Association between Lymph Node Counts and Oncological Outcomes in Lymph Node Positive Prostate Cancer

Variation in management of lymph node positive prostate cancer after radical prostatectomy within a statewide quality improvement consortium

BACKGROUND

Patients with lymph node positive (pN+) disease found at the time of radical prostatectomy with pelvic lymphadenectomy for clinically localized prostate cancer (CaP) are at high risk of disease persistence and progression. Contemporary management trends of pN+ CaP are not well described.

MATERIALS AND METHODS

Patients in the Michigan Urologic Surgery Improvement Collaborative (MUSIC) with clinically localized prostate cancer who underwent radical prostatectomy between 2012 and 2023 with cN0/pN+ disease were identified. The primary outcome was to evaluate patient and practice-level factors associated with time to secondary post-RP treatment. Secondary outcomes included practice-level variation in management of pN+ CaP and rates of secondary treatment modality. To assess factors associated with secondary treatment, a Cox proportional hazards model of a 60-day landmark analysis was performed.

RESULTS

We identified 666 patients with pN+ disease. Overall, 66% underwent secondary treatment within 12 months post-RP. About 19% of patients with detectable post-RP PSA did not receive treatment. Of patients receiving secondary treatment after 60-days post-RP, 34% received androgen deprivation therapy (ADT) alone, 27% received radiation (RT) alone, 36% received combination, and 4% received other systemic therapies. In the multivariable model, pathologic grade group (GG)3 (HR 1.5; 95%CI: 1.05-2.14), GG4-5 (HR 1.65; 95%CI: 1.16-2.34), positive margins (HR 1.46; 95%CI: 1.13-1.88), and detectable postoperative PSA ≥0.1 ng/ml (HR 3.46; 95%CI: 2.61-4.59) were significantly associated with secondary post-RP treatment. There was wide variation in adjusted practice-level 12-month secondary treatment utilization (28%-79%).

CONCLUSIONS

The majority pN+ patients receive treatment within 12 months post-RP which was associated with high-risk pathological features and post-RP PSA. Variation in management of pN+ disease highlights the uncertainty regarding the optimal management. Understanding which patients will benefit from secondary treatment, and which type, will be critical to minimize variation in care.

Prognostication in Lymph Node-Positive Prostate Cancer with No PSA Persistence After Radical Prostatectomy

BACKGROUND

This study aimed to create a prognostic model to predict disease recurrence among patients with lymph node involvement but no prostate-specific antigen (PSA) persistence and to explore its clinical utility.

METHODS

The study analyzed patients with lymph node involvement after pelvic lymph node dissection with radical prostatectomy in whom no PSA persistence was observed between 2006 and 2019 at 33 institutions. Prognostic factors for recurrence-free survival (RFS) were analyzed by the Cox proportional hazards model.

RESULTS

Among 231 patients, 127 experienced disease recurrence. The factors prognostic for RFS were PSA level at diagnosis (≥ 20 vs. < 20 ng/mL: hazard ratio [HR], 1.66; 95% confidence interval [CI], 1.09-2.52; P = 0.017), International Society of Urological Pathology grade group at radical prostatectomy (RP) specimen (group ≥ 4 vs. ≤ 3: HR, 1.63; 95% CI 1.12-2.37; P = 0.010), pathologic T-stage (pT3b/4 vs. pT2/3a: HR, 1.70; 95% CI 1.20-2.42; P = 0.0031), and surgical margin status (positive vs. negative: HR, 1.60; 95% CI 1.13-2.28; P = 0.0086). The prognostic model using four parameters were associated with RFS and metastasis-free survival.

CONCLUSION

The prognostic model in combination with postoperative PSA value and number of lymph nodes is clinically useful for discussing treatment choice with patients.

The Prognostic Role of Preoperative PSMA PET/CT in cN0M0 pN+ Prostate Cancer: A Multicenter Study

CONTEXT

Despite negative preoperative conventional imaging, up to 10% of patients with prostate cancer (PCa) harbor lymph-node involvement (LNI) at radical prostatectomy (RP). The advent of more accurate imaging modalities such as PET/CT improved the detection of LNI. However, their clinical impact and prognostic value are still unclear. We aimed to investigate the prognostic value of preoperative PET/CT in patients node positive (pN+) at RP.

EVIDENCE SYNTHESIS

We retrospectively identified cN0M0 patients at conventional imaging (CT and/or MRI, and bone scan) who had pN+ PCa at RP at 17 referral centers. Patients with cN+ at PSMA/Choline PET/CT but cN0M0 at conventional imaging were also included. Systemic progression/recurrence was the primary outcome; Cox proportional hazards models were used for multivariate analysis.

EVIDENCE ACQUISITION

We included 1163 pN+ men out of whom 95 and 100 had preoperative PSMA and/or Choline PET/CT, respectively. ISUP grade ≥4 was detected in 66.6%. Overall, 42% of patients had postoperative PSA persistence (≥0.1 ng/mL). Postoperative management included initial observation (34%), ADT (22.7%) and adjuvant RT+/-ADT (42.8%). Median follow-up was 42 months. Patients with cN+ on PSMA PET/CT had an increased risk of systemic progression (52.9% vs. 13.6% cN0 PSMA PET/CT vs. 21.5% cN0 at conventional imaging; P < .01). This held true at multivariable analysis: (HR 6.184, 95% CI: 3.386-11-295; P < .001) whilst no significant results were highlighted for Choline PET/CT. No significant associations for both PET types were found for local progression, BCR, and overall mortality (all P > .05). Observation as an initial management strategy instead of adjuvant treatments was related with an increased risk of metastases (HR 1.808; 95% CI: 1.069-3.058; P < .05).

CONCLUSIONS

PSMA PET/CT cN+ patients with negative conventional imaging have an increased risk of systemic progression after RP compared to their counterparts with cN0M0 disease both at conventional and/or molecular imaging.

Mid-term oncologic outcomes of radical prostatectomy in lymph node metastatic prostate cancer patients

OBJECTIVES

Lymph node invasion (LNI) has been reported in 10-15% of pelvic lymph node dissection during radical prostatectomy (RP). The objective of this study was to describe the mid-term oncological outcomes in prostate cancer (PCa) patients with metastatic lymph node.

METHODS

We conducted a retrospective study at two French referral centers including consecutive cN0 PCa patients who underwent RP and extended pelvic lymph node dissection and had lymph node metastases on final pathological analysis (pN1) between January 2000 and May 2020. Follow-up was per institution, which generally included a PSA level measurement every 3 to 12 months for 5 years and annually thereafter.

RESULTS

A total of 123 patients were included: two (1.6%) low-risk, 64 (52%) intermediate-risk and 57 (46.4%) high-risk PCa according to the D'Amico risk classification. The median number of nodes removed and metastatic nodes per patient was 15 (IQR 11-22) and 1 (IQR 1-2), respectively. Adverse pathological features, i.e., ≥pT3a stage, ISUP grade ≥3, and positive surgical margins were reported in 113 (91.9%), 103 (83.7%), and 73 (59%) of cases, respectively. Postoperative treatment was administered in 104 patients, including radiotherapy alone (n=6), androgen deprivation therapy alone (n=27) or combination with androgen deprivation therapy and radiotherapy (n=71). The mean follow-up was 42.7 months. The estimated 3-year biochemical-free survival, clinical recurrence-free survival, and cancer-specific survival was 66% and 85% and 98.8%, respectively. In Cox regression analysis, the number of metastatic nodes was associated with clinical recurrence (P=0.04) and a persistently elevated PSA with biochemical recurrence (P<0.001).

CONCLUSION

The management of lymph node metastatic PCa patients is challenging. Risk stratification of node-positive patients, based on postoperative PSA levels and pathologic features being identified, should help physicians determine which patient would best benefit from multimodal treatment.

LEVEL OF EVIDENCE: 4

The relationship between biochemical recurrence and number of lymph nodes removed during surgery for localized prostate cancer

PURPOSE

To assess whether completeness of pelvic lymph node dissection (PLND) as measured by lymph node yield reduces biochemical recurrence (BCR) in men undergoing radical prostatectomy (RP) for prostate cancer (PCa), stratified according to Briganti nomogram-derived risk (≥5% vs. < 5%) of lymph node invasion (LNI).

METHODS

Retrospective study of 3724 men who underwent RP between January 1995 and January 2015 from our prospectively collected institutional database. All men included had minimum five years follow-up and were not given androgen deprivation therapy or radiotherapy prior to BCR. Primary endpoint was time to BCR as defined by PSA > 0.2ng/ml. Patients were analysed according to Briganti Nomogram derived risk of 'low-risk' (< 5%) vs. 'high-risk' (≥ 5%). Extent of PLND was analysed using number of nodes yielded at dissection as a continuous variable as well as a categorical variable: Group 1 (limited, 1-4 nodes), Group 2 (intermediate, 5-8 nodes) and Group 3(extensive, ≥9 nodes).

RESULTS

Median follow-up in the overall cohort was 79.7 months and 65% of the total cohort underwent PLND. There were 2402 patients with Briganti risk of LNI < 5% and 1322 with a Briganti risk of LNI ≥5%. At multivariate analysis, only PSA (HR1.01, p < 0.001), extracapsular extension at RP (HR 1.86, p < 0.001), positive surgical margin (HR 1.61, p < 0.001) and positive lymph node on pathology (HR 1.52, p = 0.02) were independently associated with BCR. In the high-risk group, increased nodal yield at PLND was associated with reduction in risk of BCR (HR 0.97, 95%CI 0.95-1.00 p = 0.05, Cochran Mantel Haenszel test, p < 0.05: respectively). In the low-risk group increased number of nodes at PLND did not reduce risk of BCR.

CONCLUSIONS

In this study of extent of PLND at RP, higher nodal yield did not reduce risk of BCR in low-risk men (Briganti risk < 5%), however there was a weak benefit in terms of reduced long-term risk of BCR in high-risk men (Briganti risk ≥5%).

The prognostic value of lymph node staging with prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) and extended pelvic lymph node dissection in node-positive patients with prostate cancer

OBJECTIVES

To investigate whether patients with suspected pelvic lymph node metastases (molecular imaging [mi] N1) on staging prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) had a different oncological outcome compared to those in whom the PSMA PET/CT did not reveal any pelvic lymph node metastases (miN0).

PATIENTS AND METHODS

All patients with pelvic lymph node metastatic (pN1) disease after robot-assisted radical prostatectomy (RARP) and extended pelvic lymph node dissection (ePLND) between January 2017 and December 2020 were included. To assess predictors of biochemical progression of disease after RARP, a multivariable Cox regression analysis was performed, including number of tumour-positive lymph nodes, diameter of the largest nodal metastasis, and extranodal extension.

RESULTS

In total, 145 patients were diagnosed with pN1 disease after ePLND. The median biochemical progression-free survival in patients with miN0 on PSMA PET/CT was 13.7 months, compared to 7.9 months in patients with miN1 disease (P = 0.006). On multivariable Cox regression analysis, both number of tumour-positive lymph nodes (>2 vs 1-2: hazard ratio [HR] 1.97; P = 0.005) and diameter of the largest nodal metastasis (HR 1.12; P < 0.001) were significant independent predictors of biochemical progression of disease.

CONCLUSION

Patients in whom pelvic lymph node metastases were suspected on preoperative PSMA imaging (miN1), patients diagnosed with >2 tumour-positive lymph nodes, and patients with a larger diameter of the largest nodal metastasis had a significantly increased risk of biochemical disease progression after surgery.

The Changing Face of cN0M0 Prostate Cancer Being Found With pN+ After Surgery in the Contemporary Era: Results of an International European Survey on Disease Management

INTRODUCTION

The urological community's opinion over the management of men being found with pathologically positive nodes (pN+) following radical prostatectomy (RP) performed with curative intent after preoperative negative conventional staging (cN0M0) has never been assessed. This remains crucial, especially considering the advent of novel imaging modalities. Our aim was to investigate the current opinion on management of pN+ cN0M0 prostate cancer (PCa) in the European urological community.

METHODS

Following validation, a 31-item survey, complying with the Cherries checklist, was distributed using a web link from December 2021 to April 2022 to 10 urological societies mailing list. Social media (Twitter, Facebook) were also used.

RESULTS

We received 253 replies. The majority were Urologists (96.8%), younger than 60 (90.5%); 5.2% did not have access to PET-scans; 78.9% believed pN+ is a multifaceted category; 10-years CSS was marked as 71 to 95% by 17.5%. Gold standard management was stated not being ADT by 80.8% and being RT±ADT by 52.3%. Early sRT±ADT was considered an option vs. aRT±ADT by 72.4%. In case of BCR 71% would perform and decide management based on PSMA-PET whilst 3.7% would not perform PSMA-PET. pN+ management is still unclear for 77.1%. On multivariate analysis PSMA-PET availability related to a lower and higher likelihood of considering aRT±ADT as standard and of considering early salvage versus aRT respectively (P < .05).

CONCLUSIONS

The Urological community has an acceptable awareness of pN+ disease and management, although it may overestimate disease aggressiveness. The majority consider pN+ PCa as a multifaceted category and rely on a risk-adapted approach. Expectant compared to immediate upfront management and new imaging modalities are increasingly considered.

Pelvic lymph node dissection in prostate and bladder cancers

Prostate cancer and bladder cancer accounts for approximately 13.5% and 3% of all male cancers and all newly diagnosed cancers (regardless sex), respectively. Thus, these cancers represent a major health and economic burden globally. The knowledge of lymph node status is an integral part of the management of any solid tumor. In the urological field, pelvic lymph node dissection (PLND) is of paramount importance in the diagnosis, management, and prognosis of prostate and bladder cancers. However, PLND may be associated with several comorbidities. In this narrative review, the most recent updates concerning the patterns and incidence of lymph node metastasis, the role of different imaging studies and nomograms in determining patients' eligibility for PLND, and the anatomical templates of PLND in urologic patients with bladder or prostate cancer will be discussed.

Features and management of men with pN1 cM0 prostate cancer after radical prostatectomy and lymphadenectomy: a systematic review of population-based evidence

PURPOSE OF REVIEW

To investigate the features and optimal management of pN+ cM0 prostate cancer (PCa) according to registry-based studies.

RECENT FINDINGS

Up to 15% of PCa patients harbor lymph node invasion (pN+) at radical prostatectomy plus lymph node dissection. Nonetheless, the optimal management strategy in this setting is not well characterized.

SUMMARY

We performed a systematic review including n = 13 studies. Management strategies comprised 13 536 men undergoing observation, 11 149 adjuvant androgen deprivation therapy (aADT), 7,075 adjuvant radiotherapy (aRT) +aADT and 705 aRT. Baseline features showed aggressive PCa in the majority of men. At a median follow-up ranging 48-134months, Cancer-related death was 5% and overall-mortality 16.6%. aADT and aRT alone had no cancer-specific survival or overall survival advantages over observation only and over not performing aRT, respectively. aADT plus aRT yielded a survival benefit compared to observation and aADT, which in one study, were limited to certain intermediate-risk categories. Age, Gleason, Charlson score, positive surgical margins, pathological stage, and positive nodes number, but not prostate specific antigen, were most relevant prognostic factors. Our work further confirmed pN+ PCa is a multifaceted disease and will help future research in defining its optimal management based on different risk categories to maximize survival and patient's quality of life.

The prognostic value of lymph node ratio in comparison to positive lymph node count in penile squamous cell carcinoma

PURPOSE

Penile cancer is a rare male neoplasm with a wide variation in its global incidence. In this study, the prognostic value of lymph node ratio (LNR) was compared to that of positive lymph node count (PLNC) in penile squamous cell carcinoma.

METHODS

A total of 249 patients with penile squamous cell carcinoma were enrolled from The Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2015. The X-tile program was used to calculate the optimal cut-off values of LNR and PLNC that discriminate survival. We used the χ² or the Fisher exact probability test to assess the association between clinical-pathological characteristics and LNR or PLNC. Univariate and multivariate Cox regression analyses were performed to identify independent prognostic factors for survival. Spearman correlation analysis was used to determine the correlation between LNR and PLNC.

RESULTS

We found that patients with high LNR tended to have advanced N stage, the 7th AJCC stage, and higher pathological grade, while patients with high PLNC had advanced N stage and the 7th AJCC stage. Univariate Cox regression analysis revealed that the N stage, M stage, the 7th AJCC stage, lymph-vascular invasion, LNR, and PLNC were significantly associated with prognosis. Multivariate Cox regression analysis demonstrated that LNR rather than PLNC was an independent prognostic factor for cancer-specific survival. Subgroup analysis of node-positive patients showed that LNR was associated with CSS, while PLNC was not.

CONCLUSION

LNR was a better predictor for long-term prognosis than PLNC in patients with penile squamous cell carcinoma.

Associations between LncRNA MALAT1 Polymorphisms and Lymph Node Metastasis in Prostate Cancer

Current evidence elucidates that long noncoding RNA metastasis-associated lung adenocarcinoma transcript 1 (MALAT1) could regulate genetic expression and play a crucial role in both the diagnosis and prognosis of prostate cancer. Single-nucleotide polymorphisms (SNPs) of MALAT1 could alter the oncogenesis in various cancers. However, the associations between MALAT1 SNPs and prostate cancer have barely been investigated to date. This study included 579 patients with prostate cancer who received robotic-assisted radical prostatectomy at Taichung Veterans General Hospital from 2012 to 2017. Three SNPs of MALAT1 were analyzed to identify the impacts of SNPs on the clinicopathologic features in Taiwanese prostate cancer. Our results show that patients with a polymorphic G allele at rs619586 had a significantly higher risk of being in an advanced Gleason grade group (AOR: 1.764; 95% CI: 1.011–3.077; p = 0.046). Moreover, individuals with at least one polymorphic A allele at MALAT1 rs1194338 in the PSA >10 ng/mL group were positively associated with node-positive prostate cancer. In conclusion, MALAT1 SNPs are significantly associated with the susceptibility to both advanced Gleason grade and nodal metastasis in prostate cancer. The presence of MALAT1 SNPs rs619586 and rs1194338 seems to enhance oncogenesis in prostate cancer.

The effect of risk factors on surgical and oncological results in high-risk prostate cancer: A multicentre study of the urooncology society, Turkey

PURPOSE

To evaluate the effect of risk factors and selected surgical methods on operative and oncological results of patients undergoing radical prostatectomy (RP) with high-risk prostate cancer (HRPC).

METHODS

Retrospective analysis of patients who underwent RP for HRPC from 13 urology centres between 1990 and 2019 was performed. Groups were created according to the risk factors of D'Amico classification. Patients with one risk factor were included in group 1 where group 2 consisted of patients with two or three risk factors.

RESULTS

A total of 1519 patients were included in this study and 1073 (70.6%) patients were assigned to group 1 and 446 (29.4%) patients to group 2. Overall (biochemical and/or clinical and/or radiological) progression rate was 12.4% in group 1 and 26.5% in group 2 (P = .001). Surgical procedure was open RP in 844 (55.6%) patients and minimally invasive RP in 675 (44.4%) patients (laparoscopic and robot-assisted RP in 230 (15.1%) and 445 (29.3%) patients, respectively). Progression rates were similar in different types of operations (P = .22). Progression rate was not significantly different in patients who either underwent pelvic lymph node dissection (PLND) or not in each respective group.

CONCLUSION

RP alone is an effective treatment in the majority of patients with HRPC and PLND did not affect the progression rates after RP. According to the number of pre-operative high-risk features, as the number of risk factors increases, there is a need for additional treatment.

Radical prostatectomy for localized prostate cancer: 20-year oncological outcomes from a German high-volume center

INTRODUCTION

Long-term outcomes of prostate cancer (CaP) patients treated with radical prostatectomy (RP) from European cohorts are under-reported. We report on 22,843 RP patients from the Martini-Klinik Prostate Cancer Centre treated between 1992 and 2017.

PATIENTS AND METHODS

Biochemical recurrence (BCR) free survival, metastasis free survival (MFS), and cancer specific survival (CSS) were stratified according to National Comprehensive Cancer Network (NCCN) risk categories, pT, and pN stages, RP Gleason Grade Groups (GGG), and surgical margin status (R0/R1). For time to event analyses, uni- and multivariable Cox's proportional hazards models and univariable Kaplan-Meier analyses were applied.

RESULTS

Median follow up was 68 months. Most favourable 20-year survival rates were exhibited in NCCN low risk (78.7% BCR-free, 96.8% MFS, 90.1% CSS) and pT2, GGG 1 to 2, R0 patients (83.1% BCR-free, 96.7% MFS, 92.6% CSS). 20-year follow up was not constantly reached in patients with aggressive CaP features. For example, NCCN very high-risk patients exhibited 15-year BCR-free survival of 30.5%, while 20-year MFS and CSS in these individuals was reached (64.1% and 60.8%, respectively). Lowest 10-year BCR-free survival (35.6%) was exhibited in pT3b, GGG 4 to 5, R0. Lowest 10-year MFS (49.5%) was exhibited in pT2, GGG 4 to 5, R1. Lowest 10-year CSS (69.8%) was exhibited in pT3b, GGG 4 to 5, R1 patients. In separate pN1 analyses, lowest 10-year BCR-free survival (14.5%), MFS (56.9%), and CSS (71.9%) were exhibited in patients with 3 or more positive lymph nodes.

CONCLUSION

Oncological outcomes after RP can be excellent for individuals with favorable CaP characteristics, also after 20 years of follow up.

Oncological outcomes of pathologically organ-confined, lymph node-positive prostate cancer after radical prostatectomy

BACKGROUND

The aim of this study was to investigate the impact of lymph-node involvement on oncological outcomes in patients with pathologically organ-confined prostate cancer (pT2 CaP) after radical prostatectomy (RP).

METHODS

We retrospectively analyzed 9,631 pT2 CaP patients who underwent RP at a single institution between 1998 and 2018. Kaplan-Meier plots and Cox regression models (CRMs) assessed biochemical recurrence (BCR)-free survival and metastasis-free survival (MFS) according to N-stage. In subgroup analyses of N1 patients, Kaplan-Meier plots and CRMs were stratified according to adjuvant treatment.

RESULTS

Of 9,631 pT2 staged patients, 241 (2.5%) harbored lymph-node metastases after RP (pN1). The median follow-up was 60.8 months. No pT2 N1-staged patient died due to CaP. The 5-year BCR-free survival rates were 54.7 vs. 88.4% in pT2 N1 vs. pT2 N0 patients, respectively (P < 0.001). The 5-year MFS rates were 92.5 vs. 98.9% in pT2 N1 vs. pT2 N0 patients, respectively (P < 0.001). Within pT2 N1 patients, presence of ≥3 positive lymph nodes was an independent risk factor for BCR (hazard ratio [HR] 3.4, P < 0.001) and for metastatic progression (HR 1.7, P = 0.04). Finally, 3-year BCR-free survival was improved in pT2 N1 patients treated with adjuvant radiation therapy (87.1% vs. 63.7% for patients who received other treatment options [P < 0.001]).

CONCLUSION

Patients with pathologically organ-confined but lymph node-positive CaP exhibited favorable oncological outcomes after RP. Presence of ≥3 positive LNs predicted higher rates of BCR and metastatic progression. In consequence, in pT2 N1 patients treated with RP with ≥3 positive LNs, adjuvant treatment may be considered.9.

Management of Patients with Node-positive Prostate Cancer at Radical Prostatectomy and Pelvic Lymph Node Dissection: A Systematic Review

CONTEXT

Optimal management of prostate cancer (PCa) patients with lymph node invasion at radical prostatectomy and pelvic lymph node dissection still remains unclear.

OBJECTIVE

To assess the effectiveness of postoperative treatment strategies for pathologically node-positive PCa patients. The secondary aim was to identify the most relevant prognostic factors to guide the management of pN1 patients.

EVIDENCE ACQUISITION

A systematic review was performed in January 2020 using Medline, Embase, and other databases. A total of 5063 articles were screened, and 26 studies including 12 537 men were selected for data synthesis and included in the current review according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) recommendations.

EVIDENCE SYNTHESIS

Ten-year biochemical recurrence (BCR)-free, clinical recurrence-free, cancer-specific (CSS), and overall (OS) survival rates ranged from 28% to 56%, 70% to 92%, 72% to 98%, and 60% to 87.6%, respectively. A total of seven, five, and six studies assessed the oncological outcomes of observation, adjuvant radiotherapy (aRT), or adjuvant androgen deprivation therapy (ADT), respectively. Initial observation followed by salvage therapies at the time of recurrence represents a safe option in selected patients with a low disease burden. The use of aRT with or without ADT might improve survival in men with locally advanced disease and a higher number of positive nodes. Risk stratification according to pathological Gleason score, number of positive nodes, pathological stage, and surgical margins status is the key to risk stratification and selection of the optimal postoperative therapy. Limitations of this systematic review are the retrospective design of the studies included and the lack of data on adverse events.

CONCLUSIONS

While the majority of men with pN1 disease would experience BCR after surgery, long-term disease-free survival has been reported in selected patients. Management options to improve oncological outcomes include observation versus adjuvant therapies such as aRT and/or ADT. Disease characteristics should be used to select the optimal postoperative management for pN1 PCa patients.

PATIENT SUMMARY

Finding node-positive prostate cancer after a radical prostatectomy often leads to high postoperative prostate-specific antigen levels and is overall a poor prognostic factor. However, this does not necessarily translate into poor survival for all men. Management can be tailored to the severity of disease and options include observation, androgen deprivation therapy, and/or radiotherapy.

Examined and Positive Lymph Node Counts Are Associated with Mortality in Prostate Cancer: A Population-Based Analysis

BACKGROUND

Prostate cancer (PCa) is the third leading cause of death from cancer in the United States. We aimed to disclose the prognostic values of examined (dissected) lymph node (ELN), negative lymph node (NLN), and positive (metastatic) lymph node (PLN) counts and lymph node (LNs) ratio in PCa patients.

METHODS

We extracted data of PCa patients diagnosed between 2004 and 2015 from the Surveillance, Epidemiology, and End Results (SEER) program. We included patients with a histologically confirmed diagnosis having at least one ELN and with the PCa as the primary tumor only.

RESULTS

We have included 96,064 patients. Multivariable Cox proportional hazards regression modelsdisclosed that patients having more ELNs were associated with better survival. However, we demonstrated that patients having more PLNs were associated with worse survival. Additionally, older age, unmarried patients, with Gleason's score of 8-10, T4 and M1 stages and those who received chemotherapy and/or radiation but did not receive surgery were significantly associated with worse PCa survival.

CONCLUSIONS

We have disclosed several independent predictors affecting PCa patients including age, marital status, Gleason's score, T and N stages, having received therapy, surgery, and ELN and PLN counts. Moreover, we demonstrated that patients with lower ELN and higher PLN counts were a high-risk group. We strongly recommend adding the ELN and/or PLN counts into consideration during patient staging/treatment.

Adding radiotherapy to androgen deprivation therapy in men with node-positive prostate cancer after radical prostatectomy: A meta-analysis

BACKGROUND

Several studies have tested the addition of adjuvant radiotherapy (RT) to androgen deprivation therapy (ADT) in node-positive prostate cancer (PCa) after radical prostatectomy (RP). This meta-analysis aims to assess the effects of adding RT to ADT in the treatment of PCa patients with lymph node invasion.

METHODS

We systematically searched PubMed and Embase through June 2018 for human studies comparing RT plus ADT versus ADT in men with node-positive PCa after RP. The primary end point was overall survival (OS). Secondary end point was cancer-specific survival (CSS). Hazard ratios (HRs) with 95% confidence intervals (CIs) for the effects of RT plus ADT on OS and CSS were combined across studies using meta-analysis.

RESULTS

Five studies were selected for inclusion. Overall, 15,524 patients were enrolled in the 5 studies. This included 6309 (40.6%) patients receiving ADT, 4389 (28.3%) patients receiving adjuvant RT plus ADT, and 4826 (31.1%) patients receiving observation. In lymph node-positive PCa patients, the addition of adjuvant RT was associated with improved OS (HR: 0.74; 95% CI, 0.59-0.92; P = .008). Moreover, the addition of adjuvant RT was also associated with a dramatic CSS improvement (HR: 0.40; 95% CI, 0.27-0.59; P = .000).

CONCLUSIONS

Adding RT to ADT may be a clinically effective treatment option for men with lymph node-positive PCa after RP.

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.