Anatomical basis for pelvic lymphadenectomy in prostate cancer: results of an autopsy study and implications for the clinic

Can contralateral lymph-node metastases be ruled out in prostate cancer patients with only unilaterally positive prostate biopsy?

PURPOSE

Our study evaluated the diagnostic benefits of bilateral pelvic lymphadenectomy in prostate cancer patients with unilaterally positive prostate biopsy.

METHODS

Our retrospective analysis included clinical, surgical, and histopathological data of 440 prostate cancer patients treated with radical prostatectomy and bilateral sentinel-guided and risk-adapted complementary extended pelvic lymphadenectomy at our hospital between 2015 and 2022. We performed multiparametric logistic regression analysis to identify the most relevant predictive factors for detecting lymph-node metastasis in this group of patients.

RESULTS

Overall, 373 patients (85%) had histopathologically bilateral tumours and 45 (10%) pN1 status, of which 22 (49%) also had lymph-node metastasis contralateral to the side of the positive prostate biopsy. In two patients with confirmed unilateral disease in prostatectomy specimens, bilateral lymph-node metastases were observed. Eight pN1 patients would have been missed by unilateral pelvic lymphadenectomy, resulting in a false-negative rate of 18%, 82% sensitivity, and 98% accuracy. Clinical tumour category, International Society of Urological Pathology grade, and percentage of prostate biopsy cores that are positive, as well as number of dissected lymph nodes contralateral to positive prostate biopsy, were determined as the most relevant predictive factors for detecting lymph-node metastasis. Our analysis was limited by its retrospective nature as well as by the fact that 80% of the patients did not receive MRI-targeted biopsy.

CONCLUSION

Our study highlights the diagnostic value of bilateral pelvic lymphadenectomy and the need for careful planning in surgery for prostate cancer patients with unilaterally positive prostate biopsy.

Robot-Assisted Treatment of Symptomatic Lymphocele Postradical Prostatectomy and Lymphadenectomy in the Era or Robotic Surgery: Narrative Review

Background: Pelvic lymphnode dissection (PLND) is an integral part of surgical treatment for localized intermediate and high-risk prostate cancer. The most common complication of PLND is lymphocele formation. In the majority of cases the development of lymphoceles is clinically asymptomatic but in case of symptomatic/infected lymphocele an active treatment is required. The aim of this article is to analyse the current evidence on the treatment of symptomatic/infected lymphocele trough robotic approach. Materials and Methods: The search was applied to PubMed, EMBASE, and Cochrane databases with following terms: "lymphocele", "symptomatic", "infected", "robot-assisted AND radical prostatectomy", "robot-assisted", "treatment". Results: The search identified three series focusing on the treatment by robot-assisted approach of symptomatic and/or infected lymphocele. The main and most frequent reason for performing the robotic treatment was an infected lymphocele, the median time from robot-assisted radical prostatectomy and PLND to robotic treatment of lymphocele was 118 days (range 30-240). Robot-assisted treatment was successful in all reports. Conclusions: The drainage of lymphocele with the robot-assisted approach appeared safe, feasible, and with satisfactory outcomes for the definitive treatment of symptomatic/infected lymphocele.

Utility of Lymphadenectomy in Prostate Cancer: Where Do We Stand?

The purpose of this review is to summarize the current knowledge on lymph node dissection (LND) in prostate cancer (PCa) patients undergoing radical prostatectomy (RP). Despite a growing body of evidence, the utility and therapeutic and prognostic value of such an approach, as well as the optimal extent of LND, remain unsolved issues. Although LND is the most accurate staging procedure, the direct therapeutic effect is still not evident from the current literature, which limits the possibility of establishing clear recommendations. This indicates the need for further robust and adequately designed high-quality clinical trials.

The Influence of Endogenous Testosterone Density on Unfavorable Disease and Tumor Load at Final Pathology in Intermediate-Risk Prostate Cancer: Results in 338 Patients Treated with Radical Prostatectomy and Extended Pelvic Lymph Node Dissection

OBJECTIVE

The aim of this study is to evaluate the influence of endogenous testosterone density (ETD) on features of aggressive prostate cancer (PCa) in intermediate-risk disease treated with radical prostatectomy and extended pelvic lymph node dissection.

MATERIALS AND METHODS

Density measurements included the ratio of endogenous testosterone (ET), prostate-specific antigen (PSA), and percentage of biopsy positive cores (BPC) on prostate volume (ETD, PSAD, and BPCD, respectively). The ratio of percentage of cancer invading the gland (tumor load, TL) on prostate weight (TLD) was also calculated. Unfavorable disease (UD) was defined as tumor upgrading (ISUP >3) and/or upstaging (pT >2) and/or lymph node invasion (LNI). Associations of ETD with features of aggressive PCa, including UD and TLD, were evaluated by logistic and linear regression models.

RESULTS

Evaluated cases were 338. Subjects with upgrading, upstaging, and LNI were 61/338 (18%), 73/338 (21%), and 25/338 (7.4%), respectively. TLD correlated with UD (Pearson's correlation coefficient, r = 0.204; p < 0.0001), PSAD (r = 0.342; p < 0.0001), BPCD (r = 0.364; p < 0.0001), and ETD (r = 0.214; p < 0.0001), which also correlated with BMI (r = -0.223; p < 0.0001), PSAD (r = 0.391; p < 0.0001), and BPCD (r = 0.407; p < 0.0001). TLD was the strongest independent predictor of UD (OR = 2.244; 95% CI = 1.146-4.395; p = 0.018). In the multivariate linear regression model predicting BPCD, ETD was an independent predictor (linear regression coefficient, b = 0.026; 95% CI: 0.016-0.036; p < 0.0001) together with PSAD (b = 1.599; 95% CI: 0.863-2.334; p < 0.0001) and TLD (b = 0.489; 95% CI: 0.274-0.706; p < 0.0001). According to models, TLD increased as ETD increased accordingly, but mean ET levels were significantly lower for patients with UD.

CONCLUSIONS

As ETD measurements incremented, the risk of large tumors extending beyond the prostate increased accordingly, and patients with lower ET levels were more likely to occult UD. The influence of ETD on PCa biology should be addressed by prospective studies.

Preoperative Predictors of Lymph Node Invasion and Biochemical Recurrence in High-risk Prostate Cancer

AIM

To evaluate the preoperative predictors of pathological lymph node (LN) metastasis and prognostic factors for postoperative biochemical recurrence (BCR) in robot-assisted radical prostatectomy with extended pelvic LN dissection in patients with D'Amico high-risk prostate cancer (PCa).

PATIENTS AND METHODS

Overall, 107 patients with D'Amico high-risk PCa underwent robot-assisted radical prostatectomy with extended pelvic LN dissection without neoadjuvant or adjuvant therapy. BCR was defined as a prostate-specific antigen (PSA) level ≥0.2 ng/ml. Moreover, BCR-free survival rates were determined using Kaplan-Meier analysis. Logistic regression analysis was used to evaluate preoperative predictors of pathological LN metastasis. Cox regression analysis was used to evaluate the effects of preoperative and pathologic variables on BCR.

RESULTS

The median follow-up was 21 months, and the 5-year BCR-free survival rate was 59.8%. The positive LN rate was 21.5%. In multivariate analysis, the percentage of positive cores was a significant preoperative predictor of positive LNs. Patients with >50% positive cores (p=0.004) and PSA density (PSAD) >0.5 ng/ml/cc (p=0.005) had a high risk of having ≥3 positive LNs. In multivariate analysis, PSAD >0.5% was a significant preoperative predictor of BCR. Among the postoperative predictors, the number of positive LNs was significantly associated with BCR. Patients with ≥3 positive LNs (n=7) had significantly lower BCR-free survival rates than patients with one or two positive LNs (n=16) (p<0.001). Patients with >50% positive cores and PSAD >0.5 ng/ml/cc had a risk for a high number of positive LNs (≥3) that was strongly associated with shorter BCR-free survival (p<0.001).

CONCLUSION

The percentage of positive cores may be useful as a preoperative predictor of pathological LN metastasis in patients with high-risk PCa. Patients with >50% positive cores and PSAD >0.5 ng/ml/cc were found to have a high risk for ≥3 positive LNs and shorter BCR-free survival.

Pelvic lymph node dissection in high-risk prostate cancer

INTRODUCTION

The therapeutic role of pelvic lymph node dissection (PLND) in prostate cancer (PCa) is unknown due to absence of randomized trials.

OBJECTIVE

to present a critical review on the therapeutic benefits of PLND in high risk localized PCa patients.

MATERIALS AND METHODS

A search of the literature on PLND was performed using PubMed, Cochrane, and Medline database. Articles obtained regarding diagnostic imaging and sentinel lymph node dissection, PLND extension, impact of PLND on survival, PLND in node positive "only" disease and PLND surgical risks were critically reviewed.

RESULTS

High-risk PCa commonly develops metastases. In these patients, the possibility of presenting lymph node disease is high. Thus, extended PLND during radical prostatectomy may be recommended in selected patients with localized high-risk PCa for both accurate staging and therapeutic intent. Although recent advances in detecting patients with lymph node involvement (LNI) with novel imaging and sentinel node dissection, extended PLND continues to be the most accurate method to stage lymph node disease, which may be related to the number of nodes removed. However, extended PLND increases surgical time, with potential impact on perioperative complications, hospital length of stay, rehospitalization and healthcare costs. Controversy persists on its therapeutic benefit, particularly in patients with high node burden.

CONCLUSION

The impact of PLND on biochemical recurrence and PCa survival is unclear yet. Selection of patients may benefit from extended PLND but the challenge remains to identify them accurately. Only prospective randomized study would answer the precise role of PLND in high-risk pelvis confined PCa patients.

Magnetometer-Guided Sentinel Lymph Node Dissection in Prostate Cancer: Rate of Lymph Node Involvement Compared with Radioisotope Marking

Simple Summary

Pelvic lymph node dissection is recommended in prostate cancer according to the patients’ individual risk for nodal metastases. Targeted removal of sentinel lymph nodes increases the number of detected lymph node metastases in patients with prostate cancer. We previously established magnetometer-guided sentinel lymph node dissection in patients with prostate cancer to overcome logistical and technical disadvantages associated with the standard radioisotope-guided technique. This retrospective study compared the magnetometer-guided and standard techniques in terms of their ability to detect lymph node metastases. Using the magnetometer-guided technique, more sentinel lymph nodes were detected per patient. The detected rates of lymph node involvement matched the predictions in both techniques equally well. Our findings confirm the reliability of magnetometer-guided sentinel lymph node dissection and highlight the importance of the sentinel technique for detecting lymph node metastases in prostate cancer.

Abstract

Sentinel pelvic lymph node dissection (sPLND) enables the targeted removal of lymph nodes (LNs) bearing the highest metastasis risk. In prostate cancer (PCa), sPLND alone or combined with extended PLND (ePLND) reveals more LN metastases along with detecting sentinel LNs (SLNs) outside the conventional ePLND template. To overcome the disadvantages of radioisotope-guided sPLND in PCa treatment, magnetometer-guided sPLND applying superparamagnetic iron oxide nanoparticles as a tracer was established. This retrospective study compared the nodal staging ability between magnetometer- and radioisotope-guided sPLNDs. We analyzed data of PCa patients undergoing radical prostatectomy and magnetometer- (848 patients, 2015–2021) or radioisotope-guided (2092 patients, 2006–2015) sPLND. To reduce heterogeneity among cohorts, we performed propensity score matching and compared data considering sentinel nomogram-based probabilities for LN involvement (LNI). Magnetometer- and radioisotope-guided sPLNDs had SLN detection rates of 98.12% and 98.09%, respectively; the former detected more SLNs per patient. The LNI rates matched nomogram-based predictions in both techniques equally well. Approximately 7% of LN metastases were detected outside the conventional ePLND template. Thus, we confirmed the reliability of magnetometer-guided sPLND in nodal staging, with results comparable with or better than radioisotope-guided sPLND. Our findings highlight the importance of the sentinel technique for detecting LN metastases in PCa.

Occurrence of symptomatic lymphocele after open and robot-assisted radical prostatectomy

Introduction

The aim of this article was to evaluate the prevalence and predictors of symptomatic lymphocele after open retropubic radical prostatectomy (RRP) and robot-assisted radical prostatectomy (RARP).

Material and methods

A total of 472 patients undergoing RRP (n = 241) or RARP (n = 231) were retrospectively analyzed with a 2-year follow-up for age, body mass index (BMI), total serum prostate-specific antigen (PSA), lymphocele formation and histopathological features. Univariate and multivariate logistic regression models were used to identify independent predictors of symptomatic lymphocele.

Results

Patients undergoing RRP developed significantly less overall lymphoceles than after RARP (8.2% vs 16.7%; p = 0.049), but no difference was determined for symptomatic events requiring intervention (7.4% vs 11.7%, p = 0.315). Although more pelvic lymph node dissections (PLND) were performed during RARP (70.1% vs 50.6%; p <0.001), significantly more cases with lymphatic invasion were observed after RRP (18% vs 6.2%, p = 0.002). The median lymph node yield during RRP and RARP were 11 and 10, respectively (p = 0.381). In multivariate logistic regression, we identified the number of dissected lymph nodes (n = 11) (OR 1.1; 95% Cl 1.055 - 1.147; p = 0.001), the Gleason score ≥ 8 (OR 4.7; 95% Cl 2.365 – 9.363; p = 0.001) and the total PSA ≥10 ng/ml (OR 1.05; 95% Cl 1.02 – 1.074; p = 0.001) as independent predictors for the development of symptomatic lymphocele.

Conclusions

Next to an extended lymph node yield, high-grade disease was associated with a higher risk to develop symptomatic lymphocele irrespective of the technical approach. The identification of risk factors might prove valuable in clinical practice when assessing and counselling patients considering surgical treatment of prostate cancer.

High BMI, Aggressive Tumours and Long Console Time Are Independent Predictive Factors for Symptomatic Lymphocele Formation after Robot-Assisted Radical Prostatectomy and Pelvic Lymph Node Dissection

INTRODUCTION

Lymphocele (LC) formation is a common complication which may cause severe symptoms after robot-assisted radical prostatovesiculectomy (RARP) with concomitant pelvic lymph node dissection (PLND). Compared to open radical prostatectomy, the amount of data on potential risk factors for LC formation is still limited. The aim of the present study was to identify risk factors for symptomatic LC formation (sLC) after RARP with PLND.

METHODS

We used the data of a prospective multicentre series of 232 RARP patients which were treated between March 2017 and December 2017. The primary endpoint was the presence of sLC within 90 days. Asymptomatic LC (aLC) formation was also recorded. We evaluated clinical, perioperative, and histopathological criteria and compared their distribution in patients with and without post-operative sLC. Uni- and multivariable logistic regression analyses (MVAs) were performed to identify potential predictors for LC formation. Regarding the influence of patients' BMI, 2 models were calculated: BMI continuously (model 1) and BMI dichotomized with cut-off 30 kg/m2 (WHO definition, model 2).

RESULTS

Post-operative sLC was present in 21 patients (9.1%), while aLC was detected in 49 patients (21.1%) 90 days after RARP with PLND. Patients with sLC showed higher median baseline PSA levels (9.8 vs. 8.1 ng/mL), higher prevalence of obesity (BMI >30; 42.9 vs. 19.9%), and longer median console time (180 vs. 165 min) compared to patients without sLC. On MVA higher BMI {model 1: OR 1.145 (confidence interval [CI] 1.025-1.278); model 2: OR 2.761 (1.045-7.296)}, longer console time (model 1: OR 1.013 [1.005-1.021]; model 2: OR 1.013 [1.005-1.020]) and an ISUP grade ≥3 (model 1: OR 3.247 [1.182-8.917]; model 2: OR 2.791 [1.050-7.423]) were identified as independent predictors for sLC development.

CONCLUSION

Patients with aggressive tumours and higher BMI should be informed about a potentially increased risk for sLC formation. In case of a long console time, a close and regular follow-up should be considered to check for LC development.

The evolving role of lymphadenectomy for bladder cancer: why, when, and how

Radical cystectomy (RC) represents a standard treatment for non-metastatic muscle-invasive and select high-risk non-muscle invasive bladder cancer. Lymphadenectomy performed at time of RC identifies nodal metastases in up to 25% of patients despite normal imaging. There has been an increasing utilization of pelvic lymph node dissection (PLND) with RC since 1950, and in fact lymph node dissection is now recommended in contemporary National Comprehensive Cancer Network (NCCN) guidelines. Benefits of removing of nodal disease include improved staging, guidance for adjuvant treatment, and potentially improved oncologic outcomes. Advantages of dissection have been suggested among both node-negative and node-positive patients. Numerous studies have attempted to define the optimal dissection characteristics of lymphadenectomy with regard to nodal yield and anatomic boundaries of dissection. The ideal extent of lymphadenectomy remains uncertain due to the retrospective and non-randomized nature of the majority of existing reports, which are thereby limited by significant confounding and selection bias. Two randomized controlled trials have investigated this issue, one of which LEA AUO AB 25/02 recently reported its outcomes, demonstrating no significant improvement in 5-year outcomes with an extended dissection. Meanwhile, the Southwest Oncology Group 1011 trial has completed enrollment and data are maturing. While current data preclude definitive recommendations, herein we review the why, when, and how to perform a PLND for bladder cancer.

Indications for and complications of pelvic lymph node dissection in prostate cancer: accuracy of available nomograms for the prediction of lymph node invasion

OBJECTIVES

To externally validate the currently available nomograms for predicting lymph node invasion (LNI) in patients with prostate cancer (PCa) and to assess the potential risk of complications of extended pelvic lymph node dissection (ePLND) when using the recommended threshold.

METHODS

A total of 14 921 patients, who underwent radical prostatectomy with ePLND at eight European tertiary referral centres, were retrospectively identified. After exclusion of patients with incomplete biopsy or pathological data, 12 009 were included. Of these, 609 had undergone multiparametic magnetic resonance imaging-targeted biopsies. Among ePLND-related complications we included lymphocele, lymphoedema, haemorrhage, infection and sepsis. The performances of the Memorial Sloan Kettering Cancer Centre (MSKCC), Briganti 2012, Briganti 2017, Briganti 2019, Partin 2016 and Yale models were evaluated using receiver-operating characteristic curve analysis (area under the curve [AUC]), calibration plots, and decision-curve analysis.

RESULTS

Overall, 1158 patients (9.6%) had LNI, with a mean of 17.7 and 3.2 resected and positive nodes, respectively. No significant differences in AUCs were observed between the MSKCC (0.79), Briganti 2012 (0.79), Partin 2016 (0.78), Yale (0.80), Briganti 2017 (0.81) and Briganti 2019 (0.76) models. A direct comparison of older models showed that better discrimination was achieved with the MSKCC and Briganti 2012 nomograms. A tendency for underestimation was seen for all the older models, whereas the Briganti 2017 and 2019 nomograms tended to overestimate LNI risk. Decision-curve analysis showed a net benefit for all models, with a lower net benefit for the Partin 2016 and Briganti 2019 models. ePLND-related complications were experienced by 1027 patients (8.9%), and 12.6% of patients with pN1 disease.

CONCLUSIONS

The currently available nomograms have similar performances and limitations in the prediction of LNI. Miscalibration was present, however, for all nomograms showing a net benefit. In patients with only systematic biopsy, the MSKCC and Briganti 2012 nomograms were superior in the prediction of LNI.

Magnetic resonance imaging at ultra-high magnetic field strength: An in vivo assessment of number, size and distribution of pelvic lymph nodes

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.

Obesity strongly predicts clinically undetected multiple lymph node metastases in intermediate- and high-risk prostate cancer patients who underwent robot assisted radical prostatectomy and extended lymph node dissection

OBJECTIVE

To evaluate the association between obesity and risk of multiple lymph node metastases in prostate cancer (PCa) patients with clinically localized EAU intermediate and high-risk classes staged by extended pelvic lymph-node dissection (ePLND) during robot assisted radical prostatectomy (RARP).

MATERIALS AND METHODS

373 consecutive PCa intermediate or high-risk patients were treated by RARP and ePLND. According to pathology results, extension of LNI was classified as absent (pN0 status) or present (pN1 status); pN1 was further categorized as one or more than one (multiple LNI) lymph node metastases. A logistic regression model (univariate and multivariate analysis) was used to evaluate the association between significant categorized clinical factors and the risk of multiple lymph nodes metastases.

RESULTS

Overall, after surgery lymph node metastases were detected in 51 patients (13.7%) of whom 22 (5.9%) with more than one metastatic lymph node and 29 (7.8%) with only one positive node. Comparing patients with one positive node to those without, EAU high-risk class only predicted risk of single LNI (OR = 2.872; p = 0.008). The risk of multiple lymph node metastases, when compared to cases without LNI, was independently predicted by BMI ≥ 30 (OR = 6.950; p = 0.002) together with BPC ≥ 50% (OR = 3.910; p = 0.004) and EAU high-risk class (OR = 6.187; p < 0.0001). Among metastatic patients, BMI ≥ 30 was the only factor associated with the risk of multiple LNI (OR = 5.250; p = 0.041).

CONCLUSIONS

In patients with clinically localized EAU intermediate and high-risk classes PCa who underwent RARP and ePLND, obesity was a risk factor of multiple LNI.

External validation of the Briganti nomogram predicting lymph node invasion in patients with intermediate and high-risk prostate cancer diagnosed with magnetic resonance imaging-targeted and systematic biopsies: A European multicenter study

OBJECTIVE

To validate a nomogram predicting lymph node invasion (LNI) in prostate cancer patients undergoing radical prostatectomy taking into consideration multiparametric-magnetic resonance imaging (mp-MRI) parameters and targeted biopsies in a western European cohort.

PATIENTS AND METHODS

A total of 473 men diagnosed by targeted biopsies, using software-based MRI-ultrasound image fusion system, and operated by radical prostatectomy with extended pelvic lymph node dissection across 11 Europeans centers between 2012 and 2019 were identified. Area under the curve of the receiver operator characteristic curve, calibration plot and decision curve analysis were used to evaluated the performance of the model.

RESULTS

Overall, 56 (11.8%) patients had LNI on final pathologic examination with a median (IQR) of 13 (9-18) resected nodes. Significant differences (all P < 0.05) were found between patients with and without LNI in terms of preoperative PSA, clinical stage at DRE and mp-MRI, maximum diameter of the index lesion, PI-RADS score, Grade Group on systematic and targeted biopsies, total number of dissected lymph nodes, final pathologic staging and Grade Group. External validation of the prediction model showed a good accuracy with an area under the curve calculated as 0.8 (CI 95% 0.75-0.86). Graphic analysis of calibration plot and decision curve analysis showed a slight underestimation for predictive probability for LNI between 3% and 22% and a high net benefit. A cut-off at 7% was associated with a risk of missing LNI in 2.6%, avoiding unnecessary surgeries in 55.9%.

CONCLUSIONS

We report an external validation of the nomogram predicting LNI in patients treated with extended pelvic lymph node dissection in a western European cohort and a cut-off at 7% seems appropriate.

Accuracy of Magnetometer-Guided Sentinel Lymphadenectomy after Intraprostatic Injection of Superparamagnetic Iron Oxide Nanoparticles in Prostate Cancer: The SentiMag Pro II Study

Radioisotope-guided sentinel lymph node dissection (sLND) has shown high diagnostic reliability in prostate (PCa) and other cancers. To overcome the limitations of the radioactive tracers, magnetometer-guided sLND using superparamagnetic iron oxide nanoparticles (SPIONs) has been successfully used in PCa. This prospective study (SentiMag Pro II, DRKS00007671) determined the diagnostic accuracy of magnetometer-guided sLND in intermediate- and high-risk PCa. Fifty intermediate- or high-risk PCa patients (prostate-specific antigen (PSA) ≥ 10 ng/mL and/or Gleason score ≥ 7; median PSA 10.8 ng/mL, IQR 7.4–19.2 ng/mL) were enrolled. After the intraprostatic SPIONs injection a day earlier, patients underwent magnetometer-guided sLND and extended lymph node dissection (eLND, followed by radical prostatectomy. SLNs were detected in in vivo and in ex vivo samples. Diagnostic accuracy of sLND was assessed using eLND as the reference. SLNs were detected in all patients (detection rate 100%), with 447 sentinel lymph nodes SLNs (median 9, IQR 6–12) being identified and 966 LNs (median 18, IQR 15–23) being removed. Thirty-six percent (18/50) of patients had LN metastases (median 2, IQR 1–3). Magnetometer-guided sLND had 100% sensitivity, 97.0% specificity, 94.4% positive predictive value, 100% negative predictive value, 0.0% false negative rate, and 3.0% additional diagnostic value (LN metastases only in SLNs outside the eLND template). In vivo, one positive SLN/LN-positive patient was missed, resulting in a sensitivity of 94.4%. In conclusion, this new magnetic sentinel procedure has high accuracy for nodal staging in intermediate- and high-risk PCa. The reliability of intraoperative SLN detection using this magnetometer system requires verification in further multicentric studies.

Undetectable PSA after radical prostatectomy is more likely in low burden N+ prostate cancer patients when an extended lymph node dissection is performed

OBJECTIVES

To analyze the likelihood of undetectable PSA (< 0.01 ng/mL) after extended (ePLND) versus standard pelvic lymph-nodes dissection (sPLND) in pN+ patients.

MATERIALS AND METHODS

The institutional prospectively maintained Prostate Cancer Database was queried for patients who underwent radical prostatectomy with PLND and were found with 3or less lymph-nodal metastases between 2007 and 2017. The extension of the PLND was defined according to the number of lymph-nodes (LN) removed. Patients in the 75th or higher percentile of lymph-nodes removed were considered as the ePLND group; patients in the 25th or lower percentile in the sPLND group. Groups were compared in clinical and pathological variables. Student T-test was used for comparing continuous variables; chi-square test was used for categorical variables. Multivariable logistic regression assessed the probability of undetectable PSA at 3^rd month postoperatively. Kaplan-Meier method estimated the probability of biochemical recurrence. Differences between the groups were compared by Log-rank test.

RESULTS

1478 patients were treated within the time span considered. 95 with 1 to 3 lymph-nodal metastases were extracted. After accounting for inclusion criteria, 23 patients with a median of 11 LN removed were included in the sPLND group (25th percentile); 23 patients with > 27 LN were included in ePLND group (75th percentile). Surgical time was longer for ePLND. Sixteen patients (69.6%) who underwent ePLND had undetectable PSA postoperatively. At multivariable analysis, the probability of undetectable PSA at 3^rd month was higher in patients who received an ePLND (HR=5.18; IC 95%=1.16-23.11; P=.03).

CONCLUSIONS

ePLND is more likely to predict undetectable PSA at third month after radical prostatectomy, irrespective of disease characteristics.

Positive Association between Preoperative Total Testosterone and Lymph Node Invasion in Intermediate Risk Prostate Cancer

Introduction

Prostate cancer (PCa) patients who are classified into the intermediate risk category represent a heterogeneous population needing further preoperative risk assessment.

Objectives

To evaluate clinical total testosterone (TT) associations with lymph node invasion (LNI) in intermediate risk PCa.

Material and Methods

Between November 2014 and July 2016, intermediate risk PCa was assessed in 154 patients who underwent extended pelvic lymph node dissection if the risk of LNI was higher than 5%. Clinical factors associated with the risk LNI were investigated by the multinomial logistic regression model.

Results

The risk of LNI was assessed higher than 5% in 40.9% of cases of whom 15.5% had LNI. In the multivariate model, the risk of LNI was independently increased by prostate specific antigen (OR = 1.185; p = 0.021) and TT (OR = 1.004; p = 0.036). As a result, TT was an independent factor that associated with LNI because it increased the risk of LNI by 4% for each increment unit of TT.

Conclusion

Preoperative TT independently increased the risk of LNI in the intermediate risk class of PCa patients elected to radical prostatectomy and extended pelvic lymph node dissection. TT might be a useful preoperative factor for stratifying intermediate risk patients because of the positive association of TT with high grade tumors.

Risk factors, complications and management of lymphocele formation after radical prostatectomy: A mini-review

Lymphocele formation is the most common adverse event of pelvic lymphadenectomy during radical prostatectomy for prostate cancer. Previous studies failed to favor one surgical technique over the other in terms of minimizing its rate. Data on risk factors for its development are still conflicting and warranting further research. In this mini-review, we aimed to scrutinize available evidence on these aspects and outline current achievements in lymphocele prevention approaches.

Handling and reporting of pelvic lymphadenectomy specimens in prostate and bladder cancer: a web-based survey by the European Network of Uropathology

AIMS

Pathological evaluation of lymphadenectomy specimens plays a pivotal role in accurate lymph node (LN) staging. Guidelines standardising the gross handling and reporting of pelvic LN dissection (PLND) in prostate (PCa) and bladder (BCa) cancer are currently lacking. This study aimed to establish current practice patterns of PLND evaluation among pathologists.

METHODS AND RESULTS

A web-based survey was circulated to all members of the European Network of Uropathology (ENUP), comprising 29 questions focusing on the macroscopic handling, LN enumeration and reporting of PLND in PCa and BCa. Two hundred and eighty responses were received from pathologists throughout 23 countries. Only LNs palpable at grossing were submitted by 58%, while 39% routinely embedded the entire specimen. Average LN yield from PLND was ≥10 LNs in 56% and <10 LNs in 44%. Serial section(s) and immunohistochemistry were routinely performed on LN blocks by 42% and <1% of respondents, respectively. To designate a LN microscopically, 91% required a capsule/subcapsular sinus. In pN+ cases, 72% reported the size of the largest metastatic deposit and 94% reported extranodal extension. Isolated tumour cells were interpreted as pN1 by 77%. Deposits identified in fat without associated lymphoid tissue were reported as tumour deposits (pN0) by 36% and replaced LNs (pN+) by 27%. LNs identified in periprostatic fat were included in the PLND LN count by 69%.

CONCLUSION

This study highlights variations in practice with respect to the gross sampling and microscopic evaluation of PLND in urological malignancies. A consensus protocol may provide a framework for more consistent and standardised reporting of PLND specimens.

Magnetic resonance sentinel lymph node imaging and magnetometer-guided intraoperative detection in prostate cancer using superparamagnetic iron oxide nanoparticles

Purpose

Sentinel lymph node (LN) dissection (sLND) using a magnetometer and superpara-magnetic iron oxide nanoparticles (SPION) as a tracer was successfully applied in prostate cancer (PCa). The feasibility of sentinel LN (SLN) visualization on MRI after intraprostatic SPION injection has been reported. In the present study, results of preoperative MRI identification of SLNs and the outcome of subsequent intraoperative magnetometer-guided sLND following intraprostatic SPION injection were studied in intermediate- and high-risk PCa.

Patients and methods

A total of 50 intermediate- and high-risk PCa patients (prostate-specific antigen >10 ng/mL and/or Gleason score ≥7) scheduled for radical prostatectomy with magnetometer-guided sLND and extended pelvic LND (eLND), were included. Patients underwent MRI before and one day after intraprostatic SPION injection using T1-, T2-, and T2*-weighted sequences. Diagnostic rate per patient was established. Distribution of SLNs per anatomic region was registered. Diagnostic accuracy of sLND was assessed by using eLND as a reference standard.

Results

SPION-MRI identified a total of 890 SLNs (median 17.5; IQR 12–22.5). SLNs could be successfully detected using MRI in all patients (diagnostic rate 100%). Anatomic SLN distribution: external iliac 19.2%, common iliac 16.6%, fossa obturatoria 15.8%, internal iliac 13.8%, presacral 12.1%, perirectal 12.0%, periprostatic 3.7%, perivesical 2.3%, and other regions 4.4%. LN metastases were intraoperatively found in 15 of 50 patients (30%). sLND had a 100% diagnostic rate, 85.7% sensitivity, 97.2% specificity, 92.3% positive predictive value, 94.9% negative predictive value, false negative rate 14.3%, and 2.8% additional diagnostic value (LN metastases only outside the eLND template).

Conclusion

MR scintigraphy after intraprostatic SPION injection provides a roadmap for intraoperative magnetometer-guided SLN detection and can be useful to characterize a reliable lymphadenectomy template. Draining LN from the prostate can be identified in an unexpectedly high number, especially outside the established eLND template. Further studies are required to analyze discordance between the number of pre- and intraoperatively identified SLNs.

Robot-assisted extended lymphadenectomy in prostate cancer

INTRODUCTION

The extent of lymph node dissection (LND) and its potential survival benefit are still a matter of debate. Aim of our review was to summarize the latest literature data regarding the surgical templates, the potential oncological benefits, the functional outcomes and the complications of extended lymph node dissection (eLND) during robot-assisted radical prostatectomy (RARP).

EVIDENCE ACQUISITION

We systematically reviewed all relevant studies using PubMed, MEDLINE, Embase, American Urological Association (AUA), European Society of Medical Oncology (ESMO) and European Association of Urology (EAU) guidelines.

EVIDENCE SYNTHESIS

A narrative synthesis of all relevant publications on surgical templates, complications, oncological and functional outcomes of robot assisted eLND was undertaken.

CONCLUSIONS

A great deal of evidence supports that an extended template of LND is not only technically feasible but also safe in the context of RARP. It is really promising that in the era of minimally invasive surgery, parameters like the lymph node yield and the detection rates of positive lymph nodes during LND have become highly comparable with open series. The extended approach has already proved its benefits in terms of proper patient staging but more studies are needed with regard to functional outcomes and oncological benefits of this procedure.

Metastatic Involvement of the Prostatic Anterior Fat Pad: Implications for the Pathologist

OBJECTIVES

There is little information regarding the utility of pathologic evaluation of the prostatic anterior fat pad (PAFP) in patients with a low preoperative probability of recurrence. Our study aimed to determine the utility of PAFP pathologic examination, especially for this group of patients.

METHODS

We analyzed a tertiary care academic center's radical prostatectomy (RP) specimens from 2009 to 2017.

RESULTS

Of 602 RP specimens, 420(70%) included the PAFP; four of 420 (1%) had lymph node involvement (LNI) in the PAFP. In two of four cases with LNI in the PAFP, this was the only site of LNI. Of these two cases, one occurred in a patient with low probability of recurrence and involved a nonpalpable PAFP lymph node.

CONCLUSIONS

Pathologic evaluation of the PAFP may be useful even in patients with low probability of recurrence because it may change staging by detecting metastatic involvement of small PAFP lymph nodes.

Prostate-specific antigen associates with extensive lymph node invasion in high-risk prostate cancer

OBJECTIVE

To evaluate clinical predictors of lymph node invasion (LNI) in patients with high-risk prostate cancer undergoing radical prostatectomy (RP) with extended pelvic lymph node dissection (ePLND).

METHODS

A contemporary cohort of 116 patients, who underwent ePLND during RP, was retrospectively evaluated. Patients were classified into 3 groups including cases without LNI (group 1), with 1 to 3 positive nodes (group 2; limited LNI), and with more than 3 positive nodes (group 3; extensive LNI). The multinomial logistic regression model (multivariate analysis) evaluated the risk of LNI.

RESULTS

Overall, 30 patients (25.9%) had LNI, which was limited in 17 cases (14.7%) and extensive in 13 subjects (11.2%). Median prostate-specific antigen (PSA) was higher in cases with limited (11.4 ng/mL) or extensive (23.5 ng/mL) LNI than cases without (7.3 ng/mL) and the difference was significant ( p <.0001). Median proportion of biopsy-positive cores was higher in limited (0.64) or extensive (0.54) LNI than cases without (0.34) and the difference was significant ( p < .0001). The distribution of other factors did not show any significant difference among the groups. On multivariate analysis, only higher values of PSA significantly affected the odds of extensive LNI when compared to cases without (odds ratio, 1.054; p = .005); PSA showed a fair discrimination power (area under the curve 0.792).

CONCLUSION

PSA was the only independent predictor of extensive LNI and could be an important preoperative factor for stratifying high-risk patients.

Therapeutic Value of Standard Versus Extended Pelvic Lymph Node Dissection During Radical Prostatectomy for High-Risk Prostate Cancer

Extent of pelvic lymph node dissection (PLND) during radical prostatectomy (RP) remains a subject of debate. Here, we review the literature covering the value of extended PLND (ePLND) during RP for high-risk prostate cancer (PCa) over a standard PLND, with a focus on potential therapeutic advantage. PLND may provide valuable prognostic information to high-risk PCa patients, and incorporating the common iliac and presacral nodes to ePLND templates further improves pathologic nodal staging accuracy. Although increased PLND extent is associated with increased lymphocele/lymphedema rates, it is not associated with increased venous thromboembolism rates. The therapeutic role of ePLND remains uncertain. While recent retrospective studies suggest an increased number of nodes removed within the ePLND template are associated with improved survival outcomes, such retrospective studies cannot completely adjust for the Will Rodgers phenomenon or surgeon-specific factors. Thus, the results of randomized trials are eagerly awaited in this arena.

Magnetic Marking and Intraoperative Detection of Primary Draining Lymph Nodes in High-Risk Prostate Cancer Using Superparamagnetic Iron Oxide Nanoparticles: Additional Diagnostic Value

Sentinel lymph node dissection (sLND) using a magnetometer and superparamagnetic iron oxide nanoparticles (SPIONs) as a tracer was successfully applied in prostate cancer (PCa). Radioisotope-guided sLND combined with extended pelvic LND (ePLND) achieved better node removal, increasing the number of affected nodes or the detection of sentinel lymph nodes outside the established ePLND template. We determined the diagnostic value of additional magnetometer-guided sLND after intraprostatic SPION-injection in high-risk PCa. This retrospective study included 104 high-risk PCa patients (PSA >20 ng/mL and/or Gleason score ≥ 8 and/or cT2c) from a prospective cohort who underwent radical prostatectomy with magnetometer-guided sLND and ePLND. The diagnostic accuracy of sLND was assessed using ePLND as a reference standard. Lymph node metastases were found in 61 of 104 patients (58.7%). sLND had a 100% diagnostic rate, 96.6% sensitivity, 95.6% specificity, 96.6% positive predictive value, 95.6% negative predictive value, 3.4% false negative rate, and 4.4% false positive rate (detecting lymph node metastases outside the ePLND template). These findings demonstrate the high sensitivity and additional diagnostic value of magnetometer-guided sLND, exceeding that of ePLND through the individualized extension of PLND or the detection of sentinel lymph nodes/lymph node metastases outside the established node template in high-risk PCa.

Lymph node ratio determines the benefit of adjuvant radiotherapy in pathologically 3 or less lymph node-positive prostate cancer after radical prostatectomy: a population-based analysis with propensity-score matching

Background

The survival benefit of adjuvant radiotherapy (ART) in prostate adenocarcinoma, with limited numbers of pathologically involved lymph nodes (LNs) after radical prostatectomy (RP), is controversial.

Materials and Methods

From 2004 to 2014, data for prostate cancer patients categorized as N1M0 after RP were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. After propensity-score matching, the 10-year cancer-specific survival (CSS) rates between patients who received ART (ART group) or did not/unknown (no-ART group) were compared for each stratum of lymph node ratio (LNR) (%) according to the number of involved LNs.

Results

Optimal matching formed pairs of no-ART (n = 905) and ART (n = 905) groups. ART increased the CSS rate, even in patients with up to 3 positive LNs when the LNR is 7% or higher.

Conclusions

ART after RP showed a CSS benefit in prostate adenocarcinoma with 4 or more involved LNs irrespective of LNR. In prostate adenocarcinoma with up to 3 involved LNs after RP, ART may provide CSS benefits when the LNR is 7% or higher. The number of LN dissections required to achieve an LNR below 7% is 15, 29, and 43 or more for 1, 2, and 3 involved LNs, respectively.

Radical cystectomy with pelvic lymphadenectomy: pathologic, operative and morbidity outcomes in a Brazilian cohort

Introduction and Objective

Radical cystectomy (RC) with pelvic lymph node dissection is the standard treatment for muscle invasive bladder cancer and the oncologic outcomes following it are directly related to disease pathology and surgical technique. Therefore, we sought to analyze these features in a cohort from a Brazilian tertiary oncologic center and try to identify those who could negatively impact on the disease control.

Patients and Methods

We identified 128 patients submitted to radical cystectomy, for bladder cancer treatment, from January 2009 to July 2012 in one oncology tertiary referral public center (Mario Penna Institute, Belo Horizonte, Brazil). We retrospectively analyzed the findings obtained from their pathologic report and assessed the complications within 30 days of surgery.

Results

We showed similar pathologic and surgical findings compared to other large series from the literature, however our patients presented with a slightly higher rate of pT4 disease. Positive surgical margins were found in 2/128 patients (1.5%). The medium number of lymph nodes dissected were 15. Major complications (Clavien 3 to 5) within 30 days of cystectomy occurred in 33/128 (25.7%) patients.

Conclusions

In the management of invasive bladder cancer, efforts should focus on proper disease diagnosis and staging, and, thereafter, correct treatment based on pathologic findings. Furthermore, extended LND should be performed in all patients with RC indication. A critical analysis of our complications in a future study will help us to identify and modify some of the factors associated with surgical morbidity.

Contemporary update on neoadjuvant therapy for bladder cancer

Administration of neoadjuvant chemotherapy preceding radical cystectomy in patients with bladder cancer remains a matter of debate. Results of prospective, randomized studies have demonstrated an overall absolute survival benefit of 5% at 5 years, provided cisplatin-based combination regimens are used. Owing to the perception of a modest survival benefit, the medical community has been slow to adopt the use of neoadjuvant chemotherapy. Other reasons for the underuse of neoadjuvant chemotherapy range from patient ineligibility to fear of delaying potentially curative surgery in nonresponders. Instead, several institutions have adopted an individualized, risk-adapted approach, in which the decision to administer chemotherapy is based on clinical stage and patient comorbidity profile. The development of new cytotoxic and targeted therapies, in particular immune checkpoint inhibitors, warrants well-designed prospective studies to test their efficacy alone or in combination in the neoadjuvant setting. Moving forward, genomic characterization of muscle-invasive bladder cancer could offer information that aids clinicians in selecting the appropriate chemotherapy regimen. Following neoadjuvant therapy, every effort should be made to ensure optimal surgery, as surgical margins and the number of removed lymph nodes are prognostic factors; thus, radical cystectomy and a meticulous extended pelvic lymph node dissection should be performed by expert surgeons.

Current technique and results for extended pelvic lymph node dissection during robot-assisted radical prostatectomy

The practice of extended pelvic lymph node dissection (ePLND) remains one of the most controversial topics in the management of clinically localized prostate cancer. Although most urologists agree on its benefit for staging and prognostication, the role of the ePLND in cancer control continues to be debated. The increased perioperative morbidity makes it unpalatable, especially in patients with low likelihood of lymph node disease. With the advent of robotic assisted laparoscopic prostatectomy, many surgeons were slow to adopt ePLND in the robotic setting. In this study, we summarize the evidence for the prognostic and therapeutic roles of ePLND, review the clinical tools used for lymph node metastasis prediction and survey the numerous experiences of ePLND compiled by robotic urologic surgeons over the years.

The impact of extended lymph node dissection versus neoadjuvant therapy with limited lymph node dissection on biochemical recurrence in high-risk prostate cancer patients treated with radical prostatectomy: a multi-institutional analysis

The optimal treatment for high-risk prostate cancer (Pca) remains to be established. The current guidelines recommend extended pelvic lymph node dissection (e-PLND) for selected intermediate- and high-risk patients treated with RP. However, the indications, optimal extent, and therapeutic benefits of e-PLND remain unclear. The aim of this study was to assess whether e-PLND confers an oncological benefit for high-risk Pca compared to neoadjuvant luteinizing hormone-releasing hormone and estramustine (LHRH + EMP). The Michinoku Urological Cancer Study Group database contained the data of 2403 consecutive Pca patients treated with RP at four institutes between March 2000 and December 2014. In the e-PLND group, we identified 238 high-risk Pca patients who underwent RP and e-PLND, with lymphatic tissue removal around the obturator and the external iliac regions, and hypogastric lymph node dissection. The neoadjuvant therapy with limited PLND (l-PLND) group included 280 high-risk Pca patients who underwent RP and removal of the obturator node chain between September 2005 and June 2014 at Hirosaki University. The outcome measure was BRFS. The 5-year biochemical recurrence-free survival rates for the neoadjuvant therapy with l-PLND group and e-PLND group were 84.9 and 54.7%, respectively (P < 0.0001). The operative time was significantly longer in the e-PLND group compared to that of the neoadjuvant therapy with l-PLND group. Grade 3/4 surgery-related complications were not identified in both groups. Although the present study was not randomized, neoadjuvant LHRH + EMP therapy followed by RP might reduce the risk of biochemical recurrence.

Lymph node staging in prostate cancer: perspective for the pathologist

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.

Robot-Assisted Extended Pelvic Lymph Nodes Dissection for Prostate Cancer: Personal Surgical Technique and Outcomes

Objective:

Extended pelvic lymph nodes dissection (EPLND) allows the removal of a higher number of lymph nodes than limited PLND. The aims of this study were to describe our robot-assisted EPLND (RAEPLND) technique with related complications, and to report the number of lymph nodes removed and the rate of lymph nodal metastasis.

Materials and Methods:

153 patients underwent RAEPLND prior to robot-assisted radical prostatectomy (RARP). Indications were defined according to Briganti nomogram, to predict risk of lymph-nodal metastasis. Lymphatic packages covering the distal tract of the common iliac artery, the medial portion of the external iliac artery, the external iliac vein and the internal iliac vessels, together with the obturator and the presacral lymphatic packages were removed on both sides.

Results:

Median preoperative PSA was 7.5 ng/mL (IQR 5.5–11.5). Median operative time was 150 min (135–170). Median RAEPLND alone operative time was 38 min (32.75–41.25); for right and left side, 18 (15–29) and 20 min (15.75–30) (p=0.567). Median number of lymph nodes retrieved per patient was 25 (19.25–30); 13 (11–16) and 11 (8–15) for right and left side. In 19 patients (12.41%) metastasis was found at the level of pelvic lymph nodes. Median number of positive lymph nodes was 1 (1–4.6) per patient. Complications occurred in 11 patients (7.3%).

Conclusions:

the number of lymph nodes removed was comparable to published data about open series, allowing the increase of detection rate of lymph nodal metastasis for minimally invasive approach without compromising complications' rate if performing the procedure following reported technique.

Update on histopathological evaluation of lymphadenectomy specimens from prostate cancer patients

BACKGROUND

Metastases to lymph nodes (LNs) represent an unfavorable prognostic factor in patients with prostate cancer (PCa). Histological examination represents the gold standard in the evaluation of the lymphadenectomy (LND) specimens for the presence of secondary deposits.

METHODS AND RESULTS

The metastatic detection rate can vary according to the approach adopted in the microscopic analysis of the LNs, which includes frozen-section examination, total inclusion of the tissue with and without whole-mount sections, serial sectioning, and the application of immunohistochemistry. The assessment of the sentinel LN, the search for micrometastases, and the evaluation of atypical LN metastatic sites further contribute to the detection of the metastatic spread.

CONCLUSION

In this review, an update on the histopathological evaluation of LND specimens in patients with PCa is given, and focus is made on their clinical and prognostic significance.

Extended lymph node dissection in robot-assisted radical prostatectomy: lymph node yield and distribution of metastases

In this study, we reported our experience performing robotic extended lymph node dissection (eLND) in patients with prostate cancer. A total of 147 patients with intermediate and high-risk prostate cancer who underwent robotic eLND from May 2008 to December 2011 were included in this analysis. The dissection template extended to the ureter crossing the iliac vessels. We assessed lymph node yield, lymph node positivity, and perioperative outcomes. Lymph node positivity was also evaluated according to the number of lymph nodes (LNs) removed (<22 vs ≥22). The median number of LNs removed was 22 (11–51), and 97 positive LNs were found in 24 patients (16.3%). While the obturator fossa was the most common site for LN metastases (42.3%, 41/97), the internal iliac area was the most common area for a single positive LN packet (20.8%, 5/24). Eight patients (33.3%, 8/24) had positive LNs at the common iliac area. The incidence of positive LNs did not differ according to the number of LNs removed. Complications associated with eLND occurred in 21 patients (14.3%) and symptomatic lymphocele was found in five patients (3.4%). In conclusion, robotic eLND can be performed with minimal morbidity. Furthermore, LN yield and the node positive rate achieved using this robotic technique are comparable to those of open series. In addition, the extent of dissection is more important than the absolute number of LNs removed in eLND, and the robotic technique is not a prohibitive factor for performing eLND.

Topographical relationships between the obturator nerve, artery, and vein in the lateral pelvic wall

INTRODUCTION AND HYPOTHESIS

The aims of this study were to determine the topographical relationships between the obturator nerve (ON), artery (OA), and vein (OV) in the lateral pelvic wall.

METHODS

One hundred and fifty hemipelvises of 84 Korean cadavers were dissected.

RESULTS

The ON, OA, and OV ran in that order (from upper to lower) within the lateral pelvic wall in 46.7 % of specimens. In 32 % of cases, the three structures were separated at the posterior portion of the wall and then converged toward the obturator canal (OC). In 10 %, the OA and OV were in contact with each other and separate from the ON; in 2 %, the ON was contiguous with the OA and separate from the OV; in 2.7 %, all three structures were in contact with each another. Alternately, the order of ON, OA, and OV was altered in the lateral pelvic wall in 41.3 % of specimens. Finally, in 12 % specimens, either the OA or OV or both were absent from the lateral pelvic wall.

CONCLUSIONS

The possibility of the presence of either the OA or OV being between the ON and the external iliac vein, and the potential contact between the ON and either the OA or OV in the lateral pelvic wall, should be borne in mind during pelvic procedures.

Comparison of semi-extended and standard lymph node dissection in radical prostatectomy: A single-institute experience

Standard lymphadenectomy for prostate cancer is limited to the obturator lymph nodes (LNs), although the internal and external iliac LNs represent the primary landing zone for prostatic lymphatic drainage. We performed anatomically semi-extended pelvic lymph node dissection (PLND) to assess the incidence of LN metastasis in cases of clinically localized prostate cancer. A total of 730 consecutive patients underwent radical prostatectomy with either semi-extended PLND, comprising 6 selective fields, namely the external iliac, internal iliac and obturator LNs bilaterally, or standard LND (obturator LNs alone). A total of 131 patients undergoing semi-extended PLND were compared with 599 patients undergoing standard LND. The patients were stratified into high-risk [prostate-specific antigen (PSA)>20 ng/ml, Gleason score (GS)≥8], intermediate-risk (PSA 10-20 ng/ml, GS=4+3) and low-risk (PSA<10 ng/ml, GS≤3+4) subgroups. Following semi-extended LND, positive LNs were detected in 12/61 (20%) of the high-risk, 1/30 (3%) of the intermediate-risk and 0/40 (0%) of the low-risk cases. Following standard LND, positive LNs were detected in 13/182 (7%) of the high-risk, 1/164 (0.6%) of the intermediate-risk and 0/253 (0%) of the low-risk cases. In high-risk patients, the detection rate of LN metastasis was significantly higher following extended LND compared with standard LND (P<0.01). In 9 of 13 patients (69%), metastases were identified in the internal and external iliac regions, despite negative obturator LNs. There were no significant differences regarding intraoperative and postoperative complications or blood loss in the two groups. There was no lymphocele formation in patients undergoing either standard or semi-extended LND. Extended pelvic LND (PLND) is associated with a high rate of LN metastasis detection outside the fields of standard LND in cases with clinically localized prostate cancer. Therefore, LND including the internal and external iliac LNs should be performed in all patients with high-risk prostate cancer; however, in the low-risk group, PLND may be omitted.

Radical cystectomy with super-extended lymphadenectomy: impact of separate vs en bloc lymph node submission on analysis and outcomes

OBJECTIVE

To update our previous analysis of the clinical and pathological impact of the change in the submission of lymphadenectomy specimens from en bloc to 13 separate anatomically defined packets, which took place at the University of Southern California in May 2002, and to determine whether lymph node (LN) packeting resulted in any change in oncological outcomes.

PATIENTS AND METHODS

A total of 846 patients who underwent radical cystectomy (RC) with super-extended LN dissection for cTxN0M0 bladder cancer between January 1996 and December 2007 were identified. Specimens of 376 patients were sent en bloc (group 1), and specimens of 470 patients were sent in 13 separate anatomical packets (group 2).

RESULTS

The pathological tumour stage distribution and the proportion of LN-positive patients (group 1: 82 patients [22%] versus group 2: 99 patients [21%]; P = 0.80) were similar between the two groups: the median [range] number of total LNs identified increased significantly (group 1: 32 [10-97] versus group 2: 65 [10-179]; P < 0.001). LN density decreased (group 1, 11% versus group 2, 4%; P = 0.005). The median [range] number of positive LNs removed was similar (group 1: 0 [0-30] versus group 2: 0 [0-97]; P = 0.87). No nodal stage shift was observed. The 5-year overall survival (group 1: 58% versus group 2: 59%; P = 0.65) and recurrence-free survival rates (group 1: 68% versus group 2: 70%; P = 0.57) were similar.

CONCLUSIONS

The incidence of patients with positive LNs remained unchanged, regardless of how the LN specimen was submitted. Submitting 13 separate nodal packets significantly increased the total LN yield, but did not result in a significant increase in the number of positive LNs or a consecutive nodal stage shift and did not affect oncological outcomes. Based on these results LN density is not an accurate prognosticator.

Lymph node density as a prognostic variable in node-positive bladder cancer: a meta-analysis

Background

Although lymph node (LN) status and the LN burden determine the outcome of bladder cancer patients treated with cystectomy, compelling arguments have been made for the incorporation of LN density into the current staging system. Here, we investigate the relationship between LN density and clinical outcome in patients with LN-positive disease, following radical cystectomy for bladder cancer.

Methods

PubMed, SCOPUS, the Institute for Scientific Information Web of Science, and the Cochrane Library were searched to identify relevant published literature.

Results

Fourteen studies were included in the meta-analysis, with a total number of 3311 patients. Of these 14 publications, 6 studies, (533 patients), 10 studies (2966 patients), and 5 studies (1108 patients) investigated the prognostic association of LN density with disease-free survival (DFS), disease-specific survival (DSS), and overall survival (OS), respectively. The pooled hazard ratio (HR) for DFS was 1.45 (95 % confidence interval [CI], 1.10–1.91) without heterogeneity (I² = 0 %, p = 0.52). Higher LN density was significantly associated with poor DSS (pooled HR, 1.53; 95 % CI, 1.23–1.89). However, significant heterogeneity was found between studies (I² = 66 %, p = 0.002). The pooled HR for OS was statistically significant (pooled HR, 1.45; 95 % CI, 1.11–1.90) without heterogeneity (I² = 42 %, p = 0.14). The results of the Begg and Egger tests suggested that publication bias was not evident in this meta-analysis.

Conclusions

The data from this meta-analysis indicate that LN density is an independent predictor of clinical outcome in LN-positive patients. LN density may be useful in future staging systems, thus allowing better prognostic classification of LN-positive bladder cancer.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-015-1448-x) contains supplementary material, which is available to authorized users.

Variability in surgical quality in a phase III clinical trial of radical cystectomy in patients with organ-confined, node-negative urothelial carcinoma of the bladder

BACKGROUND AND OBJECTIVES

Previous studies have shown that variability in surgical technique can affect the outcomes of cooperative group trials. We analyzed measures of surgical quality and clinical outcomes in patients enrolled in the p53-MVAC trial.

METHODS

We performed a post-hoc analysis of patients with pT1-T2N0M0 urothelial carcinoma of the bladder following radical cystectomy (RC) and bilateral pelvic and iliac lymphadenectomy (LND). Measures of surgical quality were examined for associations with time to recurrence (TTR) and overall survival (OS).

RESULTS

We reviewed operative and/or pathology reports for 440 patients from 35 sites. We found that only 31% of patients met all suggested trial eligibility criteria of having ≥15 lymph nodes identified in the pathologic specimen (LN#) and having undergone both extended and presacral LND. There was no association between extent of LND, LN#, or presacral LND and TTR or OS after adjustment for confounders and multiple testing.

CONCLUSIONS

We demonstrated that there was substantial variability in surgical technique within a cooperative group trial. Despite explicit entry criteria, many patients did not undergo per-protocol LNDs. While outcomes were not apparently affected, it is nonetheless evident that careful attention to study design and quality monitoring will be critical to successful future trials.

How to minimize lymphoceles and treat clinically symptomatic lymphoceles after radical prostatectomy

The development of a lymphocele after pelvic surgery is a well-documented complication, especially where pelvic lymph node dissection (PLND) is part of the operation. However, not all lymphoceles are symptomatic and require treatment. Most lymphoceles spontaneously resolve, and even lymphoceles that become symptomatic may resolve without any intervention. Robotic assisted radical prostatectomy (RARP) is a common operation in urology where PLND is likely to be performed in intermediate and high-risk prostate cancer patients. The rationale for performing a PLND in prostate cancer is for accurate staging and potential therapeutic benefits. However, due to potential intraoperative and postoperative complications there is still a debate regarding the value of PLND in prostate cancer. In this review, we will discuss the potential risk factors to be aware of in pelvic surgery in order to minimize the formation of a lymphocele, along with the management for clinically significant lymphoceles.

Three-tiered nodal classification system for bladder cancer: a new proposal

ABSTRACT 

Aim: To evaluate a three-tiered prognostic stratification using one, two to five and >five positive lymph nodes (LNs) and this nodal staging system performs across different pelvic LN dissection (PLND) templates and adjuvant chemotherapy status. Methods: We evaluated 244 patients with positive LN urothelial cancer who underwent radical cystectomy and PLND between 2000 and 2011. Survival analyses utilizing the Kaplan-Meier method and log rank test were performed. Median follow-up was 55.3 months (range: 0.4–141). Multivariable Cox proportional hazards models were built to evaluate the prognostic stratification. Results: Extended PLND template was performed on 152 (62.3%) patients and standard on 92 (37.7%). The median number of LNs resected was 14 in the standard group vs 22 in the extended group (p < 0.01) and positive LNs was 2 vs 3 (p = 0.09), respectively. Stratification in patients with: one positive LN, two to five positive LNs or >five positive LNs lead to 5-year recurrence-free survival of: 48.6, 34.5 and 15.9% for each group, while the 5-year overall survival was: 43.0, 22.1 and 11.3%, respectively. Stratification in the three groups was also verified irrespective of PLND template and adjuvant chemotherapy. Two multivariable models confirmed the findings when controlling for demographic features and known pathologic risk factors. Conclusion: Three-tiered nodal classification system using the number of metastatic LNs (one, two to five and >five) stratifies patients with lymphatic disease into distinct prognostic groups.

(11)C-acetate PET/CT in pre-therapeutic lymph node staging in high-risk prostate cancer patients and its influence on disease management - a retrospective study

BACKGROUND

Radiation treatment with simultaneous integrated boost against suspected lymph node metastases may be a curative therapeutic option in patients with high-risk prostate cancer (>15% estimated risk of pelvic lymph node metastases according to the Cagiannos nomogram). (11)C-acetate positron emission tomography/computed tomography (PET/CT) can be used for primary staging as well as for detection of suspected relapse of prostate cancer. The aims of this study were to evaluate the association between positive (11)C-acetate PET/CT findings and the estimated risk of pelvic lymph node metastases and to assess the impact of (11)C-acetate PET/CT on patient management in high-risk prostate cancer patients.

METHODS

Fifty consecutive prostate cancer patients referred for primary staging with (11)C-acetate PET/CT prior to radiotherapy with curative intention were enrolled in this retrospective study.

RESULTS

All patients showed increased (11)C-acetate uptake in the prostate. Pelvic lymph node uptake was seen in 42% (21/50) of the patients, with positive external iliac lymph nodes in 71% (15/21) of these. The overall observed proportion of PET/CT-positive pelvic lymph nodes at patient level was higher than the average estimated risk, especially in low-risk groups (<15%). There was a significant association between observed proportion and estimated risk of pelvic lymph node metastases in groups with ≤45 and >45% estimated risk. Treatment strategy was altered due to (11)C-acetate PET/CT findings in 43% (20/47) of the patients.

CONCLUSIONS

The observed proportion of (11)C-acetate PET/CT findings suggestive of locoregional metastases was higher than the estimated risk, suggesting that the Cagiannos nomogram underestimates the risk for metastases. The imaging results with (11)C-acetate PET/CT have a considerable impact on patient management.

A novel method for intraoperative sentinel lymph node detection in prostate cancer patients using superparamagnetic iron oxide nanoparticles and a handheld magnetometer: the initial clinical experience

BACKGROUND

A sentinel lymph node (SLN) biopsy using superparamagnetic iron oxide nanoparticles (SPIOs) as a tracer instead of radioisotopes was first applied successfully in breast cancer. This study determined the feasibility of this new technique using SPIOs and a handheld magnetometer to detect SLNs in prostate cancer (PC).

METHODS

Enrolled 20 patients with intermediate and high-risk PC (PSA >10 and/or Gleason score >7) in a prospective study (12/2013-1/2014; DRKS00005473), following an ethics committee approval. After transrectal intraprostatic SPIOs injection a day earlier, patients (19/20) underwent magnetometer-guided sentinel lymphadenectomy (sPLND) and extended PLND, followed by radical prostatectomy. One patient was not operated because of an unrelated coagulation disorder. The ex vivo magnetic activity of all lymph nodes (LNs) removed was measured. The detection rate, rate of in vivo detected SLNs, and sensitivity of sPLND was established.

RESULTS

No adverse events attributable to SPIOs injection were observed. Identified 126 SLNs (median 7, IQR 4-9) and resected 334 LNs (median 17, IQR 14-19); 37 % (7/19) of the patients had LN metastases (median 1, IQR 1-3.5). The detection rate and rate of in vivo detected SLNs were 90 % (17/19) and 94 % (118/126) respectively. Using sPLND, all LN metastases were detected (15/15, sensitivity 100 %) in all patients identified with SLNs. One LN + patient showed no SLNs following transurethral prostate resection.

CONCLUSIONS

This is the first study using a magnetic tracer and magnetometer to detect SLNs in PC. Initial data indicate that this simple, radiation-free procedure is safe, feasible, and reliably identifies SLN and LN metastases in most patients.