Correlation between side of palpable tumor and side of pelvic lymph node metastasis in clinically localized prostate cancer

Association of Lymphovascular Invasion with Lymph Node Metastases in Prostate Cancer-Lateralization Concept

BACKGROUND

Lymphovascular invasion (LVI) is a vital but often overlooked prognostic factor in prostate cancer. As debates on lymphadenectomy's overtreatment emerge, understanding LVI laterality gains importance. This study pioneers the investigation into PCa, aiming to uncover patterns that could influence tailored surgical strategies in the future.

METHODS

Data from 96 patients with both LVI and lymph node invasion (LNI) were retrospectively analyzed. All participants underwent radical prostatectomy (RP) with modified-extended pelvic lymph node dissection (mePLND). All specimens underwent histopathological examination. The assessment of LVI was conducted separately for the right and left lobes of the prostate. Associations within subgroups were assessed using U-Mann-Whitney and Kruskal-Wallis tests, as well as Kendall's tau-b coefficient, yielding p-values and odds ratios (ORs).

RESULTS

Out of the 96 patients, 61 (63.5%) exhibited exclusive left-sided lymphovascular invasion (LVI), 24 (25.0%) had exclusive right-sided LVI, and 11 (11.5%) showed bilateral LVI. Regarding nodal involvement, 23 patients (24.0%) had LNI solely on the left, 25 (26.0%) exclusively on the right, and 48 (50.0%) on both sides. A significant correlation was observed between lateralized LVI and lateralized LNI (p < 0.001), particularly in patients with right-sided LVI only. LN-positive patients with left-sided LVI tended to have higher pT stages (p = 0.047) and increased odds ratios (OR) of bilateral LNI (OR = 2.795; 95% confidence interval [CI]: 1.231-6.348) compared to those with exclusive right-sided LVI (OR = 0.692; 95% CI: 0.525-0.913).

CONCLUSIONS

Unilateral LVI correlates with ipsilateral LNI in PCa patients with positive LNs, notably in cases of exclusively right-sided LVI. Left-sided LVI associates with higher pT stages and a higher percentage of bilateral LNI cases.

The role of side-specific biopsy and dominant tumor location at radical prostatectomy in predicting the side of nodal metastases in organ confined prostate cancer: is lymphatic spread really unpredictable?

BACKGROUND

The aim of this study was to evaluate the correlation between the location of prostate cancer (PCa) either at biopsy or at radical prostatectomy (RP) specimens and the side of positive lymph nodes (LNs). Furthermore, we assessed the risk of contralateral LN metastasis (LNMs) in patients with unilateral positive biopsy and/or dominant lesion at RP.

METHODS

We reviewed retrospectively our prospectively maintained database of patients with LNM treated with robot-assisted RP and bilateral robot-assisted extended pelvic lymph node dissection (EPLND) for PCa from January 2014 to May 2018 at a surgical high-volume center. All men with a suspicion for PCa underwent a 12-cores prostate biopsy. In case of a first negative biopsy but the persistence of suspicion, all the patients underwent prostate multiparametric magnetic resonance imaging (mpMRI) and subsequently either fusion targeted biopsy (TBx) or systematic standard biopsy (SBx), in case of positive or negative mpMRI, respectively. All patients underwent a robot-assisted RP. Whole-mount histological sections resected from the RP specimens were used as reference standards.

RESULTS

Eighty-seven patients were enrolled for the study. Median number of LNs retrieved per patient was 26, specifically 13 and 12, on the left and right side, respectively. Seven of 24 (29.1%) right lobe positive biopsy showed positive LNs on the left side (one exclusively left, 6 bilateral LNMs). Again, 12 of 26 (46.1%) left lobe positive biopsy showed positive LNs on the right side (one exclusively right, 11 bilateral LNMs). No significant differences of performance to predict the side of LNMs were recorded in the SBx and TBx groups. Concerning RP specimens, only five of 22 (22.7%) right lobe dominant cases showed positive LNs on the left side (two exclusively left, 3 bilateral LN metastases). Again, none of 16 left lobe dominant cases showed positive LNs on the contralateral side (15 exclusively right, 1 bilateral LNMs).

CONCLUSIONS

Our results suggest confirmed that a unilateral LN dissection limited to the tumor-bearing side of the gland evaluated by biopsy specimens should not be recommended due to the substantial risk of missing contralateral LNMs.

Sentinel node evaluation in prostate cancer

Sentinel lymph node (SLN) based pelvic lymph node dissection (PLND) in prostate cancer (PCa) is appealing over the time, cost and morbidity classically attributed to conventional PLND during radical prostatectomy. The initial report of feasibility of the SLN concept in prostate cancer was nearly 20 years ago. However, PLND based on the SLN concept, either SLN biopsy of a single node or targeted SLN dissection of multiple nodes, is still considered investigational in PCa. To better appreciate the challenges, and potential solutions, associated with SLN-based PLND in PCa, this review will discuss the rationale behind PLND in PCa and evaluate current SLN efforts in the most commonly diagnosed malignancy in men in the US.

Can side-specific biopsy findings predict the side of nodal metastasis in clinically localized prostate cancer? Results from a multicenter prospective survey

BACKGROUND

To evaluate the correlation between the side of positive biopsy (Bx) and the risk of lymph-node metastases (LNMs) on each side and to quantify the risk of contralateral LNMs in patients with unilateral positive biopsy.

METHODS

We analyzed the outcomes of 1599 patients with complete data regarding the sides of positive Bx and LN (lymph-node). By dividing each prostate into two separate sides, we assessed the accuracy of the side-specific Bx details in determining the side of positive nodes; the area under the receiver-operating characteristic (ROC) (AUCs) was used. For patients with unilateral positive Bx, we assessed the risk of homolateral and contralateral LNMs according to the number of total Bx taken and the preoperative risk of LN invasion.

RESULTS

Considering the 3198 prostate sides, there was a strict correlation between the side of positive Bx and the side of LNMs. The ratio of positive/total Bx was more informative than the number of positive core. The AUC for ipsilateral LNMs was significantly higher than that for contralateral LNMs (P = 0.039). In the 805 patients with unilateral positive Bx, the percentage of contralateral LNMs was >30% even considering a more meticulous biopsy scheme and increased in the patients at a higher clinical risk for LN invasion.

CONCLUSION

PCa preferentially metastasizes to ipsilateral LNs but >30% of contralateral LNMs are present. A unilateral LN dissection that is limited to the tumor-bearing side of the gland should not be recommended because of the substantial risk of missing contralateral metastases.

Prostate cancer topography and patterns of lymph node metastasis

Pelvic lymph node (LN) metastasis is a well-recognized route of prostate cancer spread. However, the relationship between topography and the pathologic features of primary prostatic cancers and patterns of pelvic LN metastasis has not been well studied. We reviewed original slides of radical prostatectomies and pelvic LN dissections from 125 patients with LN metastasis and recorded a total number of LN excised/laterality of positive LN, and localization, staging parameters, lymphovascular invasion, and volume of primary tumors.

LN QUANTITY AND DISTRIBUTION

14.6 (mean) and 13 (median) LNs were resected. Seventy-six (61%), 33 (26%), and 16 (13%) cases had 1, 2, and >2 positive LNs; whereas 58, 44, and 20 cases had LN metastasis on the right, left, and bilaterally.

PATHOLOGIC FEATURES

Eighty-six percent (108 of 125) and 37% (46 of 125) of the cases showed extraprostatic extension and seminal vesicle invasion, whereas 64% cases showed lymphovascular invasion. Mean and median total tumor volumes were 6.39 and 3.92 cm, with ≥50% and ≥90% Gleason patterns 4/5 in 105 (84%) and 73 (58%) cases, respectively.

CORRELATION WITH DOMINANT TUMOR LOCATION

Dominant lesions on radical prostatectomy were as follows: 50 right lobe, 44 left lobe, and 31 bilateral lobe tumors. Fifteen of 50 (30%) right lobe and 18 of 44 (41%) left lobe dominant tumors had LN metastasis on the contralateral side. Only 4% (5 of 125) of the cases were associated with anterior dominant tumors.

CONCLUSION

Thirty percent to 40% of LN metastases occurred contralateral to the dominant tumor. LN metastasis is overwhelmingly associated with high-grade, high-stage, and large volume disease. LN positivity is rarely associated with anterior dominant tumors.

Can digital rectal examination or transrectal ultrasonography biopsy findings predict the side of nodal metastasis in prostate cancer?

PURPOSE

To assess the use of several preoperative parameters in predicting the side of pelvic lymph node metastasis in patients with prostate cancer.

MATERIALS AND METHODS

A retrospective chart review (January 1982 to February 2004) identified 106 men with pathology proven lymph node positive prostate cancer for whom complete medical records were available.

RESULTS

The median serum prostate-specific antigen at diagnosis was 11 ng/ml with the clinical stage T1C in 9 patients, T2 in 68, and T3 in 29. The Gleason score on transrectal ultrasonography (TRUS) biopsy was < or =6 in 13, 7 in 41, and > or =8 in 52. A total of 93 patients had documented pretreatment digital rectal examination (DRE) findings: 54 had a unilaterally suspicious DRE, and 31 had a bilaterally suspicious DRE. Of patients with a unilaterally positive DRE, 30 had ipsilateral lymph node metastasis, 16 contralateral, and 8 bilateral. DRE showed a 71% sensitivity and 29% false-negative rate in predicting the side of nodal metastasis. A total of 98 patients had documented TRUS biopsy findings: 37 had unilaterally positive TRUS biopsies and 61 bilaterally positive biopsies. Of patients with unilaterally positive TRUS biopsies, 20 had ipsilateral lymph node metastasis, 11 contralateral, and 6 bilateral. TRUS biopsies showed an 86% sensitivity and 14% false-negative rate in predicting the side of nodal metastasis.

CONCLUSIONS

DRE and TRUS biopsies do not accurately predict the side of pelvic lymph node metastasis and should not determine the extent of the pelvic lymphadenectomy.

[Non-metastatic prostate cancer treated with exclusive radiotherapy: prognosis of patients according to lymph node radiologic or surgical assessment method. Multivariate retrospective analysis]

PURPOSE

To compare retrospectively the outcome of localized prostate cancers treated by curative external radiotherapy in which the negative lymphatic status was either surgically or radiologically assessed.

METHODS AND MATERIALS

From January 1986 to December 1995, 112 patients with localized prostate cancers were found to have no evidence of lymphatic disease in the pelvis. N0 status was assessed either surgically (61 patients, group pN-) or after a CT scan procedure (51 patients, group cN0). The treatment consisted of conventional external radiotherapy using a four-fields box technique to a total dose of 65 Gy. The pelvis was never irradiated.

RESULTS

The two groups did not statistically differ according to age, PSA level, Gleason score, T stage and hormonal therapy. Actuarial NED survival rates were 80% and 60% at five and ten years respectively. At ten years, the actuarial NED survival rates were 78% and 34% in the pN- and cN0 groups respectively (p = 0.003). The multivariate analysis corroborated the positive impact of lymphatic dissection before radiotherapy on disease free survival of T1-T2 patients, but not for T3 stages.

CONCLUSIONS

This retrospective study suggests the inability of CT scan to accurately evaluate the lymph node status in carcinoma of the prostate. Systematic ilio-obturator nodal dissection is strongly recommended in early stages before curative radiotherapy. Only pN-patients should be included in high dose conformal irradiation trials.

Treatment of patients with clinical T3 prostate cancer

OBJECTIVE

To describe and evaluate treatment alternatives for patients with clinical T3 prostate cancer.

MATERIAL AND METHODS

Literature review with main focus on recent studies in order to include the impact of prostate specific antigen (PSA). The possibility of using neoadjuvant/adjuvant hormonal therapy in combination with surgery or radiation was assessed. Results were related to life expectancy, tumour grade and serum PSA.

RESULTS

M and N-staging is mandatory before treatment with curative intent. Watchful waiting is an option for selected patients but early hormonal therapy seems to offer some survival advantages. Standard 65-70Gy external beam radiation is not sufficient for these patients with extracapsular disease but better results are obtained with dose-escalation (beyond 70Gy) and/or adjuvant hormonal therapy. Radical prostatectomy may be an option for patients with long life expectancy and "early" tumours, neoadjuvant hormonal withdrawal is of no proven value.

CONCLUSIONS

Patients with a long life expectancy should not be denied treatment with curative intent solely based on the finding of extracapsular disease.

Prognostic factors in major salivary gland cancer

OBJECTIVE

To identify features of major salivary gland cancers that are prognostic for disease-free survival.

STUDY DESIGN

A retrospective study of 78 patients with major salivary gland cancer (64 parotid and 14 submandibular gland) who underwent surgery for definitive treatment from 1976 to 1996. A select group of patients also received adjuvant radiation (56%) and/or chemotherapy (13%).

METHOD

Clinical and pathological risk factors were obtained from patients' charts and pathology reports. Age, gender, tumor site, T-stage, facial paralysis, histologic neck involvement, perineural invasion, and cancer grade were analyzed with respect to disease-free survival. The role of adjuvant treatment in terms of clinical outcome was also investigated.

RESULTS

In our series, the 5-year disease-free survival was 65%. Examining clinical and histologic features one at a time, we found poorer prognosis was associated with submandibular tumors compared with parotid (P =.02), higher T-stage (P =.001), positive cervical nodes (P <.001), perineural invasion (P =.002), and high-grade or adenoid cystic tumors (P =.002). A multivariable analysis indicated that positive lymph nodes (P =.07) and perineural invasion (P =.03) were important histologic predictors of shorter disease-free survival. Receipt of both adjuvant radiation and cisplatin-based chemotherapy (P =.05) was an independent predictor of longer disease-free survival.

CONCLUSION

Our study indicated that the presence of positive lymph nodes and perineural invasion is important independent predictors of disease-free survival. Our limited data also suggest that adjuvant chemotherapy and radiation therapy may improve disease-free survival.

Results of laparoscopic pelvic lymphadenectomy in patients at high risk for nodal metastases from prostate cancer

BACKGROUND

Laparoscopic pelvic lymphadenectomy (LPLND) can be performed safely and with minimal morbidity in the staging of prostate cancer. Its utility in evaluating patients at high risk for metastatic disease before primarily nonsurgical treatment modalities was evaluated.

METHODS

Twenty-four consecutive patients who underwent LPLND between June 1993 and July 1996 were studied. These patients were considered poor surgical candidates based on several risk factors, as follows: elevation of serum PSA >20 in 19 patients (79%); elevation of serum acid phosphatase in 4 patients (17%); digital rectal examination findings indicative of extraprostatic extension or seminal vesical involvement in 14 patients (58%); and poorly differentiated tumors on prostate biopsy in 19 patients (79%). Nineteen patients (79%) had two or more of these risk factors. Median PSA for the entire series of patients was 35.2 ng/mL (range 7.9 to 133 ng/mL), and median Gleason score was 7 (range 5 to 9). Preoperative CT or MRI was negative for pelvic lymph node metastases in 17 of 23 patients (79%), and bone scan was negative in all 24 patients.

RESULTS

Unilateral (n = 2) or bilateral (n = 22) LPLND was performed in all patients. Six patients (25%) had lymph node metastases detected laparoscopically. Five of the six patients had palpable extraprostatic extension (T3a/b) or invasion of a seminal vesical (T3c), and in four of these patients the site of the metastatic lymph nodes was ipsilateral to the palpable prostate abnormality. None of the risk factors was independently predictive of lymph node metastases within this series of patients. An average of 10.8 +/- 6.5 lymph nodes was removed at a mean operative time of 174 +/- 10 minutes for patients undergoing bilateral LPLND. Estimated blood loss was minimal for 20 of 22 patients (92%) undergoing LPLND alone, and there were no complications requiring open exploration. Mean postoperative hospital stay was 1.2 +/- 0.5 days for patients undergoing LPLND alone.

CONCLUSIONS

LPLND can be used efficiently to identify patients with nodal metastases from select high-risk patients. This, in turn, can exclude such patients from noncurative local and regional therapy.

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 in 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 +/- 10.2, range 8 to 56) was nearly identical to that from patients with prostate cancer (20.5 +/- 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.

Laparoscopic staging pelvic lymphadenectomy: extraperitoneal approach

Comparative studies have proven the feasibility as well as reduced morbidity of endoscopic pelvic lymph node dissection when compared to open pelvic lymphadenectomy. Transperitoneal laparoscopic pelvic lymphadenectomy, however, has been associated with complications related to transperitoneal access and intraperitoneal dissection. We, therefore, developed the extraperitoneal laparoscopic staging pelvis lymph node dissection which combines the anatomic principles of open pelvic lymphadenectomy with the minimally invasive endoscopic technique. Exploration of the area of our endoscopic lymphadenectomy during radical retropubic prostatectomy proved the feasibility of our dissection. In patients selected for laparoscopic lymphadenectomy, we now prefer the extraperitoneal approach.

Laparoscopic pelvic lymphadenectomy: transperitoneal approach

Laparoscopic pelvic lymph node dissection (PLND) is the most commonly performed laparoscopic procedure in urology today. Indications for laparoscopic PLND are being refined to selectively identify patients who are at high risk for lymphatic metastases. From a technical standpoint, the anatomic detail and number of lymph nodes retrieved by the laparoscopic approach are comparable to open PLND. Laparoscopic PLND is associated with a steep learning curve and increased operative time; however, the decreased postoperative discomfort, shortened hospital stay, rapid resumption of normal activities, and enhanced cosmesis are clear advantages over open PLND.

Utility of preoperative serum prostate-specific antigen concentration and biopsy Gleason score in predicting risk of pelvic lymph node metastases in prostate cancer

OBJECTIVES

To determine the accuracy of the preoperative serum concentration of prostate-specific antigen (PSA) plus the Gleason pathology score of biopsy specimens in predicting the presence of disease in the pelvic lymph nodes in patients with prostate cancer.

METHODS

The medical records of all patients treated for prostate cancer at eight medical centers from January 1988 to June 1993 were reviewed. There were 932 patients with newly diagnosed prostate cancer for whom all relevant data were available who had undergone pelvic lymphadenectomy with (n = 912) or without (n = 20) radical prostatectomy. The rate of false-negative predictions of metastases based on combined preoperative biopsy Gleason score and serum PSA concentration was analyzed. A multivariate logistic regression analysis was performed to assess the value of preoperative serum PSA and biopsy Gleason scores individually and in combination in predicting pelvic lymph node metastases.

RESULTS

The false-negative rate of metastases was 0% for preoperative PSA concentrations < or = 6 ng/mL and biopsy Gleason scores < or = 5 (n = 142) and 1.0% for PSA concentrations < or = 10 ng/mL and Gleason scores < or = 6 (n = 388). The 95% upper confidence limit for the rate of false negativity at this PSA cut-off level was 2.0%. A combination of preoperative serum PSA levels and biopsy Gleason scores provided the best prediction for the false-negative rates.

CONCLUSIONS

For patients with newly diagnosed prostate cancer who have biopsy Gleason scores < or = 6 and preoperative PSA concentrations < or = 10 ng/mL (42% of our series), a staging pelvic lymphadenectomy appears to be unnecessary. The substantial cost associated with both cross-sectional imaging and staging lymphadenectomy may therefore be avoidable in this group of patients.

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 47 mg. 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.

Laparoscopic lymphadenectomy in genitourinary malignancies

Laparoscopic pelvic lymphadenectomy has been applied to stage prostate cancer since 1989. These same laparoscopic techniques are being used to stage other urological malignancies. This report will detail the role of laparoscopic lymphadenectomy in staging genitourinary malignancies.