Cancer progression after anterograde radical prostatectomy for pathologic Gleason score 8 to 10 and influence of concomitant variables

[High risk localized and locally advanced prostate cancer: Long-term oncological outcomes after prostatectomy]

INTRODUCTION

High risk localized and locally advanced forms are responsible for the vast majority of specific deaths from prostate cancer among non-metastatic diseases at diagnosis. No randomized study has yet been published to establish the best local treatment in terms of survival.

AIM

Conduct a large-volume cohort study with long-term follow-up to analyze specific and overall survival outcomes after surgery.

METHOD

A single-center retrospective study of all patients operated on for localized high-risk and locally advanced prostate cancer was performed. Actuarial survival analyses and multivariate analyses were performed to discern predictive risk factors.

RESULTS

Five hundred patients were included. MRI stage was≥iT3a in 40.7% of cases and 50.2% of patients had a Gleason score≥8 on biopsy. The mean follow-up was 63.1 months. The overall, specific and biological recurrence-free survival were respectively 77.6%, 93.9% and 26.8% at 10 years. A PSA level≥20, a Gleason score on biopsy≥9 and a MRI stage≥iT3a were significantly associated with the 10-years biological recurrence risk.

CONCLUSION

This study shows very good long-term oncological results. In the absence of a randomized controlled trial, these results suggest the primary role of surgery in this indication and support the evolution of current practices. We pointed out very pejorative features that might help selection of the best candidates for surgical treatment.

LEVEL OF EVIDENCE: 4

ARRDC4 and UBXN1: Novel Target Genes Correlated with Prostate Cancer Gleason Score

To investigate potential markers of the prostate cancer (PCa) Gleason score (GS), genetic arrays in 841 PCa patients were conducted followed by functional validation in PCa cell lines. A total of 841 PCa patients who received radical prostatectomy (RP) from November 2003 to July 2019 were enrolled. HumanExome BeadChip 12v1-1 (Illumina, Inc.; San Diego, CA, USA) exomic arrays were performed on RP tissue samples. Unconditional logistic regression was used to calculate odds ratios to generate estimates of the relative risk of pathologic GS (≥8); SNPs with the highest association were selected and validated using PCa cell lines (PC3, LNCaP, 22Rv1 and DU145). Following transfection with target-gene siRNA, assays for cell viability, wound healing, and transwell invasion were performed. Mean age of enrolled subjects was 66.34 years and median PSA was 8.43 ng/mL. After RP, 122 patients (14.5%) had pathological Gleason scores ≥8. The results from genotyping with 242,186 SNPs by exomic array revealed that 4 SNPs (rs200944490, rs117555780, rs34625170, and rs61754877) were significantly associated with high pathological GS (≥8) within cut-off level to p < 10^-5. The most highly associated rs200944490 in ARRDC4 (p = 1.39 × 10^-6) and rs117555780 in UBXN1 (p = 2.92 × 10^-5) were selected for further validation. The knockdown of UBXN1 and ARRDC4 led to significantly reduced cell proliferation and suppressed migration and invasiveness in PCa cell lines. Epithelial mesenchymal transition (EMT) markers were significantly down-regulated in si-ARRDC4 and si-UBXN1-transfected cells. The expression levels of PI3K-phosphorylation and Akt phosphorylation and NF-κB were also suppressed following knockdown of UBXN1 and ARRDC4. The rs200944490 (ARRDC4) and rs117555780 (UBXN1) were identified as candidate markers predictive of PCa Gleason score which is strongly associated with cancer aggressiveness. Additional validation in future studies is warranted.

Investigating the role of the IGF axis as a predictor of biochemical recurrence in prostate cancer patients post-surgery

BACKGROUND

Between 20% and 35% of prostate cancer (PCa) patients who undergo treatment with curative intent (ie, surgery or radiation therapy) for localized disease will experience biochemical recurrence (BCR). Alterations in the insulin-like growth factor (IGF) axis and PTEN expression have been implicated in the development and progression of several human tumors including PCa. We examined the expression of the insulin receptor (INSR), IGF-1 receptor (IGF-1R), PTEN, and AKT in radical prostatectomy tissue of patients who developed BCR post-surgery.

METHODS

Tissue microarrays (TMA) of 130 patients post-radical prostatectomy (65 = BCR, 65 = non-BCR) were stained by immunohistochemistry for INSR, IGF-1R, PTEN, and AKT using optimized antibody protocols. INSR, IGF1-R, PTEN, and AKT expression between benign and cancerous tissue, and different Gleason grades was assessed. Kaplan-Meier survival curves were used to examine the relationship between proteins expression and BCR.

RESULTS

INSR (P < 0.001), IGF-1R (P < 0.001), and AKT (P < 0.05) expression was significantly increased and PTEN (P < 0.001) was significantly decreased in cancerous versus benign tissue. There was no significant difference in INSR, IGF-1R, or AKT expression in the cancerous tissue of non-BCR versus BCR patients (P = 0.149, P = 0.990, P = 0.399, respectively). There was a significant decrease in PTEN expression in the malignant tissue of BCR versus non-BCR patients (P = 0.011). Combinational analysis of the tissue proteins identified a combination of decreased PTEN and increased AKT or increased INSR was associated with worst outcome. We found that in each case, our hypothesized worst group was most likely to experience BCR and this was significant for combinations of PTEN+INSR and PTEN+AKT but not PTEN+IGF-1R (P = 0.023, P = 0.028, P = 0.078, respectively).

CONCLUSIONS

Low PTEN is associated with BCR and this association is strongly modified by high INSR and high AKT expression. Measurement of these proteins could help inform appropriate patient selection for postoperative adjuvant therapy and prevent BCR.

Radical Prostatectomy for Locally Advanced Prostate Cancers-Review of Literature

Twenty-five to thirty percent of patients with prostate cancer present with locally advanced disease. While risk stratification remains the same with high incidence of upstaging of disease on imaging and histopathological evaluation; there have been progressive refinements in surgical therapy. With availability of reasonably robust data, radical prostatectomy in men with locally advanced prostate cancers seems to effect improvement in both cancer specific and overall survival rates in comparison to the current standard of care of radiation with androgen deprivation therapy. Studies using radical prostatectomy as a part of multimodality approach have also shown promising results. There is an imminent need for well-designed prospective studies of benefits of radical prostatectomy over radiation and androgen deprivation as well as benefits of multimodality therapy over monotherapy. Surgery for patients with locally advanced prostate cancer is technically challenging. Surgical outcomes are comparable to those of organ-confined disease when performed in high-volume centers. Neoadjuvant therapies prior to radical prostatectomy might improve surgical outcomes, but whether they will translate into a better cancer specific and overall survival are yet to be ascertained.

Long-Term Oncological Outcomes for Young Men Undergoing Radical Prostatectomy for Localized Prostate Cancer

Aim. The aim of this study was to describe PCa characteristics and long-term outcomes in young men aged ≤55 years after radical prostatectomy (RP) and to compare them with older men cohort. Methods. Among 2,200 patients who underwent RP for clinically localized PCa at our centre between 2001 and 2015, 277 (10.3%) men aged ≤55 years were identified. All preoperative and pathological parameters were compared between groups. Biochemical progression free survival (BPFS) and disease progression free survival (DPFS) were assessed at 5 and 10 years. Results. Men aged ≤55 years had similar pathological tumor characteristics and biochemical recurrence rate (BCR) compared to their older counterparts. Disease progression rate 2.5% versus 0.4% was higher in older patients (p = 0.026). BPFS rate was not different in both study groups. Estimated 10-year DPFS was 98.8% in younger men compared to 89.2% in their older counterparts (p = 0.031). Multivariate Cox regression showed that Gleason score lymph-nodes and surgical margins status were significant predictors for disease progression. Conclusions. In our cohort, men aged ≤55 years had similar pathological PCa characteristics and BCR rate in comparison with older men. RP can be performed with excellent long-term DPFS results in men with localized PCa at ≤55 years of age.

The very-high-risk prostate cancer: a contemporary update

BACKGROUND

Treatment of high-risk prostate cancer has evolved considerably over the past two decades, yet patients with very-high-risk features may still experience poor outcome despite aggressive therapy. We review the contemporary literature focusing on current definitions, role of modern imaging and treatment alternatives in very-high-risk prostate cancer.

METHODS

We searched the MEDLINE database for all clinical trials or practice guidelines published in English between 2000 and 2016, with the following search terms: 'prostatic neoplasms' (MeSH Terms) AND ('high risk' (keyword) OR 'locally advanced' (keyword) OR 'node positive' (keyword)). Abstracts pertaining to very-high-risk prostate cancer were evaluated and 40 pertinent studies served as the basis for this review.

RESULTS

The term 'very'-high-risk prostate cancer remains ill defined. The European Association of Urology and National Comprehensive Cancer Network guidelines provide the only available definitions, categorizing those with clinical stage T3-4 or minimal nodal involvement as very high risk irrespective of PSA level or biopsy Gleason score. Modern imaging with multiparametric magnetic resonance imaging and positron emission tomography-prostate-specific membrane antigen scans has a role in pre-treatment assessment. Local definitive therapy by external beam radiation combined with androgen deprivation is supported by several randomized clinical trials, whereas the role of surgery in the very-high-risk setting combined with adjuvant radiation/androgen deprivation therapy is emerging. Growing evidence suggest neoadjuvant taxane-based chemotherapy in the context of a multimodal approach may be beneficial.

CONCLUSIONS

Men with very-high-risk tumors may benefit from local definitive treatment in the setting of a multimodal regimen, offering local control and possibly cure in well selected patients. Further studies are necessary to better characterize the 'very'-high-risk category and determine the optimal therapy for the individual patient.

Oncological outcomes in low-, intermediate- and high D'Amico-risk patients undergoing laparoscopic radical prostatectomy at a single UK centre

Background and purpose

Laparoscopic radical prostatectomy (LRP) is an established treatment option for patients with prostate cancer in selected centres with appropriate expertise. The goal of LRP is to achieve excellent cancer control whilst attempting to preserve normal urinary continence and erectile function. We studied our single-centre experience evaluating the oncological outcomes in patients undergoing LRP.

Patients and methods

Three hundred and six patients underwent LRP between 2005 and 2011. Patients were divided into D'Amico low-, intermediate- and high-risk groups.

Results

The mean age was 61.9 years (range 46-74 years). The two most important factors predictive of positive surgical margins (PSMs) at LRP were the initial prostate-specific antigen (PSA) level and tumour stage at diagnosis. The overall PSM rate was 26.7%. For low D'Amico-risk patients, the PSM was 24.5%, intermediate-risk patients had a PSM of 32.4%, while high-risk patients had a PSM of 13.6%; 6.4% (nine of 139) of patients sampled had evidence of lymph node-positive disease. Five-year PSA progression-free survival rates were 83% in low-risk patients, 57% in intermediate-risk and 41% in high-risk patients.

Conclusion

LRP offers good oncological outcomes in the low- and intermediate-risk groups with low incidence of biochemical recurrence for patients with localised disease. Our high-risk group has a low incidence of PSM and a five-year PSA progression-free survival rate of 41%. Patients with high-risk, but non-metastatic, prostate cancer can be offered a minimally invasive prostatectomy in an experienced centre.

The need for more aggressive therapy for men with Gleason 9-10 disease compared to Gleason ≤8 high-risk prostate cancer

PURPOSE

To evaluate the outcomes of prostate cancer patients with high-risk disease stratified by Gleason Score (GS) (GS ≤8 vs GS ≥9) treated with external beam radiotherapy (EBRT).

METHODS

The medical records of patients who underwent EBRT between 2003 and 2011 and had nonmetastatic high-risk disease were analyzed retrospectively. Patients were treated with EBRT and all patients received a dose ≥7,560 cGy. Androgen deprivation therapy was given in most patients (90%).

RESULTS

A total of 155 patients were identified (GS ≤8 n = 104, GS ≥9 n = 51), and they had a median presenting prostate-specific antigen (PSA) of 14.7 ng/mL. At a median follow-up of 69 months, the 7-year biochemical failure-free survival was 59.1% in those with GS ≥9 and 69.2% in those with GS ≤8 (p = 0.12). On MVA, Gleason 9-10 (HR 1.83, p = 0.08) was not associated with an increased risk of biochemical recurrence, while a PSA &gt;20 ng/mL (HR 2.39, p = 0.04) was associated with an increased likelihood of biochemical recurrence. Patients with GS ≥9 were noted to have worse 7-year distant metastatic-free survival (79.6% vs 90.5% p = 0.02) and cancer-specific survival (88.5% vs 97.9%, p = 0.006). On MVA, GS ≥9 was a significant indicator of distant metastatic failure and cancer-related death. Seven-year overall survival rates remained similar between the groups.

CONCLUSIONS

In this high-risk cohort, patients with GS 9-10 had significantly worse prostate cancer-related outcomes than other high-risk patients, suggesting that this group may warrant more aggressive treatment modalities than their high-risk counterparts.

Locally advanced and high risk prostate cancer: The best indication for initial radical prostatectomy?

High risk prostate cancer is a deadly disease that needs aggressive treatment. High risk prostate cancer is often treated with androgen deprivation therapy or combined radiohormonotherapy while there is a place for surgery in cases of operable and resectable locally advanced or high risk disease. This review summarises the results of the different treatment strategies for locally advanced and high risk prostate cancer. Radical prostatectomy monotherapy or in combination with radiotherapy and/or hormonal treatment are analysed. They show that radical prostatectomy is an effective treatment modality for these tumours. After surgery, the results of the pathology and the follow-up of serum PSA may indicate the need of additional adjuvant or salvage treatment strategies.

The prognostic significance of Gleason scores in metastatic prostate cancer

PURPOSE

Although the majority of metastatic prostate cancer (mPCa) will arise from tumors with Gleason scores (GS) of 8 to 10 existing tumor grade analyses for mPCa have been almost uniformly limited to comparisons of ≤7 vs. ≥8. In this analysis, we comprehensively evaluate the GS as a prognostic factor for mPCa in the era of the updated Gleason grading system.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was queried for patients with mPCa, GS 6 to 10, diagnosed from 2006 to 2008. GS and primary-secondary Gleason pattern variations were analyzed for overall survival and prostate cancer-specific survival (PCSS).

RESULTS

A total of 4,654 patients were evaluable. At 4 years, the overall survival rates were 51%, 45%, 34%, 25%, and 15% and PCSS rates were 69%, 57%, 44%, 33%, and 21% for GS 6, 7, 8, 9, and 10, respectively. Survival differences for GS 7 vs. 8, 8 vs. 9, and 9 vs. 10 were highly significant on both univariate and multivariate analyses accounting for age, prostate-specific antigen level, and T stage (all P<0.001). Gleason pattern 5 was an independent prognostic factor, both overall for patients with GS 6 to 10 and on primary-secondary Gleason pattern comparisons within the GS 8 (4+4 vs. 3+5 and 5+3) and GS 9 (4+5 vs. 5+4) subgroups. No survival differences were observed between 3+4 vs. 4+3. Overall, lower prostate-specific antigen level, younger age, and lower GS were associated with improved survival, with GS being the strongest prognostic factor for PCSS.

CONCLUSIONS

In this large population-based cohort, stratified survival outcomes were observed for GS 6 to 10, with sequential comparisons of GS 7 to 10, and the presence and extent of Gleason pattern 5 representing independent prognostic factors in the metastatic setting.

Oncologic outcomes of surgery in t3 prostate cancer: experience of a single tertiary center

Aim. The aim of this study is to present the oncologic outcomes and to determine the prognostic factors of overall survival (OS), cancer-specific survival (CSS), disease-progression-free survival (DPFS), and biochemical-progression-free survival (BPFS) after surgery for pT3 prostate cancer (PCa). Methods. Between 2002 and 2007, a pT3 stage after radical prostatectomy was detected in 182 patients at our institution. The Kaplan-Meier analysis was used to calculate OS, CSS, DPFS, and BPFS. Cox regression was used to identify predictive factors of survival. Results. pT3a was detected in 126 (69%) and pT3b in 56 (31%) of cases. Five-year OS, CSS, DPFS, and BPFS rates were 90.7%, 94%, 91.8%, and 48.4%, respectively. Survival was significantly different when comparing pT3a to pT3b groups. The 5-year OS, CSS, DPFS, and BPFS were 96% versus 72%, 98% versus 77%, 97.3% versus 79.3%, and 60% versus 24.2%, respectively. Specimen Gleason score was the most significant predictor of OS, CSS, DPFS, and BPFS. The risk of death increased up to 3-fold when a Gleason score 8-10 was present at the final pathology. Conclusions. Radical prostatectomy may offer very good CSS, OS, DPFS, and BPFS rates in pT3a PCa. However, outcomes in patients with pT3b or specimen Gleason ≥8 were significantly worse, suggesting the need for multimodality treatment in those cases.

Urinary and sexual outcomes in long-term (5+ years) prostate cancer disease free survivors after radical prostatectomy

BACKGROUND

After long term disease free follow up (FUp) patients reconsider quality of life (QOL) outcomes. Aim of this study is assess QoL in prostate cancer patients who are disease-free at least 5 years after radical prostatectomy (RP).

METHODS

367 patients treated with RP for clinically localized pCa, without biochemical failure (PSA <or= 0.2 ng/mL) at the follow up >or= 5 years were recruited.Urinary (UF) and Sexual Function (SF), Urinary (UB) and Sexual Bother (SB) were assessed by using UCLA-PCI questionnaire. UF, UB, SF and SB were analyzed according to: treatment timing (age at time of RP, FUp duration, age at time of FUp), tumor characteristics (preoperative PSA, TNM stage, pathological Gleason score), nerve sparing (NS) procedure, and hormonal treatment (HT).We calculated the differences between 93 NS-RP without HT (group A) and 274 non-NS-RP or NS-RP with HT (group B). We evaluated the correlation between function and bother in group A according to follow-up duration.

RESULTS

Time since prostatectomy had a negative effect on SF and a positive effect SB (both p < 0.001). Elderly men at follow up experienced worse UF and SF (p = 0.02 and p < 0.001) and better SB (p < 0.001).Higher stage PCa negatively affected UB, SF, and SB (all: p <or= 0.05). NS was associated with better UB, SF and SB (all: p <or= 0.05); conversely, HT was associated with worse UF, SF and SB (all: p <or= 0.05).More than 8 years after prostatectomy SF of group A and B were similar. Group A subjects (NS-RP without HT) demonstrated worsening SF, but improved SB, suggesting dissociation of the correlation between SF and SB over time.

CONCLUSION

Older age at follow up and higher pathological stage were associated with worse QoL outcomes after RP. The direct correlation between UF and age at follow up, with no correlation between UF and age at time of RP suggests that other issues (i.e: vascular or neurogenic disorders), subsequent to RP, are determinant on urinary incontinence. After NS-RP without HT the correlation between SF and SB is maintained for 7 years, after which function and bother appear to have divergent trajectories.

Outcomes for patients with high-grade prostate cancer treated with a combination of brachytherapy, external beam radiotherapy and hormonal therapy

OBJECTIVE

To assess the outcomes for patients with Gleason score 8-10 prostate cancer treated with brachytherapy, external beam radiotherapy (EBRT) and hormonal therapy (HT).

PATIENTS AND METHODS

In all, 181 patients with Gleason scores 8-10 prostate cancer were treated from 1994 to 2006 with a (103)Pd implant (prescription dose 100 Gy), 45 Gy of EBRT and 9 months of HT. The median (range) follow-up was 65 (24-150) months; freedom from biochemical failure (FBF) rates were calculated using the Phoenix definition.

RESULTS

The 8-year actuarial FBF, freedom from distant metastases, prostate-cancer specific survival and overall survival were 73%, 80%, 87% and 79%, respectively. The pretreatment prostate-specific antigen (PSA) level significantly affected FBF, with 8-year rates of 72%, 82% and 58% for patients with PSA level of <or=10, >10-20 and >20 ng/mL, respectively (P = 0.006). The PSA level had no significant effect on rates of distant metastases. The Gleason score had the most significant affect on FBF in a multivariate analysis, and was the only factor to significantly affect rates of distant metastases; the 8-year FBF rates were 84%, 55% and 30% for scores of 8, 9 and 10, respectively (P = 0.003). The corresponding freedom from distant metastases and prostate-cancer specific survival rates were 86%, 76%, 30% (P < 0.001) and 92%, 80%, 62.5% (P = 0.003), respectively.

CONCLUSIONS

The 8-year outcomes after this regimen showed favourable biochemical and distant control, as well disease-specific survival rates for patients with Gleason scores of 8-10. This treatment approach should be considered as a viable option for this subset of patients with high-risk disease.

Determining risk of biochemical recurrence in prostate cancer by immunohistochemical detection of PTEN expression and Akt activation

PURPOSE

A considerable fraction of patients who undergo radical prostatectomy as treatment for primary prostate cancer experience biochemical recurrence detected by elevated serum levels of prostate-specific antigen. In this study, we investigate whether loss of expression of the tumor suppressor phosphatase and tensin homologue deleted on chromosome 10 (PTEN) and the phosphorylated form of the cell survival protein Akt (pAkt) predicts biochemical recurrence.

EXPERIMENTAL DESIGN

Expression of PTEN and pAkt was detected by immunohistochemistry in paraffin-embedded prostate cancer tissue obtained from men undergoing radical prostatectomy. Outcome was determined by 60-month follow-up determining serum prostate-specific antigen levels.

RESULTS

By itself, PTEN was not a good predictor of biochemical recurrence; however, in combination with pAkt, it was a better predictor of the risk of biochemical recurrence compared with pAkt alone. Ninety percent of all cases with high pAkt and negative PTEN were recurrent whereas 88.2% of those with low pAkt and positive PTEN were nonrecurrent. In addition, high Gleason scores resulted in reduced protection from decreased pAkt and increased PTEN. By univariate logistic regression, pAkt alone gives an area under the receiver-operator characteristic curve of 0.82 whereas the area under the receiver-operator characteristic curve for the combination of PTEN, pAkt, and Gleason based on a stepwise selection model is 0.89, indicating excellent discrimination.

CONCLUSIONS

Our results indicate that loss of PTEN expression, together with increased Akt phosphorylation and Gleason score, is of significant predictive value for determining, at the time of prostatectomy, the risk of biochemical recurrence.

Limitations of Radioguided Surgery in High-Risk Prostate Cancer

OBJECTIVES

To determine how many men with high-risk prostate cancer (prostate-specific antigen [PSA]>20 ng/ml or biopsy Gleason score 8-10) have positive lymph nodes (sentinel lymph nodes [SLNs] and nonsentinel lymph nodes [NSLNs]) and whether these positive nodes are localised in the region of SLN dissection or in other regions, too.

METHODS

In 228 men with high-risk prostate cancer radical retropubic prostatectomy combined with radioguided pelvic lymph node dissection and extended lymphadenectomy were performed. Serial sections of the SLNs were analysed immunohistochemically.

RESULTS

A median of 7 SLNs (mean, 7) and 11 NSLNs (mean, 11) were dissected per patient. Ninety-six of 228 men (42.1%) had lymph node metastases. Most men had positive lymph nodes along the internal iliac artery alone or in combination with other regions. Twenty-two men had only micrometastatic disease. In 94 of 96 men the SLNs were positive. Twenty-six of 96 men had also positive NSLNs. When SLNs and NSLNs were positive, in more than half the patients the NSLNs were localised outside the region of sentinel lymphadenectomy.

CONCLUSIONS

The dissection of SLNs in prostate cancer has a high sensitivity in detecting positive nodes. When SLNs are negative, the other pelvic lymph nodes are also negative in a high percentage of men (sensitivity 97.1%). When the SLNs are positive, patients with high-risk disease also have a high incidence of positive NSLNs. Therefore, when it is aspired to remove all pelvic lymph node metastases sentinel and extended lymphadenectomy should be performed.

Marges après prostatectomie totale : aspects techniques et valeur pronostique

The status of surgical margins after radical prostatectomy is a major prognostic factor. The role of several technical aspects of radical prostatectomy, such have surgical access, bladder neck preservation or neurovascular bundle sparing, in generating supplementary positive margins has been controversial for many years. Positive margins along with other poor prognostic factors are important elements in the decision to perform adjuvant therapy after radical prostatectomy. This review of the literature, based on a Medline search, was designed to update these various issues encountered by urologists in their everyday practice.

Role of lymphadenectomy in clinically organ-confined prostate cancer

There has been considerable debate about the utility of pelvic lymph node dissection (PLND) when performing a radical prostatectomy. Reported practices vary from those who always perform an extended PLND to those who employ a predictive nomogram in their decision making to those who are increasingly not performing a PLND in low-risk disease. A Medline search was used to identify relevant manuscripts dealing with the role of lymphadenectomy in clinically organ-confined prostate cancer. A greater number of lymph nodes (LN) removed and examined at prostatectomy for prostate cancer appears to increase the likelihood of finding LN metastases and increase prostate cancer-specific survival even in patients who have histologically uninvolved LN. This survival benefit may result from more accurate staging and possible removal of occult metastases. The need for and extent of PLND in prostate cancer, especially in low-risk disease, however, is unlikely.