Does increasing the nodal yield improve outcomes in contemporary patients without nodal metastasis undergoing radical prostatectomy?

Diagnostic and prognostic factors in patients with prostate cancer: a systematic review

OBJECTIVES

As part of the PIONEER Consortium objectives, we have explored which diagnostic and prognostic factors (DPFs) are available in relation to our previously defined clinician and patient-reported outcomes for prostate cancer (PCa).

DESIGN

We performed a systematic review to identify validated and non-validated studies.

DATA SOURCES

MEDLINE, Embase and the Cochrane Library were searched on 21 January 2020.

ELIGIBILITY CRITERIA

Only quantitative studies were included. Single studies with fewer than 50 participants, published before 2014 and looking at outcomes which are not prioritised in the PIONEER core outcome set were excluded.

DATA EXTRACTION AND SYNTHESIS

After initial screening, we extracted data following the Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of prognostic factor studies (CHARMS-PF) criteria and discussed the identified factors with a multidisciplinary expert group. The quality of the included papers was scored for applicability and risk of bias using validated tools such as PROBAST, Quality in Prognostic Studies and Quality Assessment of Diagnostic Accuracy Studies 2.

RESULTS

The search identified 6604 studies, from which 489 DPFs were included. Sixty-four of those were internally or externally validated. However, only three studies on diagnostic and seven studies on prognostic factors had a low risk of bias and a low risk concerning applicability.

CONCLUSION

Most of the DPFs identified require additional evaluation and validation in properly designed studies before they can be recommended for use in clinical practice. The PIONEER online search tool for DPFs for PCa will enable researchers to understand the quality of the current research and help them design future studies.

ETHICS AND DISSEMINATION

There are no ethical implications.

Sentinel node evaluation in prostate cancer

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

Radical Prostatectomy for High-risk Localized or Node-Positive Prostate Cancer: Removing the Primary

PURPOSE OF REVIEW

We reviewed the literature to determine what role, if any, radical prostatectomy should play in the treatment of high-risk and/or node-positive prostate cancer.

RECENT FINDINGS

The AUA, NCCN, and EAU all include radical prostatectomy as a treatment option for high-risk prostate cancer based on evidence that has shown improvements in biochemical-free and disease-specific survival. Lymph node-positive patients may also derive benefit from radical prostatectomy with lymph node dissection, however, only retrospective studies with high risk of selection bias have been published to date. High-risk prostate cancer is a heterogeneous disease representing a wide range of disease characteristics. Radical surgery, historically avoided in such patients, may now be considered a valid treatment option for select cases. The adverse effects of surgery using modern techniques lead to similar quality of life outcomes as radiation therapy, and treatment of the primary tumor is likely beneficial when compared to ADT alone.

Is More Always Better? An Assessment of the Impact of Lymph Node Yield on Outcome for Clinically Localized Prostate Cancer with Low/Intermediate Risk Pathology (pT2-3a/pN0) Managed with Prostatectomy Alone

The clinical impact of lymph node dissection extent remains undetermined in the contemporary setting, as reflected in care pattern variations. Despite some series demonstrating a direct relationship between number of lymph nodes identified and detection of nodal involvement, the correlation between lymph node yield and disease control or survival outcomes remains unclear. Patients with clinically localized prostate cancer, pre-RP PSA <30, and pT2-3a/N0 disease at RP were retrospectively identified from two databases for inclusion. Those who received pre- or post-RP radiotherapy or hormone therapy were excluded. Kaplan-Meier method was employed for survival probability estimation. Cox regression models were used to assess bRFS differences between subsets. From 2002 to 2010, 667 eligible patients were identified. The median age was 61 yrs. (range, 43-76), with median PSA 5.6 ng/dL (0.9-28.0). At RP, most patients had pT2c (64%) disease with Gleason Score (GS) ≤6 (43%) or 7 (48%); 218 (33%) patients had positive margins (M+). At median clinical and PSA follow-up of 96 and 87 months, respectively, 146 patients (22%) experienced PSA failure with an estimated bRFS of 81%/76% at 5/8 years. For patients who underwent LND, univariable analysis identified PSA (at diagnosis), higher GS (≥7, at biopsy or RP), intermediate/high risk stratification, M+ as adversely associated with bRFS (all p < 0.01). A higher number of LNs excised was not associated with improved bRFS for the entire cohort (HR = 0.97, p = 0.27), nor for any clinical risk stratum, biopsy GS, or RP GS subgroup. This study did not demonstrate an association between LN yield and bRFS in patients with clinically localized pT2-3a/pN0 prostate cancer managed with RP alone, either in the entire population or with substratification by clinical risk stratum or GS.

Utilization of Pelvic Lymph Node Dissection for Patients With Low-Risk Prostate Cancer Treated With Robot-Assisted Radical Prostatectomy

INTRODUCTION

Pelvic lymph node dissection (PLND) is not recommended for low-risk prostate cancer (PCa) patients. However, the rate of PLND in this population is unknown.

METHODS

We queried the National Cancer Data Base for PCa patients who underwent robot-assisted radical prostatectomy from 2010 to 2013 and stratified them by D'Amico risk classification. We identified the frequency of PLND in low-risk patients and identified factors associated with receipt of PLND. Further, we determined the number of lymph nodes evaluated (quality) and proportion of patients with detected nodal metastatic disease (utility) in each risk group.

RESULTS

Of 51,971 patients with low-risk PCa who underwent robot-assisted radical prostatectomy, 19,059 (36.7%) received PLND. Predictors of PLND in low-risk patients included rural residence (odds ratio [OR], 1.157; 95% confidence interval [CI], 1.009-1.327), treatment at an academic center (OR, 1.492; 95% CI 1.188-1.874), and high-volume facility (OR, 1.327; 95% CI, 1.078-1.633). The mean number of lymph nodes obtained in low-risk patients was lower than in intermediate/high-risk patients (4.74 vs. 5.86, P < .0001). Lymph node positivity was identified in 0.4% of low-risk patients and 4.6% of intermediate/high-risk patients.

CONCLUSION

While PLND is not recommended for low-risk PCa by clinical practice guidelines, it was performed frequently (36.7%) in a large hospital-based data set. PLND in this population was of lower quality (nodal yield) and had less utility of detecting nodal metastatic disease than PLND in intermediate/high-risk PCa. Treatment at a high-volume or academic center was associated with increased use of PLND. Reasons for the variation in practice patterns should be investigated to improve the value of PCa care.