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Harke NN, Fuhrmann C, Czerner C, Rudolf F, Ross TL, Katzendorn O, Bengel F, Kuczyk MA, Weiberg D, Derlin T. Feasibility of Using a Novel Drop-In Gamma Probe for 99mTc-PSMA-I&S-Guided Lymph Node Detection During Robot-Assisted Radical Prostatectomy for Primary Prostate Cancer. Clin Nucl Med 2024:00003072-990000000-01210. [PMID: 38968541 DOI: 10.1097/rlu.0000000000005385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2024]
Abstract
PURPOSE Prostate-specific membrane antigen (PSMA)-targeted radioguided surgery (RGS) has gained increased interest in prostate cancer (PCa). This analysis aims to evaluate the feasibility, safety, and limitations of RGS with a novel drop-in gamma probe in primary PCa. PATIENTS AND METHODS The data of 13 patients with primary PCa undergoing RGS were analyzed retrospectively. After preoperative administration of 99mTc-PSMA-I&S, a SPECT/CT was conducted and a robotic radical prostatectomy was performed the following day including intraoperative assessment of the lymph node stations using a novel robotic drop-in gamma probe. This was followed by an extended pelvic lymph node dissection (ePLND) with ex vivo control measurement using the drop-in and a conventional rigid gamma probe. RESULTS Eleven patients (median PSA value of 11 ng/mL) had high-risk and 2 patients had intermediate-risk PCa. Overall, a median of 22 ePLND lymph nodes were dissected. In 1 patient, preoperative SPECT/CT imaging showed suspicious lymph nodes, which could be confirmed intraoperatively with the robotic drop-in probe and subsequently in the final histopathological analysis. RGS failed to identify 2 patients with micrometastases (<3 mm) preoperatively and intraoperatively. No postoperative complications related to 99mTc-PSMA-I&S RGS or ePLND occurred. CONCLUSIONS RGS with the novel drop-in gamma probe and 99mTc-PSMA-I&S allows for a reliable intraoperative screening for lymph node metastases in robot-assisted radical prostatectomy for primary PCa with an acceptable safety profile. However, limitations in the detection of micrometastases need to be overcome before omitting extended ePLND in patients at risk for lymphatic spread.
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Affiliation(s)
| | | | | | - Frank Rudolf
- Radiation Protection, Hannover Medical School, Hannover, Germany
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Tenbergen CJA, Fortuin AS, van Asten JJA, Veltien A, Philips BWJ, Hambrock T, Orzada S, Quick HH, Barentsz JO, Maas MC, Scheenen TWJ. The Potential of Iron Oxide Nanoparticle-Enhanced MRI at 7 T Compared With 3 T for Detecting Small Suspicious Lymph Nodes in Patients With Prostate Cancer. Invest Radiol 2024; 59:519-525. [PMID: 38157433 DOI: 10.1097/rli.0000000000001056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND Accurate detection of lymph node (LN) metastases in prostate cancer (PCa) is a challenging but crucial step for disease staging. Ultrasmall superparamagnetic iron oxide (USPIO)-enhanced magnetic resonance imaging (MRI) enables distinction between healthy LNs and nodes suspicious for harboring metastases. When combined with MRI at an ultra-high magnetic field, an unprecedented spatial resolution can be exploited to visualize these LNs. PURPOSE The aim of this study was to explore USPIO-enhanced MRI at 7 T in comparison to 3 T for the detection of small suspicious LNs in the same cohort of patients with PCa. MATERIALS AND METHODS Twenty PCa patients with high-risk primary or recurrent disease were referred to our hospital for an investigational USPIO-enhanced 3 T MRI examination with ferumoxtran-10. With consent, they underwent a 7 T MRI on the same day. Three-dimensional anatomical and T2*-weighted images of both examinations were evaluated blinded, with an interval, by 2 readers who annotated LNs suspicious for metastases. Number, size, and level of suspicion (LoS) of LNs were paired within patients and compared between field strengths. RESULTS At 7 T, both readers annotated significantly more LNs compared with 3 T (474 and 284 vs 344 and 162), with 116 suspicious LNs on 7 T (range, 1-34 per patient) and 79 suspicious LNs on 3 T (range, 1-14 per patient) in 17 patients. For suspicious LNs, the median short axis diameter was 2.6 mm on 7 T (1.3-9.5 mm) and 2.8 mm for 3 T (1.7-10.4 mm, P = 0.05), with large overlap in short axis of annotated LNs between LoS groups. At 7 T, significantly more suspicious LNs had a short axis <2.5 mm compared with 3 T (44% vs 27%). Magnetic resonance imaging at 7 T provided better image quality and structure delineation and a higher LoS score for suspicious nodes. CONCLUSIONS In the same cohort of patients with PCa, more and more small LNs were detected on 7 T USPIO-enhanced MRI compared with 3 T MRI. Suspicious LNs are generally very small, and increased nodal size was not a good indication of suspicion for the presence of metastases. The high spatial resolution of USPIO-enhanced MRI at 7 T improves structure delineation and the visibility of very small suspicious LNs, potentially expanding the in vivo detection limits of pelvic LN metastases in PCa patients.
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Affiliation(s)
- Carlijn J A Tenbergen
- From the Department of Medical Imaging, Radboud University Medical Center, Nijmegen, the Netherlands (C.J.A.T., A.S.F., J.J.A.v.A., A.V., B.W.J.P., T.H., J.O.B., M.C.M., T.W.J.S.); Department of Radiology, Ziekenhuis Gelderse Vallei, Ede, the Netherlands (A.S.F.); Erwin L. Hahn Institute for MR Imaging, University of Duisburg-Essen, Essen, Germany (S.O., H.H.Q., T.W.J.S.); High-Field and Hybrid MR Imaging, University Hospital Essen, Essen, Germany (S.O., H.H.Q.); and Medical Physics in Radiology, German Cancer Research Center, Heidelberg, Germany (S.O.)
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Sigg S, Lehner F, Keller EX, Saba K, Moch H, Sulser T, Eberli D, Mortezavi A. Outcomes of robot-assisted laparoscopic extended pelvic lymph node dissection for prostate Cancer. BMC Urol 2024; 24:24. [PMID: 38287319 PMCID: PMC10823685 DOI: 10.1186/s12894-024-01409-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 01/16/2024] [Indexed: 01/31/2024] Open
Abstract
INTRODUCTION Extended pelvic lymph node dissection (ePLND) in men undergoing robot-assisted laparoscopic radical prostatectomy (RARP) is a widely used procedure. However, little is known about anatomical site-specific yields and subsequent metastatic patterns in these patients. PATIENTS AND METHODS Data on a consecutive series of 1107 patients undergoing RARP at our centre between 2004 and 2018 were analysed. In men undergoing LN dissection, the internal, external and obturator nodes were removed and sent in separately. We performed an analysis of LN yields in total and for each anatomical zone, patterns of LN metastases and complications. Oncological outcome in pN+ disease was assessed including postoperative PSA persistence and survival. RESULTS A total of 823 ePLNDs were performed in the investigated cohort resulting in 98 men being diagnosed as pN+ (8.9%). The median (IQR) LN yield was 19 (14-25), 10 (7-13) on the right and 9 (6-12) on the left side (P < 0.001). A median of six (4-8) LNs were retrieved from the external, three (1-6) from the internal iliac artery, and eight (6-12) from the obturator fossa. More men had metastatic LNs on the right side compared to the left (41 vs. 19). Symptomatic lymphoceles occurred exclusively in the ePLND group (2.3% vs. 0%, p = 0.04). Postoperatively, 47 (47.9%) of men with pN+ reached a PSA of < 0.1μg/ml. There was no association between a certain pN+ region and postoperative PSA persistence or BCRFS. The estimated cancer specific survival rate at 5 years was 98.5% for pN+ disease. CONCLUSION Robot-assisted laparoscopic ePLND with a high LN yield and low complication rate is feasible. However, we observed an imbalance in more removed and positive LNs on the right side compared to the left. A high rate of postoperative PSA persistence and early recurrence in pN+ patients might indicate a possibly limited therapeutical value of the procedure in already spread disease. Yet, these men demonstrated an excellent survival.
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Affiliation(s)
- Silvan Sigg
- Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Fabienne Lehner
- Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Etienne Xavier Keller
- Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Karim Saba
- Urologiezentrum Hirslanden, Hirslanden Klinik Aarau, Aarau, Switzerland
| | - Holger Moch
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Tullio Sulser
- Department of Urology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Daniel Eberli
- Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Ashkan Mortezavi
- Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
- Department of Urology, University Hospital Basel, University of Basel, Basel, Switzerland.
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
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Falkenbach F, Kachanov M, Leyh-Bannurah SR, Maurer T, Knipper S, Köhler D, Graefen M, Sauter G, Budäus L. Size of lymph-node metastases in prostate cancer patients undergoing radical prostatectomy: implication for imaging and oncologic follow-up of 2705 lymph-node positive patients. World J Urol 2024; 42:38. [PMID: 38244095 PMCID: PMC10799788 DOI: 10.1007/s00345-023-04724-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 10/28/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Despite modern imaging modalities, lymph-node staging before radical prostatectomy (RP) remains challenging in patients with prostate cancer (PCa). The visibility of lymph-node metastases (LNMs) is critically influenced by their size. OBJECTIVE This study aims to describe the distribution of maximal tumor diameters (i.e., size) in LNMs of pN1-PCa at RP and its consequences on visibility in preoperative imaging and oncological outcomes. DESIGN, SETTING, AND PARTICIPANTS A total of 2705 consecutive patients with pN1-PCa at RP, harboring a cumulative 7510 LNMs, were analyzed. Descriptive and multivariable analyses addressed the risk of micrometastases (MM)-only disease and the visibility of LNMs. Kaplan-Meier curves and Cox analyses were used for biochemical recurrence-free survival (BCRFS) stratified for MM-only disease. RESULTS The median LNM size was 4.5mm (interquartile range (IQR): 2.0-9.0 mm). Of 7510 LNMs, 1966 (26%) were MM (≤ 2mm). On preoperative imaging, 526 patients (19%) showed suspicious findings (PSMA-PET/CT: 169/344, 49%). In multivariable analysis, prostate-specific antigen (PSA) (OR 0.98), age (OR 1.01), a Gleason score greater than 7 at biopsy (OR 0.73), percentage of positive cores at biopsy (OR 0.36), and neoadjuvant treatment (OR 0.51) emerged as independent predictors for less MM-only disease (p < 0.05). Patients with MM-only disease compared to those harboring larger LNMs had a longer BCRFS (median 60 versus 29 months, p < 0.0001). CONCLUSION Overall, 26% of LNMs were MM (≤ 2mm). Adverse clinical parameters were inversely associated with MM at RP. Consequently, PSMA-PET/CT did not detect a substantial proportion of LNMs. LNM size and count are relevant for prognosis.
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Affiliation(s)
- Fabian Falkenbach
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Mykyta Kachanov
- Institute of Human Genetics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sami-Ramzi Leyh-Bannurah
- Prostate Center Northwest, Department of Urology, Pediatric Urology and Uro-Oncology, St. Antonius-Hospital, Gronau, Germany
| | - Tobias Maurer
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sophie Knipper
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Daniel Köhler
- Department for Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Markus Graefen
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Guido Sauter
- Department of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lars Budäus
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
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Lehner F, Crippa A, Sigg S, Eberli D, Mortezavi A. Transperineal template saturation and conventional biopsy for stage prediction in prostate cancer. BJU Int 2023; 132:696-704. [PMID: 37704215 DOI: 10.1111/bju.16181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
OBJECTIVE To evaluate the performance of risk calculators (RCs) predicting lymph node invasion (LNI) and extraprostatic extension (EPE) in men undergoing transperineal magnetic resonance imaging/transrectal ultrasound (TRUS)-fusion template saturation biopsy (TTSB) and conventional systematic TRUS-guided biopsy (SB). PATIENTS AND METHODS The RCs were tested in a consecutive cohort of 645 men undergoing radical prostatectomy with extended pelvic LN dissection between 2005 and 2019. TTSB was performed in 230 (35.7%) and SB in 415 (64.3%) men. Risk of LNI and EPE was calculated using the available RCs. Discrimination, calibration, and clinical usefulness stratified by different biopsy techniques were assessed. RESULTS Lymph node invasion was observed in 23 (10%) and EPE in 73 (31.8%) of cases with TTSB and 53 (12.8%) and 158 (38%) with SB, respectively. RCs showed an excellent discrimination and acceptable calibration for prediction of LNI based on TTSB (area under the curve [AUC]/risk estimation: Memorial Sloan Kettering Cancer Center [MSKCC]-RC 0.79/-4%, Briganti (2012)-RC 0.82/-4%, Gandaglia-RC 0.81/+6%). These were comparable in SB (MSKCC-RC 0.78/+2%; Briganti (2012)-RC 0.77/-3%). Decision curve analysis (DCA) revealed a net benefit at threshold probabilities between 3% and 6% when TTSB was used. For prediction of EPE based on TTSB an inferior discrimination and variable calibration were observed (AUC/risk estimation: MSKCC-RC 0.71/+8% and Martini (2018)-RC 0.69/+2%) achieving a net benefit on DCA only at risk thresholds of >17%. Performance of RCs for prediction of LNI and EPE based on SB showed comparable results with a better performance in the DCA for LNI (risk thresholds 1-2%) and poorer performance for EPE (risk threshold >20%). This study is limited by its retrospective single-institution design. CONCLUSIONS The potentially more accurate grading ability of TTSB did not result in improved performance of preoperative RCs. Prediction tools for LNI proved clinical usefulness while RCs for EPE did not.
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Affiliation(s)
- Fabienne Lehner
- Department of Urology, University Hospital Zurich, Zurich, Switzerland
| | - Alessio Crippa
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Silvan Sigg
- Department of Urology, University Hospital Zurich, Zurich, Switzerland
| | - Daniel Eberli
- Department of Urology, University Hospital Zurich, Zurich, Switzerland
| | - Ashkan Mortezavi
- Department of Urology, University Hospital Zurich, Zurich, Switzerland
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Urology, University Hospital Basel, Basel, Switzerland
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Gottlieb J, Chang SC, Choe J, Grunkemeier GL, Hanes DA, Krasne D, Hoon DSB, Wilson TG. Characterization of Lymph Node Tumor Burden in Node-Positive Prostate Cancer Patients after Robotic-Assisted Radical Prostatectomy with Extended Pelvic Lymph Node Dissection. Cancers (Basel) 2023; 15:3707. [PMID: 37509368 PMCID: PMC10378308 DOI: 10.3390/cancers15143707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/18/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Prostate cancer (PCa) nodal staging does not account for lymph node (LN) tumor burden. The LN anatomical compartment involved with the tumor or the quantified extent of extranodal extension (ENE) have not yet been studied in relation to biochemical recurrence-free survival (BRFS). METHODS Histopathological slides of 66 pN1 PCa patients who underwent extended pelvic lymph node dissection were reviewed. We recorded metrics to quantify LN tumor burden. We also characterized the LN anatomical compartments involved and quantified the extent of ENE. RESULTS The median follow-up time was 38 months. The median number of total LNs obtained per patient was 30 (IQR 23-37). In the risk-adjusted cox regression model, the following variables were associated with BRFS: mean size of the largest LN deposit per patient (log2: adjusted hazard ratio (aHR) = 1.91, p < 0.001), the mean total span of all LN deposits per patient (2.07, p < 0.001), and the mean percent surface area of the LN involved with the tumor (1.58, p < 0.001). There was no significant BRFS association for the LN anatomical compartment or the quantified extent of ENE. CONCLUSION LN tumor burden is associated with BRFS. The LN anatomical compartments and the quantified extent of ENE did not show significant association with BRFS.
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Affiliation(s)
- Josh Gottlieb
- Department of Urologic Oncology, Providence St. John's Cancer Institute, Santa Monica, CA 90404, USA
| | - Shu-Ching Chang
- Department of Biostatistics, Providence St. Joseph Health, Portland, OR 97213, USA
| | - Jane Choe
- Department of Urologic Oncology, Providence St. John's Cancer Institute, Santa Monica, CA 90404, USA
| | - Gary L Grunkemeier
- Department of Biostatistics, Providence St. Joseph Health, Portland, OR 97213, USA
| | - Douglas A Hanes
- Department of Biostatistics, Providence St. Joseph Health, Portland, OR 97213, USA
| | - David Krasne
- Department of Pathology, Providence St. John's Cancer Institute, Santa Monica, CA 90404, USA
| | - Dave S B Hoon
- Department of Translational Molecular Medicine, Providence St. John's Cancer Institute, Santa Monica, CA 90404, USA
| | - Timothy G Wilson
- Department of Urologic Oncology, Providence St. John's Cancer Institute, Santa Monica, CA 90404, USA
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Moussa M, Abou Chakra M, Peyromaure M, Barry Delongchamps N, Bailly H, Duquesne I. Comparison of oncological, surgical, and functional outcomes between radical retropubic and radical perineal prostatectomy: A multi-institutional study. Urologia 2022; 90:89-99. [PMID: 35837737 DOI: 10.1177/03915603221111286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: To investigate the safety, oncologic, surgical, and functional outcomes of RPP and RRP for localized prostate cancer (Pca), especially focusing on RPP. Materials and methods: From March 2005 to January 2021, we retrospectively reviewed the records of 685 patients undergoing RPP ( n = 320) or RRP ( n = 365) for localized Pca. Surgical and functional outcomes, and complications were compared. Oncological outcomes were also compared using Kaplan-Meier survival analysis. Results: A higher biochemical recurrence rate were noted in RRP than in RPP group (28.8% vs 21.6%, respectively; p = 0.03). A local recurrence was detected in a few numbers of patients (4.4%) with no statistically significant differences by surgical groups ( p = 0.71). No significant differences were observed in the cancer-specific survival and the overall survival according to the surgical approach. Positive surgical margins were similar in the two techniques. In comparison to RRP, patients undergoing RPP have less postoperative pain, decreased transfusion rate, and less catheterization time. Complete continence was achieved in 96.9% of the RPP group at 18 and 24 months versus 91.8% and 92.3% in the RRP group at 18 and 24 months, respectively ( p = 0.005 and p = 0.01, respectively). At 18 months of follow-up, the nerve-sparing technique was performed equally between the two groups, the mean of erectile function domain improved more in RPP than RRP (12.71 vs 10.42 respectively, p < 0.001). Medical and surgical complication rates were higher for RRP than RPP. Conclusions: RPP showed acceptable oncologic outcomes and excellent functional outcomes when compared to RRP.
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Affiliation(s)
- Mohamad Moussa
- Urology Department, Zahraa Hospital, University Medical Center, Lebanese University, Beirut, Lebanon
| | - Mohamad Abou Chakra
- Faculty of Medicine, Urology Department, Lebanese University, Beirut, Lebanon
| | - Michael Peyromaure
- Department of Urology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, Paris, France
| | - Nicolas Barry Delongchamps
- Department of Urology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, Paris, France
| | - Hugo Bailly
- Department of Urology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, Paris, France
| | - Igor Duquesne
- Department of Urology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, Paris, France
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Wang X, Wen Q, Zhang H, Ji B. Head-to-Head Comparison of 68Ga-PSMA-11 PET/CT and Multiparametric MRI for Pelvic Lymph Node Staging Prior to Radical Prostatectomy in Patients With Intermediate to High-Risk Prostate Cancer: A Meta-Analysis. Front Oncol 2021; 11:737989. [PMID: 34745959 PMCID: PMC8564188 DOI: 10.3389/fonc.2021.737989] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 09/24/2021] [Indexed: 11/30/2022] Open
Abstract
PURPOSE To compare the diagnostic performance of 68Ga-PSMA-11 PET/CT and mpMRI for pelvic lymph node staging prior to radical prostatectomy in prostate cancer (PCa) patients based on per patient data. METHODS PubMed and Embase databases were searched until October 2020 for eligible studies evaluating head-to-head comparison of 68Ga-PSMA-PET/CT and mpMRI for the detection of pelvic lymph node metastases (PLNMs) using pelvic lymph node dissection (PLND) as gold standard. The pooled sensitivity, specificity, and area under the summary receiver-operating characteristics curve (AUC) were determined for the two imaging modalities. RESULTS Nine studies with 640 patients were included. The pooled sensitivity, specificity, and AUC for 68Ga-PSMA-11 PET/CT vs. mpMRI were 0.71 (95% CI: 0.48-0.86) vs. 0.40 (95% CI: 0.16-0.71), 0.92 (95% CI: 0.88-0.95) vs. 0.92 (95% CI: 0.80-0.97), and 0.92 (95% CI: 0.88-0.95) vs. 0.82 (95% CI: 0.79-0.86), respectively. There was substantial heterogeneity for both imaging modalities, and meta-regression analysis revealed that the number of patients, prevalence of PLNMs, PSA level, reference standard, and risk classification might be the potential causes of heterogeneity. CONCLUSION This meta-analysis of head-to-head comparison studies confirms that there is a trend toward a higher sensitivity and diagnostic accuracy of 68Ga-PSMA-11 PET/CT compared to mpMRI for the detection of PLNMs in PCa patients. Nevertheless, according to current guidelines, PLND still needs to be recommended in case of negative results from 68Ga-PSMA-11 PET/CT due to significant risk of malignancy.
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Affiliation(s)
- Xueju Wang
- Department of Pathology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Qiang Wen
- Department of Nuclear Medicine, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Haishan Zhang
- Department of Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Bin Ji
- Department of Nuclear Medicine, China-Japan Union Hospital of Jilin University, Changchun, China
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Prognostic significance of histomorphologic features of lymph node metastases in prostate cancer patients treated with radical prostatectomy: A single center study. Urol Oncol 2021; 39:829.e1-829.e8. [PMID: 33985876 DOI: 10.1016/j.urolonc.2021.03.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/20/2021] [Accepted: 03/22/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE We assessed the prognostic value of histomorphologic features of lymph node (LN) metastases in patients with prostate cancer treated with radical prostatectomy MATERIALS AND METHODS: We evaluated the effect of the features of LN metastasis on the risk of biochemical recurrence (BCR) in 280 LN-positive patients who underwent radical prostatectomy between 2006 to 2018. LN specific parameters recorded included number of metastatic LNs, size of the largest metastatic focus, Gleason Grade (GG) of the metastatic focus, and extranodal extension (ENE). RESULTS A solitary positive LN was found in 166/280 (59%), 95/280 (34%) patients had 2-4 positive LNs, and 19/280 (7%) had 5 or more positive LNs. The size of the largest metastatic focus > 2 mm (macrometastasis) in 154/261 (59%). GG of the metastatic focus was as follows: GG 1-2: 29/224 (13%); GG 3: 27/224 (12%); and GG 4-5: 168/224 (75%). ENE was identified in 99/244 (41%). We found the number of LNs positive (2-4 vs. 1 Hazard ratio (HR) = 1.60; 95% CI: 1.02 to 2.5; P = 0.04) and GG of the metastatic focus (GG 4&5 vs. 1-3 HR = 1.90; 95% CI: 1.14-3.2; P= 0.014) to be independent predictors of the risk of BCR after surgery on multivariate analysis. CONCLUSIONS Our study showed the number of LNs positive and GG of the LN metastatic focus to be significant independent predictors of BCR after radical prostatectomy. We recommend reporting histomorphologic parameters of LN metastasis as they may help in defining BCR risk categorization.
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Fortuin AS, Philips BWJ, van der Leest MMG, Ladd ME, Orzada S, Maas MC, Scheenen TWJ. Magnetic resonance imaging at ultra-high magnetic field strength: An in vivo assessment of number, size and distribution of pelvic lymph nodes. PLoS One 2020; 15:e0236884. [PMID: 32735614 PMCID: PMC7394386 DOI: 10.1371/journal.pone.0236884] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 07/15/2020] [Indexed: 01/17/2023] Open
Abstract
Objective The definition of an in vivo nodal anatomical baseline is crucial for validation of representative lymph node dissections and accompanying pathology reports of pelvic cancers, as well as for assessing a potential therapeutic effect of extended lymph node dissections. Therefore the number, size and distribution of lymph nodes in the pelvis were assessed with high-resolution, large field-of-view, 7 Tesla (T) magnetic resonance imaging (MRI) with frequency-selective excitation. Materials and methods We used 7 T MRI for homogeneous pelvic imaging in 11 young healthy volunteers. Frequency-selective imaging of water and lipids was performed to detect nodal structures in the pelvis. Number and size of detected nodes was measured and size distribution per region was assessed. An average volunteer-normalized nodal size distribution was determined. Results In total, 564 lymph nodes were detected in six pelvic regions. Mean number was 51.3 with a wide range of 19–91 lymph nodes per volunteer. Mean diameter was 2.3 mm with a range of 1 to 7 mm. 69% Was 2 mm or smaller. The overall size distribution was very similar to the average volunteer-normalized nodal size distribution. Conclusions The amount of in vivo visible lymph nodes varies largely between subjects, whereas the normalized size distribution of nodes does not. The presence of many small lymph nodes (≤2mm) renders representative or complete removal of pelvic lymph nodes to be very difficult. 7T MRI may shift the in vivo detection limits of lymph node metastases in the future.
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Affiliation(s)
- Ansje S. Fortuin
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Radiology, Ziekenhuis Gelderse Vallei, Ede, The Netherlands
| | - Bart W. J. Philips
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Mark E. Ladd
- Medical Physics in Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Faculty of Physics and Astronomy and Faculty of Medicine, University of Heidelberg, Heidelberg, Germany
- Erwin L. Hahn Institute for Magnetic Resonance Imaging, Essen, Germany
| | - Stephan Orzada
- Erwin L. Hahn Institute for Magnetic Resonance Imaging, Essen, Germany
| | - Marnix C. Maas
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tom W. J. Scheenen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Erwin L. Hahn Institute for Magnetic Resonance Imaging, Essen, Germany
- * E-mail:
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11
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Fournier DE, Groh AM, Nair SM, Norley CJ, Pollmann SI, Holdsworth DW, Power NE, Beveridge TS. Microcomputed Tomography Is a Precise Method That Allows for Topographical Characterization of Lymph Nodes and Lymphatic Vessels. Lymphat Res Biol 2020; 18:166-173. [DOI: 10.1089/lrb.2019.0007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Dale E. Fournier
- Health and Rehabilitation Sciences (Physical Therapy), Faculty of Health Sciences, Collaborative Specialization in Musculoskeletal Health Research, and Bone and Joint Institute, The University of Western Ontario, London, Ontario, Canada
| | - Adam M.R. Groh
- Department of Anatomy and Cell Biology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Shiva M. Nair
- Urology Division, Department of Surgery, London Health Sciences Centre, London, Ontario, Canada
- Surgical Oncology Division, Department of Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Chris J.D. Norley
- Imaging Research Laboratories, John P. Robarts Research Institute, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Steven I. Pollmann
- Imaging Research Laboratories, John P. Robarts Research Institute, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - David W. Holdsworth
- Imaging Research Laboratories, John P. Robarts Research Institute, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
- Department of Surgery, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Nicholas E. Power
- Urology Division, Department of Surgery, London Health Sciences Centre, London, Ontario, Canada
- Surgical Oncology Division, Department of Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Tyler S. Beveridge
- Department of Anatomy and Cell Biology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
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12
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Wilczak W, Wittmer C, Clauditz T, Minner S, Steurer S, Büscheck F, Krech T, Lennartz M, Harms L, Leleu D, Ahrens M, Ingwerth S, Günther CT, Koop C, Simon R, Jacobsen F, Tsourlakis MC, Chirico V, Höflmayer D, Vettorazzi E, Haese A, Steuber T, Salomon G, Michl U, Budäus L, Tilki D, Thederan I, Fraune C, Göbel C, Henrich MC, Juhnke M, Möller K, Bawahab AA, Uhlig R, Adam M, Weidemann S, Beyer B, Huland H, Graefen M, Sauter G, Schlomm T. Marked Prognostic Impact of Minimal Lymphatic Tumor Spread in Prostate Cancer. Eur Urol 2018; 74:376-386. [PMID: 29908878 DOI: 10.1016/j.eururo.2018.05.034] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 05/28/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND Nodal metastasis (N1) is a strong prognostic parameter in prostate cancer; however, lymph node evaluation is always incomplete. OBJECTIVE To study the prognostic value of lymphatic invasion (L1) and whether it might complement or even replace lymph node analysis in clinical practice. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of pathological and clinical data from 14 528 consecutive patients. INTERVENTION Radical prostatectomy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The impact of L1 and N1 on patient prognosis was measured with time to biochemical recurrence as the primary endpoint. RESULTS AND LIMITATIONS Nodal metastases were found in 1602 (12%) of 13 070 patients with lymph node dissection. L1 was seen in 2027 of 14 528 patients (14%) for whom lymphatic vessels had been visualized by immunohistochemistry. N1 and L1 continuously increased with unfavorable Gleason grade, advanced pT stage, and preoperative prostate-specific antigen (PSA) values (p<0.0001 each). N1 was found in 4.3% of 12 501 L0 and in 41% of 2027 L1 carcinomas (p<0.0001). L1 was seen in 11% of 9868 N0 and in 61% of 1360 N1 carcinomas (p<0.0001). Both N1 and L1 were linked to PSA recurrence (p<0.0001 each). This was also true for 17 patients with isolated tumor cells (ie, <200 unequivocal cancer cells without invasive growth) and 193 metastases ≤1mm. Combined analysis of N and L status showed that L1 had no prognostic effect in N1 patients but L1 was strikingly linked to PSA recurrence in N0 patients. N0L1 patients showed a similar outcome as N1 patients. CONCLUSIONS Analysis of lymphatic invasion provides comparable prognostic information than lymph node analysis. Even minimal involvement of the lymphatic system has pivotal prognostic impact in prostate cancer. Thus, a thorough search for lymphatic involvement helps to identify more patients with an increased risk for disease recurrence. PATIENT SUMMARY Already minimal amounts of tumor cells inside the lymph nodes or intraprostatic lymphatic vessels have a severe impact on patient prognosis.
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Affiliation(s)
- Waldemar Wilczak
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Corinna Wittmer
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Till Clauditz
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sarah Minner
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Steurer
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franziska Büscheck
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Till Krech
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian Lennartz
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Luisa Harms
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Diane Leleu
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marc Ahrens
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sebastian Ingwerth
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Christina Koop
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ronald Simon
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Frank Jacobsen
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maria C Tsourlakis
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Viktoria Chirico
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Doris Höflmayer
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eik Vettorazzi
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexander Haese
- Martini-Clinic Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Steuber
- Martini-Clinic Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Georg Salomon
- Martini-Clinic Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uwe Michl
- Martini-Clinic Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lars Budäus
- Martini-Clinic Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Derya Tilki
- Martini-Clinic Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Imke Thederan
- Martini-Clinic Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Fraune
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Cosima Göbel
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Manuela Juhnke
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Katharina Möller
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ahmed Abdullah Bawahab
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Pathology, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | - Ria Uhlig
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Meike Adam
- Martini-Clinic Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sören Weidemann
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Burkhard Beyer
- Martini-Clinic Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hartwig Huland
- Martini-Clinic Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Markus Graefen
- Martini-Clinic Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Guido Sauter
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Thorsten Schlomm
- Martini-Clinic Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, Section for Translational Prostate Cancer Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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13
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Porpiglia F, Manfredi M, Mele F, Bertolo R, Bollito E, Gned D, De Pascale A, Russo F, Passera R, Fiori C, De Luca S. Indication to pelvic lymph nodes dissection for prostate cancer: the role of multiparametric magnetic resonance imaging when the risk of lymph nodes invasion according to Briganti updated nomogram is <5%. Prostate Cancer Prostatic Dis 2018; 21:85-91. [DOI: 10.1038/s41391-017-0026-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 10/29/2017] [Accepted: 11/17/2017] [Indexed: 12/12/2022]
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14
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Luchini C, Fleischmann A, Boormans JL, Fassan M, Nottegar A, Lucato P, Stubbs B, Solmi M, Porcaro A, Veronese N, Brunelli M, Scarpa A, Cheng L. Extranodal extension of lymph node metastasis influences recurrence in prostate cancer: a systematic review and meta-analysis. Sci Rep 2017; 7:2374. [PMID: 28539662 PMCID: PMC5443831 DOI: 10.1038/s41598-017-02577-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 04/12/2017] [Indexed: 12/12/2022] Open
Abstract
The extranodal extension (ENE) of nodal metastasis involves the extension of neoplastic cells through the lymph node capsule into the perinodal adipose tissue. This morphological feature has recently been indicated as an important prognostic factor in various cancer types, but its role in prostate cancer is still unclear. We aimed to clarify it, performing the first meta-analysis on this issue, comparing prognostic parameters in surgically treated, node-positive prostate cancer patients with (ENE+) vs. without (ENE-) ENE. Data were summarized using risk ratios (RRs) for number of deaths/recurrences and hazard ratios (HRs), with 95% confidence intervals (CI), for the time-dependent risk related to ENE positivity. Six studies followed-up 1,113 patients with N1 prostate cancer (658 ENE+ vs. 455 ENE-) for a median of 83 months. The presence of ENE was associated with a significantly higher risk of biochemical recurrence (RR = 1.15; 95%CI: 1.03-1.28; I2 = 0%; HR = 1.40, 95%CI: 1.12-1.74; I2 = 0%) and "global" (biochemical recurrence and distant metastasis) recurrence (RR = 1.15; 95%CI: 1.04-1.28; I2 = 0%; HR = 1.41, 95%CI: 1.14-1.74; I2 = 0%). ENE emerged as a potential prognostic moderator, earmarking a subgroup of patients at higher risk of recurrence. It may be considered for the prognostic stratification of metastatic patients. New possible therapeutic approaches may explore more in depth this prognostic parameter.
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Affiliation(s)
- Claudio Luchini
- Department of Diagnostics and Public Health, University and Hospital Trust of Verona, Verona, Italy.
- ARC-NET Research Center, University and Hospital Trust of Verona, Verona, Italy.
- Department of Pathology, Santa Chiara Hospital, Trento, Italy.
| | - Achim Fleischmann
- Institute of Pathology, University of Bern, CH-3010, Bern, Switzerland
| | - Joost L Boormans
- Department of Urology, Erasmus MC - Cancer Institute, Rotterdam, The Netherlands
| | - Matteo Fassan
- Department of Medicine, DIMED, University of Padua, Padua, Italy
| | - Alessia Nottegar
- Department of Diagnostics and Public Health, University and Hospital Trust of Verona, Verona, Italy
| | - Paola Lucato
- Department of Medicine, DIMED, University of Padua, Padua, Italy
| | - Brendon Stubbs
- Health Service and Population Research Department, King's College London, De Crespigny Park, London, SE5 8AF, United Kingdom
| | - Marco Solmi
- Department of Neuroscience, University of Padua, Padua, Italy
| | - Antonio Porcaro
- Urologic Clinic, University and Hospital trust of Verona, Verona, Italy
| | - Nicola Veronese
- National Research Council, Neuroscience Institute, Aging Branch, Padova, Italy
- Institute for clinical Research and Education in Medicine (IREM), Padova, Italy
| | - Matteo Brunelli
- Department of Diagnostics and Public Health, University and Hospital Trust of Verona, Verona, Italy
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, University and Hospital Trust of Verona, Verona, Italy
- ARC-NET Research Center, University and Hospital Trust of Verona, Verona, Italy
| | - Liang Cheng
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
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15
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Nehra A, Karnes RJ, Gandaglia G, Briganti A. Lymph node dissection in urological cancers: one topic, many controversies. World J Urol 2017; 35:493-495. [PMID: 28251283 DOI: 10.1007/s00345-017-2027-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 02/14/2017] [Indexed: 11/28/2022] Open
Affiliation(s)
- Avinash Nehra
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | | | - Giorgio Gandaglia
- Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alberto Briganti
- Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy.
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16
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Prendeville S, van der Kwast TH. Lymph node staging in prostate cancer: perspective for the pathologist. J Clin Pathol 2016; 69:1039-1045. [PMID: 27555432 DOI: 10.1136/jclinpath-2016-203643] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 07/30/2016] [Indexed: 11/03/2022]
Abstract
Pelvic lymph node dissection (PLND) currently represents the gold standard method for nodal staging in the setting of localised prostate cancer and may also have a therapeutic benefit in certain patients. The histopathological evaluation of PLND specimens plays a critical role in accurate lymph node staging, however there is currently a lack of consensus regarding the optimum approach and no quality parameters are in place. In addition, there are no guidelines as to the handling of less commonly encountered nodal specimens such as those identified within the anterior fat pad. This summary provides an overview of pertinent issues regarding lymph node staging in prostate cancer, with a focus on the histopathological evaluation of resected nodal specimens. We hope that this review will further the discussion on how to achieve a more standardised approach to the processing and reporting of PLND specimens in the setting of prostate cancer.
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Affiliation(s)
- Susan Prendeville
- Department of Pathology, Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada
| | - Theodorus H van der Kwast
- Department of Pathology, Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada
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