting and nonvoting panel members prior to the conference following a modified Delphi process.

RESULTS AND LIMITATIONS

Panellists voted based on their opinions rather than a standard literature review or formal meta-analysis. The answer options for the consensus questions had varying degrees of support by the panel, as reflected in this article and the detailed voting results reported in the Supplementary material.

CONCLUSIONS

These voting results from a panel of prostate cancer experts can help clinicians and patients navigate controversial areas of advanced prostate management for which high-level evidence is sparse. However, diagnostic and treatment decisions should always be individualised based on patient-specific factors, such as disease extent and location, prior lines of therapy, comorbidities, and treatment preferences, together with current and emerging clinical evidence and logistic and economic constraints. Clinical trial enrolment for men with advanced prostate cancer should be strongly encouraged. Importantly, APCCC 2019 once again identified important questions that merit assessment in specifically designed trials.

PATIENT SUMMARY

The Advanced Prostate Cancer Consensus Conference provides a forum to discuss and debate current diagnostic and treatment options for patients with advanced prostate cancer. The conference, which has been held three times since 2015, aims to share the knowledge of world experts in prostate cancer management with health care providers worldwide. At the end of the conference, an expert panel discusses and votes on predefined consensus questions that target the most clinically relevant areas of advanced prostate cancer treatment. The results of the voting provide a practical guide to help clinicians discuss therapeutic options with patients as part of shared and multidisciplinary decision making.

The impact of histopathological analysis of anterior peri-prostatic fat in radical prostatectomy patients

Objective:

To determine the usefulness of histopathological analysis of peri-prostatic fat in a cohort of prostate cancer patients undergoing radical prostatectomy (RP) in an Australian regional centre. During RP, removal of the anterior peri-prostatic fat (APPF) is commonly undertaken; some surgeons routinely request histopathological analysis of this specimen. Previously published data show positive cancer detection in peri-prostatic fat in 0–2.5% of specimens and positive yields are mostly detected in patients with adverse pathological features.

Subjects and methods:

All patients undergoing RP in a regional urology unit in Queensland were identified. Pathology results were examined retrospectively to determine the rate of cancer involvement in APPF specimens and medical records were reviewed to assess any clinical impact.

Results:

APPF was sent for pathological analysis in 270/298 (90%) of patients undergoing RP. Prostate cancer was detected in one sample containing a single involved lymph node in a patient with Gleason 5 + 4 = 9 prostate cancer and pathological stage pT3bN1R1Mx. The presence of the cancer in the APPF did not affect the decision to offer adjuvant radiotherapy.

Conclusion:

In our population, we have identified a positive cancer yield of 0.3% in APPF specimens. When combined with all previously published series, we found positive cancer detection in 72/7391 (1%) specimens, and most patients with positive fat involvement had adverse pre-operative and final pathological features. Surgeons may consider omitting sending APPF specimens for analysis based on the low yield with little additional staging information. If surgeons continue this practice, they should consider selectively requesting analysis in intermediate- and high-risk patients.

Level of evidence:

2b

Is the Recommendation of a Pelvic Lymphadenectomy in Conjunction with Radical Prostatectomy in Prostate Cancer Patients Justified? Report from a Multidisciplinary Expert Panel Meeting

INTRODUCTION

Pelvic lymphadenectomy (pLA) in prostate cancer (PCa) is one of the most common uro-oncologic surgical procedures. An increased complication rate is accompanied by unproven oncologic benefit. Extent of pLA and mechanisms of metastasis are discussed controversially. We aimed to explore evidence and knowledge gaps in pLA and mechanisms of metastasis in PCa and to develop further steps to clarify oncologic benefits through an expert panel.

METHODS

A multidisciplinary expert meeting was initiated, compiling available facts on pLA and mechanisms of metastasis in PCa. Questions and hypotheses were formulated. The resulting protocol was modeled on priority and consistency in four anonymized voting rounds using the Delphi method (March 2018-June 2018).

RESULTS

The oncologic benefit of pLA in PCa is still unclear. Results of randomized trials (RCTs) are pending. Extent and techniques of pLA are differently applied and inconsistently recommended by the guidelines as well as the indication for pLA. Different growth rates for the primaries and metastases and different survival curves for lymph node and organ metastasis at diagnosis argue against metastasis originating from positive nodes. However, results from clinical and basic research support this opportunity in PCa.

CONCLUSIONS

The RCTs required to clarify the estimated low oncologic benefit of pLA prove to be difficult because of the great effort (e.g., high case number). Establishing a network of treatment centers for implementation of high-quality cohort studies could be an alternative approach. Future studies with larger panels and international participants based on the presented feasibility should be launched to set this process in motion. Until valid data are available, benefits and harms of pLA should be weighted under consideration of low-invasive techniques (e.g., sentinel pLA).

Utility of Ga68 prostate-specific membrane antigen positron-emission tomography for pre-operative staging of high-risk prostate cancer in a prospective cohort

INTRODUCTION

To assess the yield of Ga68 PSMA PET/CT added to the conventional staging of high-risk prostate cancer in terms of altered staging and changes to management.

METHODS

Patients with high-risk prostate cancer without metastatic disease on conventional staging referred for Ga68 PSMA PET/CT at Mercy Radiology, Auckland, New Zealand, were prospectively recruited. Conventional staging was double read in a blinded fashion by oncology fellowship-trained radiologists, who were also experienced in PET/CT, followed by interpretation of the PSMA PET/CT by the same radiologists. Confirmation of changes in management decision was obtained from the treating surgeon and multidisciplinary team meeting records. Ethical approval was obtained from the Health and Disability Ethics Committee. All patients gave written informed consent.

RESULTS

A total of 49 patients were scanned. Three who were otherwise eligible for radical prostatectomy elected alternative treatments, leaving 46 patients included for analysis in the study. The addition of PSMA PET/CT was associated with highly statistically significant changes in both staging and management. The stage was changed in 32.6% (95% CI 20.8-47.1%, P < 0.001) patients upstaging in 60% and downstaging in 40%; clinical management in 34.8% (95% CI 22.6-49.3%; P < 0.001), with intramodality change in 25% and intermodality change in 75%. Factors predictive of a change in management with PSMA PET/CT included higher Gleason score and a greater proportion of prostatic cores positive for tumour.

CONCLUSION

The addition of Ga68 PSMA PET/CT to conventional staging in high-risk prostate cancer frequently leads to changes in staging and management.

The Role of Radical Prostatectomy and Lymph Node Dissection in Clinically Node Positive Patients

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.

Oncological Outcome After Radical Prostatectomy without Pelvic Lymph Node Dissection for Localized Prostate Cancer: Follow-up Results in a Single Institution

The oncological benefit of pelvic lymph node dissection (PLND) is still debatable because data on clinical outcomes of radical prostatectomy (RP) without PLND are lacking. In this study, we reported oncological outcome in consecutive 146 patients who underwent RP without PLND. Although 27% of our patients developed biochemical recurrence, the estimated 5-year overall survival rates were 100%, 96.3%, and 95.7% in the low-, intermediate-, and high-risk groups, respectively. These data in our patients were not inferior to those in previous reports that investigated the survivals in patients who received PLND during RP. The therapeutic significance of PLND should be re-evaluated.

Significance of examined lymph-node count in accurate staging and long-term survival in patients undergoing radical prostatectomy: a population-based study

PURPOSE

The number of examined lymph node (ELN) is regarded as the critical quality index for cancer care. We scrutinize the relationship among ELN number, accurate staging, and long-term survival in prostate cancer (Pca).

METHODS

Population-based data on Pca patients in 2004-2015 from the US SEER database were investigated. The connection among ELN number and stage migration, overall survival (OS), and prostate cancer-specific survival (CSS) were evaluated by performing multivariable-adjusted logistic, Cox proportional hazards, and fine-gray competing-risk regression models, respectively. LOWESS smoother was used to fit the series of ELN number, odds ratios (OR), and hazard ratios (HR), while the Chow test was used to resolve the structural breakpoints. Subgroup and interaction analyses were performed in different risk populations.

RESULTS

Overall, 84,838 patients were analyzed. Serial improvements were seen in stage migration (OR, 1.072, P < 0.001), OS (HR, 0.991; P < 0.001), and CSS (HR, 0.983; P < 0.001) per additional ELN after adjusting for confounders. Subgroup analysis revealed that the ELN number gains the most staging and survival benefits in high-risk population (P for interaction < 0.001). Cut-point analyses suggested that an optimal number of 12 ELNs, which was verified by the cumulative incidence curve, had a strong capability to distinguish different probabilities of CSS.

CONCLUSIONS

Higher quantities of ELNs are related to more-accurate nodal staging and long-term survival of Pca patients undergoing RP. We highlight that 12 ELNs are the optimal cut-point for the high-risk population to investigate the quality of LN detection and stratifying postoperative prognosis.

Comparison between Zumsteg classification and Briganti nomogram for the risk of lymph-node invasion before radical prostatectomy

PURPOSE

To evaluate the performance of the Zumsteg classification to estimate the risk of lymph-node invasion (LNI) compared with the Briganti nomogram (BN) in prostatectomy patients with intermediate-risk prostate cancer (IRPC).

METHODS

We included consecutive patients who had extended pelvic lymph-node dissection associated with radical prostatectomy for IRPC. To be classified favorable intermediate risk (FIR), patients could only have one intermediate-risk factor, fewer than 50% positive biopsies and no primary Gleason score of 4.

RESULTS

On the 387 patients included, 149 (38.5%) and 238 (54.3%) were classified FIR and unfavorable intermediate risk (UIR), respectively, and 212 (54.8%) had a BN inferior to 5%. Thirty-eight patients (9.8%) had LNI: 6 FIR patients (4.0%) versus 32 UIR patients (13.4%) and 14 patients (6.6%) with a BN inferior to 5% versus 24 patients (13.7%) with a BN superior to 5%. Eight patients with a BN inferior to 5%, but classified UIR, had LNI. Sensitivity to detect LNI was higher with the Zumsteg classification than with the BN: 84.2% (CI 95% [68-93]) versus 63.2% (CI 95% [46-78]). Both screening tests were concordant to predict LNI (kappa coefficient of 0.076, p < 0.05 for Zumsteg and Briganti) CONCLUSIONS: Zumsteg classification appeared to be more sensitive and as effective (despite the impossibility to make decision curve analysis) than the BN to estimate the risk of LNI. Regarding the modest number of pN+ patients, further studies are needed to see the interest of proposing ePLND for UIR patients only.

68Ga-PSMA I&T PET/CT for primary staging of prostate cancer

PURPOSE

The present study is based on a retrospective analysis of Gallium-68 (⁶⁸Ga)-labelled prostate-specific membrane antigen (⁶⁸Ga-PSMA I&T) PET/CT performed in newly diagnosed, treatment-naïve prostate cancer (PCa) patients prior to definitive treatment.

METHODS

A total of 82 men were included in the study and were imaged with ⁶⁸Ga-PSMA I&T PET/CT to assess the distribution of PSMA-avid disease for staging purposes (11 with low-risk, 32 with intermediate-risk, and 39 with high-risk PCa). Forty patients (20 with intermediate- and 20 with high-risk disease) underwent subsequent radical prostatectomy with extended pelvic lymph node dissection which allowed for correlation of imaging findings with histopathologic data.

RESULTS

PSMA-positive disease was detected in 83% of patients with 66/82 (80.5%) primary tumours being visualized. PSMA-avid lymph nodes were recorded in 17/82 patients (20.7%, 3 with intermediate-risk and 14 with high-risk PCa); distant disease was found in 14/82 subjects (17.1%, 2 with intermediate-risk and 12 with high-risk PCa). No extraprostatic disease was found in low-risk PCa. SUV_max of primary tumours showed a weak but significant correlation with serum PSA values (r = 0.51, p < 0.001) and Gleason scores (GSC; r = 0.35, p = 0.001), respectively. In correlation with histopathology, calculated per-region sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for detection of lymph node metastases were 35.0%, 98.4%, 63.6%, 95.0%, and 93.0%, respectively.

CONCLUSIONS

In patients with initial diagnosis of intermediate- and high-risk prostate cancer, ⁶⁸Ga-PSMA I&T PET/CT emerges as a relevant staging procedure by identifying nodal and/or distant metastases. Due to the low prevalence of extraprostatic disease, its value seems to be limited in low-risk disease.

Extended pelvic lymph node dissection during radical prostatectomy: comparison between initial robotic experience of a high-volume open surgeon and his contemporary open series

BACKGROUND

The aim of this study was to evaluate intra- and perioperative outcomes of a single high volume open radical prostatectomy (ORP) surgeon, during his learning curve period for robot-assisted radical prostatectomy (RARP) and extended pelvic lymph node dissection (ePLND).

METHODS

The study included 264 intermediate-high risk prostate cancer patients, treated by ORP + ePLND or RARP + ePLND, prospectively collected. Descriptive statistics compared clinical and pathological variables between groups. Bivariate (Pearson) correlation analysis assessed the relationship between the number of lymph node (LN) removed, positive surgical margins (PSM), surgical time and the number of procedures performed per group.

RESULTS

pT stage and Gleason score (GS) were lower in RARP than in ORP group (both P=0.04), while PSM were more frequent in the RARP group (40% vs. 25%; P=0.02). However, PSM decreased with the increase of RARP procedures. The number of LNs removed was 25 and 22, in RARP and ORP group (P=0.03). However, LN+ rate did not differ between groups (11% vs. 16%; P=0.216). In the RARP group, overall surgical time and ePLND time decreased with the increase of surgical procedures (all P<0.001).

CONCLUSIONS

RARP requires significant learning curve to reduce operative room time and obtain PSM comparable to those of an ORP high-volume surgeon. On the contrary, the quality of ePLND during RARP seems to be not related to the number of procedures performed, allowing removal of a number of LNs that is clinically comparable to ORP.

Rise in Node-Positive Prostate Cancer Incidence in Context of Evolving Use and Extent of Pelvic Lymphadenectomy

BACKGROUND

The incidence of node-positive prostate cancer has risen and might be partially explained by evolving use of lymphadenectomy at a population level. We assessed trends of node-positive prostate cancer in context of extent of lymphadenectomy among men treated surgically for prostate cancer.

PATIENTS AND METHODS

This was a retrospective study using data from a population-based cancer registry to identify men older than 50 years of age diagnosed with prostate cancer from 2010 to 2015 without distant metastases. We considered extent of node dissection as ordinal (1-4, 5-9, 10-14, 15-19, ≥20) and dichotomous (1-14, ≥15) variables. We fit multivariable models to assess trends in receipt of extended lymphadenectomy and then estimated odds of node-positive cancer on the basis of extent of lymphadenectomy.

RESULTS

We identified 280,156 men diagnosed from 2010 to 2015; 5355 men (1.9%) had positive lymph nodes. Incidence of positive nodes increased from 6.4 to 8.4 cases per 100,000 men from 2010 to 2015 (standardized rate ratio, 1.31; 95% confidence interval [CI], 1.20-1.44). Compared with 2010, prostatectomy patients with high-risk (odds ratio [OR], 1.66; 95% CI, 1.42-1.95) and intermediate-risk tumors (OR, 1.66; 95% CI, 1.47-1.88) were more likely to undergo extended lymphadenectomy in 2015. Among high-risk patients, men with ≥20 nodes removed were 7 times more likely to have positive nodes, versus <5 removed (6.1% for 1-4 vs. 32.4% for ≥20; OR, 7.32; 95% CI, 6.16-8.71). After adjusting for extent of dissection, odds of node-positive disease did not increase between 2010 and 2015 (OR, 1.17; 95% CI, 0.98-1.39) among high-risk patients.

CONCLUSION

Increased incidence of node-positive prostate cancer in the United States is partially explained by more frequent use of extended lymphadenectomy.

Benefits of Elective Para-Aortic Radiotherapy for pN1 Prostate Cancer Using Arc Therapy (Intensity-Modulated or Volumetric Modulated Arc Therapy): Protocol for a Nonrandomized Phase II Trial

BACKGROUND

In patients with prostate cancer (PCa) with histopathologically proven pelvic lymph node (LN) metastasis (pN1) after extended pelvic lymph node dissection (ePLND), multimodality treatment consisting of treatment of the primary tumor and whole pelvic radiotherapy (WPRT) combined with androgen deprivation therapy (ADT) offers promising results, leading to better cause-specific survival rates compared with ADT alone. However, in case more than one pelvic LN is invaded by the tumor, approximately 40% of the patients relapse biochemically and clinically. Clinical relapse is present in the para-aortic LNs (M1a disease) in up to 77% of the relapsing cases.

OBJECTIVE

We hypothesize that, based on the evidence that positive LNs represent the door to hematogenous dissemination, elective para-aortic irradiation will reduce the development of both retroperitoneal nodal (M1a) and distant metastasis (M1b or M1c disease), postpone the need for palliative ADT, and prolong the time to castration-refractory disease.

METHODS

To test this hypothesis, we will conduct a prospective, nonrandomized phase II trial to study the efficacy of additional elective para-aortic radiotherapy (PART) in pN1 patients compared with those who were historically treated with adjuvant WPRT alone. We aim to include 137 patients with PCa and presence of pN1 disease after ePLND. With this number of patients, an improvement of 15% in the 5-year clinical relapse-free survival can be detected with a power of 80%.

RESULTS

Recruitment of patients for this trial started in 2017 and will be completed approximately by March 2020.

CONCLUSIONS

This is the first phase II trial to investigate the benefits of an elective PART in patients with PCa. The results of this trial will potentially serve as a sound base for a later randomized phase III trial. All participants are given a PART information sheet and required to give written informed consent. Results are expected to be published in a peer-reviewed journal.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03079323; https://clinicaltrials.gov/ct2/show/NCT03079323 (Archived by WebCite at http://www.webcitation.org/73ELimv1d).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/11256.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU – Actualisation 2018–2020 : cancer de la prostate French ccAFU guidelines – Update 2018–2020: Prostate cancer

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: DOI:10.1016/j.purol.2019.01.007. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the DOI:10.1016/j.purol.2019.01.007. That newer version of the text should be used when citing the article.

Developing a personalized template for lymph node dissection during radical prostatectomy

Lymph node dissection (LND) represents a critical step in order to determine lymph node invasion (LNI), not only for prognostic means but also as a therapeutic strategy in the management of patients with prostate cancer (CaP). Indications for performing LND are inconsistent with the American Urologic Association (AUA), European Association of Urology (EAU), and National Comprehensive Cancer Network (NCCN) recommendations differing. A thorough appreciation of lymph node drainage patterns and extent of LND has reshaped our understanding of this disease. Moreover, newer research into this field has directly resulted in refinements to current nomograms with utilization of various prostate-specific antigen (PSA) parameters and genomic medicine. Lastly, the application of newer imaging modalities in combination with molecular-guided robotic surgery has personalized the approach of LND espousing excellent safety, efficacy, and oncologic outcomes in these patients.

Urologic Pathology: Key Parameters from a Urologist's Perspective

Prostate cancer, bladder cancer, and kidney cancer represent the 3 most common urologic malignancies, and form a heterogenous group of disease processes, with a wide range of pathologic features. As a urologist, a strong understanding of the pathologic features of urologic malignancies is essential to prognosticate and counsel patients and to determine the most effective course of treatment. This review discusses the pathologic features of prostate, bladder, and kidney cancer, and examines how detailed pathologic reporting is critical to today's practicing urologist.

Difference in Frequency and Distribution of Nodal Metastases Between Intermediate and High Risk Prostate Cancer Patients: Results of a Superextended Pelvic Lymph Node Dissection

Objectives: To evaluate the frequency and distribution of pelvic nodes metastases, in intermediate-high risk prostate cancer (PCa) patients (pts), who underwent open radical prostatectomy (ORP) and superextended pelvic lymph node dissection (sePLND). Patients and Methods: We retrospectively evaluated 630 consecutive pts with clinically localized, intermediate-high risk PCa, treated with ORP and sePLND from 2009 to 2016 at a single institution. The sePLND always removed all nodal/fibro-fatty tissue of the internal iliac, external iliac, obturator, common iliac, and presacral regions. Results: Positive lymph nodes (LN+) were found in 133 pts (21.1%). The median number of removed nodes and LN+ was 25 and 1, respectively. LN+ were found in 64 (48.1%), 58 (43.6%), 53 (39.8%), 16 (12%), and 20 (15%) pts and were present as a single site in 27 (20.3%), 22 (16.5%), 20 (15%), 0, and 6 (4.5%) cases in the internal iliac, external iliac, obturator, common iliac, and presacral chain, respectively. An ePLND would have correctly staged 127 (95%) pts but removed all LN+ in only 97 (73%) pts. Presacral nodes harbored LN+ in 20 patients. Among them, 18 were high-risk patients. Moreover, all but 1 pts with common iliac LN+ were in high risk group. Conclusions: These results suggest that removal of presacral and common iliac nodes could be omitted in intermediate risk pts. However, a PLND limited to external iliac, obturator, and internal iliac region may be adequate for nodal staging purpose, but not enough accurate if we aim to remove all possible site of LN+ in high risk pts.

Effectiveness of extended pelvic lymphadenectomy in the survival of prostate cancer: a systematic review and meta-analysis

Introduction

To determine the effectiveness and safety of extended pelvic lymphadenectomy compared with standard lymphadenectomy in the overall, cancer-specific survival and biochemical recurrence-free survival of patients with localized prostate cancer who underwent radical prostatectomy.

Material and methods

Clinical trials and cohort studies were included without language restrictions with the following participants: men older than 40 years of age diagnosed with localized prostate cancer who received radical prostatectomy plus pelvic lymphadenectomy. Standard vs. extended pelvic lymphadenectomy were compared. The primary outcomes were overall and cancer-specific survival. A search strategy in MEDLINE, EMBASE, CENTRAL, LILACS, and other databases was conducted to obtain published and unpublished literature. The risk of bias was evaluated with the Cochrane Collaboration tool. The statistical analysis was performed in STATA 14.

Results

Six studies were included, of which only one was experimental; the other studies were cohort studies. The surgical technique was robot-assisted in three studies. Two studies only had information concerning the adverse effects. It was not possible to include one clinical trial that met the criteria because an erratum was published in which falsification of the experimental data was proven. There was a biochemical recurrence-free survival hazard ratio (HR) = 0.62 and a 95% confidence interval (CI) (0.36 to 0.87).

Conclusions

According to current literature, a mild difference was evident favoring the extended lymphadenectomy in biochemical recurrence-free survival. Additionally, there was no evidence to draw a conclusion regarding the overall survival since we did not find any studies concerning this outcome.

Focal therapy for prostate cancer: concepts and future directions

PURPOSE OF REVIEW

To present a perspective on the current status and future directions of focal therapy for prostate cancer (PCa).

RECENT FINDINGS

Focal therapy for localized PCa is a rapidly evolving field. Various recent concepts - the index lesion driving prognosis, the enhanced detection of clinically significant PCa using multiparametric MRI and targeted biopsy, improved risk-stratification using novel blood/tissue biomarkers, the recognition that reducing radical treatment-related morbidity (along with reducing pathologic progression) is a clinically meaningful end-point - have all led to a growing interest in focal therapy. Novel focal therapy modalities are being investigated, mostly in phase 1 and 2 studies. Recently, level I prospective randomized data comparing partial gland ablation with a standard-of-care treatment became available from one study. Recent developments in imaging, including 7-T MRI, functional imaging, radiomics and contrast-enhanced ultrasound show early promise. We also discuss emerging concepts in patient selection for focal therapy.

SUMMARY

PCa focal therapy has evolved considerably in the recent few years. Overall, these novel focal therapy treatments demonstrate safety and feasibility, low treatment-related toxicity and acceptable short-term and in some cases medium-term oncologic outcomes. As imaging techniques evolve, patient selection, detection of clinically significant PCa and noninvasive assessment of therapeutic efficacy will be further optimized. The aspirational goal of achieving oncologic control while reducing radical treatment-related morbidity will drive further innovation in the field.

Performance of 111In-labelled PSMA ligand in patients with nodal metastatic prostate cancer: correlation between tracer uptake and histopathology from lymphadenectomy

PURPOSE

Intraoperative identification of lymph node (LN) metastases (LNM) detected on preoperative PSMA PET/CT may be facilitated by PSMA radioguided surgery with the use of a gamma probe. We evaluated the uptake of ¹¹¹In-labelled PSMA ligand DKFZ-617 (referred to as ¹¹¹In-PSMA-617) in unaffected LN and LNM at the level of single LN.

METHODS

Six patients with prostate cancer (PCa) with suspicion of LNM on preoperative PSMA PET/CT underwent ¹¹¹In-PSMA-617-guided lymphadenectomy (LA; four salvage LA and two primary LA). ¹¹¹In-PSMA-617 (109 ± 5 MBq). was injected Intravenously 48 h prior to surgery Template LAs were performed in small subregions: common, external, obturator and internal iliac vessels, and presacral and retroperitoneal subregions (n = 4). Samples from each subregion were isolated aiming at the level of single LN. Uptake was measured ex situ using a germanium detector. Receiver operating characteristic (ROC) analysis was performed based on ¹¹¹In-PSMA-617 uptake expressed as standardized uptake values normalized to lean body mass (SUL).

RESULTS

Overall 310 LN (mean 52 ± 19.7) were removed from 74 subregions (mean 12 ± 3.7). Of the 310 LN, 35 turned out to be LNM on histopathology. Separation of the samples from all subregions resulted in 318 single specimens: 182 PCa-negative LN samples with 275 LN, 35 single LNM samples, 3 non-nodal PCa tissue samples and 98 fibrofatty tissue samples. The median SULs of nonaffected LN (0.16) and affected LN (13.2) were significantly different (p < 0.0001). Based on 38 tumour-containing and 182 tumour-free specimens, ROC analysis revealed an area under the curve of 0.976 (95% CI 0.95-1.00, p < 0.0001). Using a SUL cut-off value of 1.136, sensitivity, specificity, positive predictive value, negative predictive value and accuracy in discriminating affected from nonaffected LN were 92.1% (35/38), 98.9% (180/182), 94.6% (35/37), 98.4% (180/183) and 97.7% (215/220), respectively.

CONCLUSION

Ex situ analysis at the level of single LN showed that ¹¹¹In-PSMA-617 had excellent ability to discriminate between affected and nonaffected LN in our patients with PCa. This tracer characteristic is a prerequisite for in vivo real-time measurements during surgery.

Robot-assisted extended lymphadenectomy in prostate cancer

INTRODUCTION

The extent of lymph node dissection (LND) and its potential survival benefit are still a matter of debate. Aim of our review was to summarize the latest literature data regarding the surgical templates, the potential oncological benefits, the functional outcomes and the complications of extended lymph node dissection (eLND) during robot-assisted radical prostatectomy (RARP).

EVIDENCE ACQUISITION

We systematically reviewed all relevant studies using PubMed, MEDLINE, Embase, American Urological Association (AUA), European Society of Medical Oncology (ESMO) and European Association of Urology (EAU) guidelines.

EVIDENCE SYNTHESIS

A narrative synthesis of all relevant publications on surgical templates, complications, oncological and functional outcomes of robot assisted eLND was undertaken.

CONCLUSIONS

A great deal of evidence supports that an extended template of LND is not only technically feasible but also safe in the context of RARP. It is really promising that in the era of minimally invasive surgery, parameters like the lymph node yield and the detection rates of positive lymph nodes during LND have become highly comparable with open series. The extended approach has already proved its benefits in terms of proper patient staging but more studies are needed with regard to functional outcomes and oncological benefits of this procedure.

Effect of the number of removed lymph nodes on prostate cancer recurrence and survival: evidence from an observational study

Background

The aim of this article is to analyze the effect on biochemical recurrence and on overall survival of removing an extensive number of pelvic lymph nodes during prostate cancer surgery. The lack of evidence from randomized clinical trials to address this specific question has hampered the ability to determine the true effect of the number of nodes removed.

Results

Our analysis is based on a large observational study, and this can lead unadjusted estimates to be very sensitive to confounding bias due to the different prognosis of individuals. We assess the effect of the number of lymph nodes removed by means of an Inverse Probability Weighting adjustment based on a Poisson regression model, and by a Doubly-robust adjustment.

Conclusions

Our findings suggest that a large number of nodes removed is associated with a significant improvement in time to biochemical recurrence. However, it appears to have no impact on overall survival.

Prospective Randomized Controlled Trial Exploring the Effect of TachoSil on Lymphocele Formation After Extended Pelvic Lymph Node Dissection in Prostate Cancer

OBJECTIVE

To explore whether TachoSil, a hemostatic patch, can reduce the incidence of lymphocele formation. Development of a lymphocele is a frequent complication after pelvic lymph node dissection (PLND) for nodal staging in prostate cancer.

MATERIALS AND METHODS

From 2013 to 2017, 100 patients with prostate cancer who were set to undergo a staging PLND before external beam radiotherapy (n = 50) or PLND concomitant with radical prostatectomy (RP) (n = 50) were prospectively randomized 1:1 between bilateral TachoSil placement or nonplacement. Primary end points were radiographic lymphocele development, lymphocele volume (1 week and 1 month postoperatively), and the duration and volume of postoperative catheter drainage.

RESULTS

Patient, tumor, and surgical characteristics of the TachoSil and the control groups did not differ significantly. In total, 65 patients (65%) experienced a radiographic lymphocele up to 3 months after surgery: 29 (58%) in the TachoSil group and 36 (72%) in the control group (P = .34). Significantly less radiographic lymphoceles were observed 1 week postoperatively for patients who underwent sole PLND and 1 month postoperatively for patients who underwent PLND with RP in the TachoSil group compared with the control group (16% vs 48%, P = .024, and 24% vs 52%, P = .047, respectively). The other postoperative characteristics presented no significant differences between the 2 groups, neither for patients undergoing sole PLND nor for patients undergoing PLND with RP.

CONCLUSION

Patients undergoing bilateral TachoSil placement after PLND seem less likely to develop a radiographic lymphocele early postoperatively. Nevertheless, the clinical relevance of the use of TachoSil remains highly debatable.

Fluorescence-supported lymphography and extended pelvic lymph node dissection in robot-assisted radical prostatectomy: a prospective, randomized trial

PURPOSE

To demonstrate the benefits of fluorescence-supported extended pelvic lymph node dissection (ePLND) compared to regular ePLND in robot-assisted radical prostatectomy.

METHODS

120 patients with intermediate- or high-risk prostate cancer were prospectively randomized (1:1): in the intervention group, indocyanine green (ICG) was injected transrectally into the prostate before docking of the robot. In both groups, ePLND was performed including additional dissection of fluorescent lymph nodes (LN) in the ICG group.

RESULTS

After drop-out of two patients, 59 patients were allocated to the control (A) and intervention group (B) with a median PSA of 8,6 ng/ml. Median console time was 159 (A) vs. 168 (B) min (p = 0.20) with a longer time for ICG-ePLND: 43 (A) vs. 55 min (B) (p = 0.001). 2609 LN were found with significantly more LN after ICG-supported ePLND with a median of 25 vs. 17 LN in A (p < 0.001). Nodal metastases were detected in 6 patients in A (25 cancerous LN) vs. 9 patients in B (62 positive LN) (p = 0.40). In seven of nine patients, ICG-ePLND identified at least one cancer-positive LN (sensitivity 78%), 27 of 62 cancerous LN were fluorescent. Symptomatic lymphocele occurred in one patient in a and in three patients in b (p = 0.62). After a median follow-up of 22.9 months, PSA levels were similar.

CONCLUSIONS

While ICG-ePLND seems to be beneficial for a better understanding of the lymphatic drainage and a more meticulous diagnostic approach, the sensitivity is not sufficient to recommend stand-alone ICG lymph node dissection.

Extent of lymph node dissection improves survival in prostate cancer patients treated with radical prostatectomy without lymph node invasion

PURPOSE

To assess the effect of pelvic lymph node dissection (PLND) extent on cancer-specific mortality (CSM) in prostate cancer (PCa) patients without lymph node invasion (LNI) treated with radical prostatectomy (RP).

METHODS

Within the Surveillance, Epidemiology, and End results (SEER) database (2004-2014), we identified patients with D'Amico intermediate- or high-risk characteristics who underwent RP with PLND, without evidence of LNI. First, multivariable logistic regression models tested for predictors of more extensive PLND, defined as removed lymph node count (NRN) ≥75th percentile. Second, Kaplan-Meier analyses and multivariable Cox regression models tested the effect of NRN ≥75th percentile on CSM. Finally, survival analyses were repeated using continuously coded NRN.

RESULTS

In 28 147 RP and PLND patients without LNI, 67.3% versus 32.7% exhibited D'Amico intermediate- or high-risk characteristics. The median NRN was 6 (IQR 3-10), the 75th percentile defined patients with NRN ≥11. Patients with NRN ≥11 had higher rate of cT2/3 stage (29.8 vs 26.1%), GS ≥8 (25.7 vs 22.4%), and respectively more frequently exhibited D'Amico high-risk characteristics (34.6 vs 32.1%). In multivariable logistic regression models predicting the probability of more extensive PLND (NRN ≥11), higher biopsy GS, higher cT stage, higher PSA, more recent year of diagnosis, and younger age at diagnosis represented independent predictors. At 72 months after RP, CSM-free rates were 99.5 versus 98.1% for NRN ≥11 and NRN ≤10, respectively and resulted in a HR of 0.50 (P = 0.01), after adjustment for all covariates. Similarly, continuously coded NRN achieved independent predictor status (HR: 0.955, P = 0.01), where each additional removed lymph node reduced CSM risk by 4.5%.

CONCLUSION

More extensive PLND at RP provides improved staging information and consequently is associated with lower CSM in D'Amico intermediate- and high-risk PCa patients without evidence of LNI. Hence, more extensive PLND should be recommended in such individuals.

Increased Paxillin expression in prostate cancer is associated with advanced pathological features, lymph node metastases and biochemical recurrence

Purpose Paxillin regulates cell-cell adhesion, and altered Paxillin expression has been associated with human carcinogenesis. This study analyzed the association between Paxillin expression in prostate cancer (PCa) tissues with clinicopathological features, lymph node metastasis and biochemical PCa recurrence.

Methods A total of 386 tissue specimens from PCa patients who received radical prostatectomy and 60 tissue specimens from benign prostatic hyperplasia (BPH) cases were collected to construct tissue microarrays, which were subsequently immunostained for Paxillin expression. Thirty positive lymph node tissue specimens and 10 healthy prostate tissue specimens were randomly selected for Paxillin immunostaining.

Results The association between Paxillin expression, lymph node metastasis and biochemical PCa recurrence was analyzed. Paxillin expression was significantly higher in PCa than both normal and BPH tissues (P<0.001) and was correlated with preoperative prostate-specific antigen level, Gleason score, clinical tumor stage, lymph node metastasis, positive surgical margin, extracapsular extension and seminal vesicle invasion (P<0.05 for all). Logistic regression analysis showed that Paxillin and Gleason score were independent risk factors for PCa lymph node metastasis (P<0.05). The receiver operating characteristic (ROC) curve indicated that Paxillin expression (AUC=0.723) more accurately predicted PCa lymph node metastasis than Gleason score (AUC=0.692). Kaplan-Meier curve analysis showed that increased Paxillin expression was associated with shortened biochemical-free survival (BFS) after radical prostatectomy (P<0.001).

Conclusion Paxillin was significantly upregulated in PCa compared with BPH and normal tissues and associated with lymph node metastasis and shortened BFS of PCa. Further study will investigate the underlying molecular mechanism and the role of Paxillin in PCa.

Utilization of pelvic lymph node dissection in patients undergoing robot-assisted radical prostatectomy in India versus the United States - A Vattikuti Collective Quality Initiative database analysis

BACKGROUND

The utilization and extent of pelvic lymph node dissection (PLND) varies depending on the disease and practice patterns.

AIMS

This study compares practice patterns in utilization of PLND between Indian and United States (US) practices.

SETTINGS AND DESIGN

We focused on 415 patients (204 India; 211 US) prostate cancer patients treated with robot-assisted radical prostatectomy, between 2015 and 2016, within the Vattikuti Collective Quality Initiative database.

SUBJECTS AND METHODS

Utilization of PLND and number of nodes removed were evaluated for the entire cohort, and after stratifying for Country of treatment and D'Amico risk groups. Logistic regression tested the relationship between PLND and country of treatment, after adjusting for disease risk.

RESULTS

Indian patients had a higher risk distribution (D'Amico high-risk 53.4% in India vs. 27% in the US; P< 0.001) compared to their US counterparts. Overall, 193/204 (94.6%) Indian patients underwent PLND versus 181/211 (85.8%) US patients (P = 0.003). When stratified based on disease risk, PLND was performed more frequently in Indian patients with low-risk disease (81.0% vs. 41.4%,P= 0.008), but not in those with intermediate and high-risk disease. On multivariable analysis, Indian patients had a 2.57-fold higher probability of undergoing PLND than their US counterparts (P = 0.02). The analysis of the number of lymph nodes removed showed similar trends.

CONCLUSIONS

Indian patients are more likely to undergo PLND than US patients. This is, especially true for patients with low-risk disease, who are unlikely to benefit from this procedure. Efforts should focus on optimizing the utilization of PLND, and deliver it only when there is clinical indication.

Therapeutic Value of Standard Versus Extended Pelvic Lymph Node Dissection During Radical Prostatectomy for High-Risk Prostate Cancer

Extent of pelvic lymph node dissection (PLND) during radical prostatectomy (RP) remains a subject of debate. Here, we review the literature covering the value of extended PLND (ePLND) during RP for high-risk prostate cancer (PCa) over a standard PLND, with a focus on potential therapeutic advantage. PLND may provide valuable prognostic information to high-risk PCa patients, and incorporating the common iliac and presacral nodes to ePLND templates further improves pathologic nodal staging accuracy. Although increased PLND extent is associated with increased lymphocele/lymphedema rates, it is not associated with increased venous thromboembolism rates. The therapeutic role of ePLND remains uncertain. While recent retrospective studies suggest an increased number of nodes removed within the ePLND template are associated with improved survival outcomes, such retrospective studies cannot completely adjust for the Will Rodgers phenomenon or surgeon-specific factors. Thus, the results of randomized trials are eagerly awaited in this arena.

Management of Patients with Advanced Prostate Cancer: The Report of the Advanced Prostate Cancer Consensus Conference APCCC 2017

BACKGROUND

In advanced prostate cancer (APC), successful drug development as well as advances in imaging and molecular characterisation have resulted in multiple areas where there is lack of evidence or low level of evidence. The Advanced Prostate Cancer Consensus Conference (APCCC) 2017 addressed some of these topics.

OBJECTIVE

To present the report of APCCC 2017.

DESIGN, SETTING, AND PARTICIPANTS

Ten important areas of controversy in APC management were identified: high-risk localised and locally advanced prostate cancer; "oligometastatic" prostate cancer; castration-naïve and castration-resistant prostate cancer; the role of imaging in APC; osteoclast-targeted therapy; molecular characterisation of blood and tissue; genetic counselling/testing; side effects of systemic treatment(s); global access to prostate cancer drugs. A panel of 60 international prostate cancer experts developed the program and the consensus questions.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The panel voted publicly but anonymously on 150 predefined questions, which have been developed following a modified Delphi process.

RESULTS AND LIMITATIONS

Voting is based on panellist opinion, and thus is not based on a standard literature review or meta-analysis. The outcomes of the voting had varying degrees of support, as reflected in the wording of this article, as well as in the detailed voting results recorded in Supplementary data.

CONCLUSIONS

The presented expert voting results can be used for support in areas of management of men with APC where there is no high-level evidence, but individualised treatment decisions should as always be based on all of the data available, including disease extent and location, prior therapies regardless of type, host factors including comorbidities, as well as patient preferences, current and emerging evidence, and logistical and economic constraints. Inclusion of men with APC in clinical trials should be strongly encouraged. Importantly, APCCC 2017 again identified important areas in need of trials specifically designed to address them.

PATIENT SUMMARY

The second Advanced Prostate Cancer Consensus Conference APCCC 2017 did provide a forum for discussion and debates on current treatment options for men with advanced prostate cancer. The aim of the conference is to bring the expertise of world experts to care givers around the world who see less patients with prostate cancer. The conference concluded with a discussion and voting of the expert panel on predefined consensus questions, targeting areas of primary clinical relevance. The results of these expert opinion votes are embedded in the clinical context of current treatment of men with advanced prostate cancer and provide a practical guide to clinicians to assist in the discussions with men with prostate cancer as part of a shared and multidisciplinary decision-making process.