The contemporary incidence of lymph node metastases in prostate cancer: implications for laparoscopic lymph node dissection

Development and validation of a preoperative nomogram for predicting survival of patients with locally advanced prostate cancer after radical prostatectomy

Background

For selected locally advanced prostate cancer (PCa) patients, radical prostatectomy (RP) is one of the first-line treatments. We aimed to develop a preoperative nomogram to identify what kinds of patients can get the most survival benefits after RP.

Methods

We conducted analyses with data from the Surveillance, Epidemiology, and End Results (SEER) database. Covariates used for analyses included age at diagnosis, marital status, race, American Joint Committee on Cancer (AJCC) 7th TNM stage, Prostate specific antigen, Gleason biopsy score (GS), percent of positive cores. We estimated the cumulative incidence function for cause-specific death. The Fine and Gray’s proportional subdistribution hazard approach was used to perform multivariable competing risk analyses and reveal prognostic factors. A nomogram was built by these factors (including GS, percent of positive cores and N stage) and validated by concordance index and calibration curves. Risk stratification was established based on the nomogram.

Results

We studied 14,185 patients. N stage, GS, and percent of positive cores were the independent prognostic factors used to construct the nomogram. For validating, in the training cohort, the C-index was 0.779 (95% CI 0.736–0.822), and in the validation cohort, the C-index was 0.773 (95% CI 0.710–0.836). Calibration curves showed that the predicted survival and actual survival were very close. The nomogram performed better over the AJCC staging system (C-index 0.779 versus 0.764 for training cohort, and 0.773 versus 0.744 for validation cohort). The new stratification of risk groups based on the nomogram also showed better discrimination than the AJCC staging system.

Conclusions

The preoperative nomogram can provide favorable prognosis stratification ability to help clinicians identify patients who are suitable for surgery.

Histologically Confirmed Diagnostic Efficacy of 18F-rhPSMA-7 PET for N-Staging of Patients with Primary High-Risk Prostate Cancer

¹⁸F-rhPSMA-7 (radiohybrid prostate-specific membrane antigen [PSMA]) is a novel ligand for PET imaging. Here, we present data from a retrospective analysis using PET/CT and PET/MRI examinations to investigate the efficacy of ¹⁸F-rhPSMA-7 PET for primary N-staging of patients with prostate cancer (PC) compared with morphologic imaging (CT or MRI) and validated by histopathology. Methods: Data from 58 patients with high-risk PC (according to the D'Amico criteria) who were staged with ¹⁸F-rhPSMA-7 PET/CT or PET/MRI at our institution between July 2017 and June 2018 were reviewed. The patients had a median prescan prostate-specific antigen value of 12.2 ng/mL (range, 1.2-81.6 ng/mL). The median injected activity of ¹⁸F-rhPSMA-7 was 327 MBq (range, 132-410 MBq), with a median uptake time of 79.5 min (range, 60-153 min). All patients underwent subsequent radical prostatectomy and extended pelvic lymph node dissection. The presence of lymph node metastases was determined by an experienced reader independently for both the PET and the morphologic datasets using a template-based analysis on a 5-point scale. Patient-level and template-based results were both compared with histopathologic findings. Results: Lymph node metastases were present in 18 patients (31.0%) and were located in 52 of 375 templates (13.9%). Receiver-operating-characteristic analyses showed ¹⁸F-rhPSMA-7 PET to perform significantly better than morphologic imaging on both patient-based and template-based analyses (areas under curve, 0.858 vs. 0.649 [P = 0.012] and 0.765 vs. 0.589 [P < 0.001], respectively). On patient-based analyses, the sensitivity, specificity, and accuracy of ¹⁸F-rhPSMA-7 PET were 72.2%, 92.5%, and 86.2%, respectively, and those of morphologic imaging were 50.0%, 72.5%, and 65.5%, respectively. On template-based analyses, the sensitivity, specificity, and accuracy of ¹⁸F-rhPSMA-7 PET were 53.8%, 96.9%, and 90.9%, respectively, and those of morphologic imaging were 9.6%, 95.0%, and 83.2%, respectively. Conclusion: ¹⁸F-rhPSMA-7 PET is superior to morphologic imaging for N-staging of high-risk primary PC. The efficacy of ¹⁸F-rhPSMA-7 is similar to published data for ⁶⁸Ga-PSMA-11.

Prognostic impact of nodal relapse in definitive prostate-only irradiation

BACKGROUND

Whole pelvic irradiation in prostate cancer patients might prevent metastatic spread of cancer cells through lymphatic drainages in patients eligible for definitive radiotherapy, but its use has declined in the last decades in favor of prostate-only irradiation (POI). The aim of our study is to assess the incidence of pelvic lymph nodal relapse and outcome in prostate cancer patients receiving POI.

MATERIALS AND METHODS

Data from 207 consecutive patients were collected. Clinical and treatment variables were collected. Biochemical relapse-free survival (BRFS), pelvic nodal relapse-free survival (PNRFS), distant metastasis-free survival (DMFS), disease-specific survival (DSS) and overall survival (OS) were calculated; analysis of prognostic variables was performed.

RESULTS

Five-year BRFS, PNRFS, DMFS, DSS and OS were, respectively, 90, 98, 96, 97 and 91%. On multivariate analysis, independent negative predictors of BRFS were Gleason score ≥ 7 (HR: 3.25) and PSA nadir ≥ 0.08 (HR: 4.86). Pelvic nodal relapse was not correlated to impaired outcome.

CONCLUSIONS

Lymph nodal pelvic relapse occurs in 2% of patients at 5 years and does not correlate with impaired outcome, suggesting the lack of theoretical benefit of a prophylactic nodal irradiation. Tumor biology and response to treatment are the main determinants of outcome.

PET Imaging of Prostate Cancer Using Radiolabeled Choline

Although PET using fludeoxyglucose F 18 (FDG) is a promising modality for metabolic imaging of different tumors, the results in prostate cancer have been somewhat inconsistent. Low FDG avidity of most prostate cancer cells and urinary activity are suggested as the main limitations of FDG PET for the evaluation of prostate cancer. Prostate cancer exhibits increased choline metabolism, which is the rationale for using radiolabeled choline for PET. This article describes the basic concepts of radiolabeled choline regarding pharmacokinetics, radiation dosimetry, synthesis, and biodistribution, in addition to advances concerning clinical PET using 11C- and 18F-choline in primary staging and restaging of prostate cancer patients.

[Imaging diagnostics of advanced prostate cancer]

The diagnostic approach to prostate cancer is still a big challenge for the treating physician. Regarding an individualized and risk-adapted evaluation of different therapeutic options, precise diagnostic tools are crucial to accurately distinguish between localized and advanced prostate cancer. Imaging of advanced prostate cancer is currently changing due to numerous technical innovations. While choline-based hybrid positron emission tomography-computed tomography (PET/CT) has been established as an important diagnostic tool in clinical imaging of advanced prostate cancer, well-investigated methods, such as magnetic resonance imaging (MRI) and bone scintigraphy are currently expanding the diagnostic potential due to technical improvements. The specific use of imaging for advanced prostate cancer may help to offer the patient a well-tailored oncologic therapy. Further research is needed to evaluate whether this individualized therapy can consistently improve the prognosis of patients suffering from advanced prostate cancer.

Utility of choline positron emission tomography/computed tomography for lymph node involvement identification in intermediate- to high-risk prostate cancer: a systematic literature review and meta-analysis

CONTEXT

Determination of tumour involvement of regional lymph nodes in patients with prostate cancer (PCa) is of key importance for the proper planning of treatment.

OBJECTIVES

To provide a critical overview of published reports and to perform a meta-analysis about the diagnostic performance of 18F-choline and 11C-choline positron emission tomography (PET) or PET/computed tomography (CT) in the lymph node staging of PCa.

EVIDENCE ACQUISITION

A Medline, Web of Knowledge, and Google Scholar search was carried out to select English-language articles published before January 2012 that discussed the diagnostic performance of choline PET to individualise lymph node disease at initial staging in PCa patients. Articles were included only if absolute numbers of true-positive, true-negative, false-positive, and false-negative test results were available or derivable from the text and focused on lymph node metastases. Reviews, clinical reports, and editorial articles were excluded. All complete studies were reviewed; thus qualitative and quantitative analyses were performed.

EVIDENCE SYNTHESIS

From the year 2000 to January 2012, we found 18 complete articles that critically evaluated the role of choline PET and PCa at initial staging. The meta-analysis was carried out and consisted of 10 selected studies with a total of 441 patients. The meta-analysis provided the following results: pooled sensitivity 49.2% (95% confidence interval [CI], 39.9-58.4) and pooled specificity 95% (95% CI, 92-97.1). The area under the curve was 0.9446 (p<0.05). The heterogeneity ranged between 22.7% and 78.4%. The diagnostic odds ratio was 18.999 (95% CI, 7.109-50.773).

CONCLUSIONS

Choline PET and PET/CT provide low sensitivity in the detection of lymph node metastases prior to surgery in PCa patients. A high specificity has been reported from the overall studies. Studies carried out on a larger scale with a homogeneous patient population together with the evaluation of cost effectiveness are warranted.

Use of [11C]choline PET-CT as a noninvasive method for detecting pelvic lymph node status from prostate cancer and relationship with choline kinase expression

PURPOSE

To evaluate the accuracy and biological basis for [(11)C]choline-PET-CT in the nodal staging of high risk localized prostate cancer patients.

EXPERIMENTAL DESIGN

Twenty-eight patients underwent dynamic [(11)C]choline-PET-CT of the pelvis and lower abdomen prior to extended laparoscopic pelvic lymph node dissection (eLPL). The sensitivity and specificity of [(11)C]choline PET, [(11)C]choline PET-CT, and MRI for nodal detection were calculated. Average and maximal standardized uptake values (SUV(ave), SUV(max)) were compared with choline kinase alpha (CHKα) and Ki67 immunohistochemistry scores.

RESULTS

Four hundred and six lymph nodes (LN), in 26 patients, were assessable. Twenty-seven (6.7%) involved pelvic nodes at eLPL were detected in 9 patients. Seventeen of the 27 involved nodes were subcentimeter. The sensitivity and specificity on a per nodal basis were 18.5% and 98.7%, 40.7% and 98.4%, and 51.9% and 98.4% for MRI, [(11)C]choline PET, and [(11)C]choline PET-CT, respectively. Sensitivity was higher for [(11)C]choline PET-CT compared with MRI (P = 0.007). A higher nodal detection rate, including subcentimeter nodes, was seen with [(11)C]choline PET-CT than MRI. Malignant lesions showed CHKα expression in both cytoplasm and nucleus. SUV(ave) and SUV(max) strongly correlated with CHKα staining intensity (r = 0.68, P < 0.0001 and r = 0.63, P = 0.0004, respectively). In contrast, Ki67 expression was generally low in all tumors.

CONCLUSION

This study establishes the relationship between [(11)C]choline PET-CT uptake with choline kinase expression in prostate cancer and allows it to be used as a noninvasive means of staging pelvic LNs, being highly specific and more sensitive than MRI, including the detection of subcentimeter disease.

Positron emission tomography for benign and malignant disease

Functional imaging using radiolabeled probes that specifically bind and accumulate in target tissues has improved the sensitivity and specificity of conventional imaging. Fluorodeoxyglucose (FDG)-positron emission tomography (PET) has shown improved diagnostic accuracy in differentiating benign from malignant lesions in the setting of solitary pulmonary nodules. FDG-PET has become useful in preoperative staging of patients with lung cancer, and is being tested with many other malignancies for its ability to change patient management. This article provides an overview of the current status of FDG-PET and presents the challenges of moving toward routine use.

Choline PET/CT for prostate cancer: main clinical applications

Several studies investigated the potential roles of imaging modalities in prostate cancer patients for the evaluation of intra-prostatic disease, stage and restage. However no precise guidelines exist about the use of imaging modalities, in particular about the role of PET/CT hybrid imaging. Considering the results of the literature and our experience, we tried to summarize the main applications of choline positron emission tomography (PET) in prostate cancer patients. The use of choline PET/CT for initial diagnosis and staging is not recommended as a first-line method. Instead the main and important application of choline PET/CT is represented by the restaging of the disease in case of biochemical relapse for the detection of lymph node and distant recurrence. In particular choline PET/CT could play a crucial role as first diagnostic procedure in prostate cancer patients who show a fast growing Prostate Specific Antigen (PSA) kinetics.

Utilité clinique de la tomographie par émission de positons dans le cancer de la prostate

In prostate cancer, use of FDG, the radiopharmaceutical currently most widely used in oncology, is limited to the most aggressive cancers and, in the absence of another tracer, to attempting to localise occult recurrences detected biochemically (elevated PSA serum levels). Four other PET tracers are currently suggested in various situations of prostate cancer development: for guiding biopsies, for diagnosis and staging of the primary cancer and of local or metastatic recurrences, especially in bone, and for localizing occult biochemical recurrence. This article is illustrated by cases summarising our experience with fluoromethylcholine-(18F) and PET/CT. They cover a wide spectrum of clinical settings: localisation of intraprostatic neoplastic lesions, initial staging, monitoring treatment by ultrasound, detection of occult recurrences and characterisation of images on conventional imaging modalities, which are questionable or difficult to interpret.

Laparoscopic Extended Pelvic Lymph Node Dissection for Prostate Cancer: Description of the Surgical Technique and Initial Results

OBJECTIVE

In patients with prostate cancer, extended pelvic lymph node dissection (ePLND) yields a higher number of lymph node metastases (LNM) than standard pelvic lymph node dissection (PLND) of the obturator fossa only. We describe our laparoscopic technique of extended lymph node dissection and provide the number and locations of positive lymph nodes from our experience.

METHODS

In a total of 35 selected patients with clinically localized prostate cancer, laparoscopic ePLND was performed prior to laparoscopic radical prostatectomy. The template included the genitofemoral nerve up to the bifurcation of the common iliac artery and down to the epigastric artery. In the "split and roll" technique the internal and external iliac arteries including the bifurcation and the external iliac vein were completely mobilized. After freeing the obturator nerve, the entire lymph node package was released from the pelvic side wall.

RESULTS

Mean operative time was 90min/patient. The complications were two temporary and reversible neurapraxias (ischiatic nerve and obturator nerve), one deep vein thrombosis, and two lymphoceles. One lymphocele healed conservatively; the second was marsupialized laparoscopically. Eleven (31.4%) patients had lymph node metastases; their mean prostate-specific antigen (PSA) level was 20.3+/-7.0 ng/ml (range: 5.2-39.7 ng/ml) and their median Gleason sum in biopsy was 7 (range: 6-8). Mean size of the LNM was 3.1+/-1.0 mm (range: 0.2-8). In 5 of the 11 patients with LNM these were detected exclusively outside the obturator fossa. LNM were in the obturator fossa only in two (one bilateral), around the external iliac artery only in two, around the internal iliac artery only in two, and around the external iliac artery and internal iliac only in one patient.

CONCLUSIONS

Laparoscopic ePLND can be combined with laparoscopic radical prostatectomy. Standardization of the technique facilitates surgery to a great extent. e-PLND detects LNM in a significant number of patients. The majority of LNM are outside the obturator fossa. The transperitoneal approach allows a wide exposure and is the most important factor to enable successful ePLND.

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.

Presence of prostate cancer metastasis correlates with lower lymph node reactivity

BACKGROUND

Several reports suggest that the dissemination of neoplastic cells and cancer progression are associated with the generation of an immunosuppressive environment.

METHODS

In this report, we investigated immunological effects of prostate cancer by comparing metastastic and non-metastatic pelvic lymph nodes (LNs) from 25 patients with carcinomatous involvement of LNs to the non-metastatic LNs from 26 control patients with no metastatic involvement by immunohistochemistry and histological analyses.

RESULTS

Our results showed a decreased abundance of CD20+ B lymphocytes (P = 0.031), CD38+ activated lymphocytes (P = 0.038), and CD68+ macrophages (P < 0.001), and less evidence of follicular hyperplasia (P = 0.014), sinus hyperplasia (P < 0.001), and fibrosis (P=0.028) in metastatic LNs comparatively to control LNs. Finally, we observed that metastatic LNs were significantly smaller than control LNs (P = 0.005).

CONCLUSIONS

Our results suggest that the development of prostate cancer LN metastasis is accompanied with smaller LN size and decreased LN reactivity suggesting the development of an immununosuppressive microenvironment.

Radical perineal prostatectomy and simultaneous extended pelvic lymph node dissection via the same incision

OBJECTIVES

Assess the feasibility of extended bilateral pelvic lymph node dissection (ePLND) in radical perineal prostatectomy (RPP) via the same incision under direct vision.

METHODS

In 90 consecutive patients with prostate cancer and a prostate-specific antigen level >10 ng/ml or a Gleason score >5 or more than two positive biopsies, RPP and ePLND via the same incision were performed in a prospective trial. After removing the prostate, the endopelvic fascia was opened with scissors and the bladder pushed medially. We performed an extended dissection along the obturator nerve, the external iliac vessels up to the ureter and along the internal iliac artery. Complications, number of nodes removed, and number of patients with tumour-positive nodes were recorded. Recovery of urinary continence and erectile function were assessed by a patient-reported questionnaire and the International Index of Erectile Function 5 questionnaire, respectively, administered preoperatively and at 1, 3, 6, and 12 mo.

RESULTS

We removed a mean and median number of 19 and 18.7 lymph nodes, respectively. Twelve patients had lymph node metastasis. Mean operation time was 149 min, including the complete learning curves of three surgeons. Seven lymphoceles but no major complications occurred. After 1, 3, 6, and 12 mo, 32 (36%), 50 (56%), 74 (82%), and 84 (93%) patients were completely dry, using no pads.

CONCLUSION

ePLND and RPP under direct vision via the same incision are feasible, efficient, and associated with a fast recovery of urinary continence and a low complication rate. Because lymphadenectomy needs no second access, the major disadvantage of RPP is resolved.

Current status of lymph node-positive prostate cancer: Incidence and predictors of outcome

In early surgical series, the incidence of positive lymph nodes in patients with prostate cancer was approximately 40%. In the modern era of screening and improved patient selection, the incidence is now <10%, although most series excluded patients with higher risk disease. The risk of having positive lymph nodes is influenced by disease stage, prostate-specific antigen level, and tumor grade and by the aggressiveness of lymph node dissection. Many of the same factors predict the outcome of these patients. Although the percentage of patients with positive lymph nodes has declined, there remain significant numbers of patients with lymph node-positive prostate cancer, and it remains a therapeutic dilemma.

The role of whole pelvic radiotherapy in locally advanced prostate cancer

Routine PSA testing has led to diagnosis and treatment of prostate cancer at earlier stages than previously. Earlier and technically-improved treatment, together with escalation of dose has enhanced cure rates. Although, the incidence of nodal metastases is now lower than in pre-PSA days, more extended pelvic lymphadenectomies have shown the actual rate of lymph node involvement to be higher than had been determined from standard radical prostate surgery. As in cancers in other sites, especially in their earlier stages, lymph node metastases may exist in the absence of haematogenous dissemination. This, together with the improved rates of control of the primary prostate tumour, suggests that elective irradiation of early-stage lymph nodes from prostate cancer should enhance survival in a manner analogous to improvements seen with this approach in other cancers. Although, the absolute incidence of positive nodes in locally advanced prostate cancer warrants elective radiotherapy, it is relatively low and the modest improvements to be expected may be undetected in the results of a small trial.

Treatment options in lymph node-positive prostate cancer

With improved awareness and screening, the incidence of lymph node-positive prostate cancer has declined dramatically over the last 50 years. Stage of cancer, prostate-specific antigen, and grade are risk factors for positive lymph nodes; and those factors, along with the number of involved lymph nodes, are prognostic factors for outcome. Although the numbers have declined, the number of men with lymph node-positive prostate cancer remains significant, and the current challenge is how best to treat these patients. Commonly used treatments include any combination of androgen ablation, surgery, and radiation. There have been a few studies with chemotherapy, and no treatment has been proven superior to the others. Consequently, there remain several reasonable alternatives to treatment, and long-term survival is not unusual.

Laparoscopic sentinel lymph node dissection--a novel technique for the staging of prostate cancer

OBJECTIVES

Pelvic lymph node metastases indicate a poor prognosis for prostate cancer patients. The aim of this study was to evaluate the suitability of laparoscopic radioisotope guided sentinel lymph node (SLN) dissection in staging of prostate carcinoma.

METHODS

28 patients with prostate cancer and intermediate or high risk for lymph node metastases considered for external beam radiotherapy underwent laparoscopic pelvic lymphadenectomy at our institution. For visualization of individual SLN distribution, an image fusion system consisting of a gamma-camera with integrated X-ray tube was used. During laparoscopic lymphadenectomy, SLN were identified using a laparoscopic gamma probe.

RESULTS

Preoperative imaging and laparoscopic gamma probe allowed an excellent delineation of SLN. 57% (preoperative imaging) as well as 48% (intraoperative measurements) of SLN were found outside the obturator fossa. All SLN were removed successfully without intra- or postoperative complications. Despite extended lymphadenectomy, no significant lymphocele appeared. 10 lymph node metastases were found in 7 out of the 31 patients (23%) with 3 of the 10 metastases lying outside the obturator fossa representing the standard lymphadenectomy area.

CONCLUSIONS

The present data demonstrate that laparoscopic SLN dissection is an excellent minimally invasive and technically feasible tool for staging of intermediate and high risk prostate cancer.

Positron emission tomography for prostate, bladder, and renal cancer

Prostate cancer, renal cancer, bladder, and other urothelial malignancies make up the common tumors of the male genitourinary tract. For prostate cancer, common clinical scenarios include managing the patient presenting with 1) low-risk primary cancer; 2) high-risk primary cancer; 3) prostate-specific antigen (PSA) recurrence after apparently successful primary therapy; 4) progressive metastatic disease in the noncastrate state; and 5) progressive metastatic disease in the castrate state. These clinical states dictate the appropriate choice of diagnostic imaging modalities. The role of positron emission tomography (PET) is still evolving but is likely to be most important in determining early spread of disease in patients with aggressive tumors and for monitoring response to therapy in more advanced patients. Available PET tracers for assessment of prostate cancer include FDG, 11C or 18F choline and acetate, 11C methionine, 18F fluoride, and fluorodihydrotestosterone. Proper staging of prostate cancer is particularly important in high-risk primary disease before embarking on radical prostatectomy or radiation therapy. PET with 11C choline or acetate, but not with FDG, appears promising for the assessment of nodal metastases. PSA relapse frequently is the first sign of recurrent or metastatic disease after radical prostatectomy or radiation therapy. PET with FDG can identify local recurrence and distant metastases, and the probability for a positive test increases with PSA. However, essentially all studies have shown that the sensitivity for recurrent disease detection is higher with either acetate or choline as compared with FDG. Although more data need to be gathered, it is likely that these two agents will become the PET tracers of choice for staging prostate cancer once metastatic disease is strongly suspected or documented. 18F fluoride may provide a more sensitive bone scan and will probably be most valuable when PSA is greater than 20 ng/mL in patients with high suspicion or documented osseous metastases. Several studies suggest that FDG uptake in metastatic prostate cancer lesions reflects the biologic activity of the disease. Accordingly, FDG can be used to monitor the response to chemotherapy and hormonal therapy. Androgen receptor imaging agents like fluorodihydrotestosterone are being explored to predict the biology of treatment response for progressive tumor in late stage disease in castrated patients. The assessment of renal masses and primary staging of renal cell carcinoma are the domain of helical CT. PET with FDG may be helpful in the evaluation of "equivocal findings" on conventional studies, including bone scan, and also in the differentiation between recurrence and posttreatment changes. The value of other PET tracers in renal cell carcinoma is under investigation. Few studies have addressed the role of PET in bladder cancer. Because of its renal excretion, FDG is not a useful tracer for the detection of primary bladder tumors. The few studies that investigated its role in the detection of lymph node metastases at the time of primary staging were largely disappointing. Bladder cancer imaging with 11C choline, 11C methionine, or 11C- acetate deserves further study.

[Prostate cancer: Diagnosis and staging]

The discovery and the use of serum prostate specific antigen (PSA) has considerably improved the diagnosis of prostate cancer during the past 20 years. Before PSA era, early diagnosis was only based on the digital rectal examination (DRE) of which the Limitations have been evidenced; over half of the tumours diagnosed by such means had already spread out of the prostate and were incurable. Assessment of serum PSA has allowed the diagnosis to be made at an earlier stage of the disease, curable by current treatments. Whichever the diagnostic tools, transrectal ultrasound (TRUS) prostatic biopsies remain necessary for diagnosis ascertainment, taking into account the low specificity of PSA assessment. The feasibility of a diagnosis at an early and curable stage of the disease has logically resulted in screening procedures aimed at reducing the high mortality related to prostate cancer. The numerous publications on prostate cancer screening provide precise information on the accuracy of available diagnostic means (PSA, DRE, TRUS, combined PSA and DRE), on the characteristics of screened tumours (stage and differentiation), and also on the population of men likely to benefit from the screening (age at beginning and end of the screening, frequency of PSA testing, identification of the men with ethnic and/or genetic predisposition). In those early diagnosed prostate cancers, the assessment of loco-regional cancer extension (extracapsular and/or, microscopic nodal involvement), remains unsatisfactory because no imaging technique (ultrasonography, CT scan, MRI,...) allows visualising the tumour itself or microscopic metastases. Nevertheless, the combination of multiple parameters such as DRE data, PSA level, biopsy data and tumour differentiation helps approaching with an increasing precision (nomograms) the true pathologic stage of the disease. Such advances allow distinguishing, among the very heterogeneous group of prostate cancers, tumours that differ from one to another in terms of disease stage, progression and prognosis, which is helpful for the determination of an adapted therapeutic strategy.

No difference in six-year biochemical failure rates with or without pelvic lymph node dissection during radical prostatectomy in low-risk patients with localized prostate cancer

OBJECTIVES

To compare differences in the actuarial biochemical relapse-free survival rates at 6 years in a contemporary series of patients who underwent radical prostatectomy with and without pelvic lymph node dissection (PLND). Biochemical failure was defined as a serum prostate-specific antigen level greater than 0.2 ng/mL confirmed at least 1 week later.

METHODS

The records of 806 consecutive radical prostatectomy cases performed between January 1995 and June 1999 were reviewed. A total of 336 patients with favorable tumor characteristics (prostate-specific antigen 10 ng/mL or less, biopsy Gleason score 6 or less, and clinical Stage T1 or T2) not receiving adjuvant or neoadjuvant therapy were divided into two groups according to whether PLND was performed (PLND group, n = 140) or omitted (no-PLND group, n = 196). A Cox proportional hazards model was used to analyze the effect of age, race, family history, initial prostate-specific antigen level, tumor stage, biopsy Gleason score, PLND, extracapsular extension, and seminal vesicle invasion on the likelihood of biochemical failure. Biochemical relapse-free survival for each group was estimated by Kaplan-Meier analysis. The mean follow-up time for the entire group was 60.0 months, with a similar follow-up for both cohorts (mean 61.8 and 58.2 months, respectively, P value not statistically significant). Follow-up information was obtained through an institutional review board-approved prospective patient registry.

RESULTS

The 6-year biochemical relapse-free rate for the PLND versus no-PLND group was 86% and 88%, respectively (P = 0.28). On multivariate analysis, PLND was not an independent predictor of outcome (P = 0.33).

CONCLUSIONS

Our study results demonstrated that the omission of PLND in patients with favorable tumor characteristics does not adversely affect biochemical relapse rates at 6 years after surgery. Such patients can be spared the morbidity and cost of PLND without affecting the chance for cure.

The Predictors of Pelvic Lymph Node Metastasis at Radical Retropubic Prostatectomy

PURPOSE

We studied preoperative variables in a contemporary series of patients who underwent radical retropubic prostatectomy (RRP) to determine which variables were associated with lymph node metastasis.

MATERIALS AND METHODS

Between January 1995 and November 1999, 1,091 men underwent RRP, 695 of whom underwent bilateral pelvic lymph node dissection without any prior therapy. We evaluated biopsy Gleason score, maximum tumor length and maximum percentage of tumor in the positive core(s), location and number of positive cores, and total prostate specific antigen before surgery in 295 of these patients. We also developed a classification and regression tree analysis algorithm to segregate the risk of positive lymph node metastasis. Stepwise logistic regression analyses were used to determine independent predictors of lymph node metastasis.

RESULTS

Of the 695 patients 19 (2.7%) had lymph node metastasis. Clinical stage, Gleason score, positive basal core, greatest percentage of tumor on positive cores and maximum tumor length in positive core were significant predictors of lymph node metastasis in the Mann-Whitney U test and chi-square test. Classification and regression trees analysis revealed that 4 or more positive cores with any Gleason grade 4 or 5, serum prostate specific antigen 15.0 ng/ml or greater, or the presence of dominant Gleason 4 or 5 were independent predictors of lymph node metastasis. Our algorithm had a significantly higher diagnostic performance than the Hamburg algorithm (p = 0.002).

CONCLUSIONS

Our algorithm may be a valid tool for the prediction of lymph node metastasis and may help to select men who do not need to undergo bilateral pelvic lymph node dissection with RRP.

Radical perineal prostatectomy: a novel approach for lymphadenectomy from perineal incision

PURPOSE

A major disadvantage of radical perineal prostatectomy is that lymphadenectomy cannot be performed through the same incision. We developed a novel approach to access the obturator and internal iliac lymph nodes, partially the external iliac lymph nodes, via the perineal incision. We describe the method of lymphadenectomy.

MATERIALS AND METHODS

After moving the rectum off of the prostate we separate the levator ani muscle and endopelvic fascia from the lateral prostate with finger dissection. A trocar mounted balloon distention device is inserted toward this space and distended with 200 cc air to create an intrapelvic space. Using several retractors or laparoscopy for viewing we first identify the obturator nerve and then the external iliac vessels next in order of depth. By retracting the obturator nerve with vessel tape we perform lymph node dissection between the obturator nerve and external iliac vessels under direct vision or laparoscopic guidance.

RESULTS

We have performed this technique in 20 consecutive patients because of prostate specific antigen greater than 10 ng/ml, Gleason score greater than 7 or bilateral disease. Bilateral lymph node dissection required 15 to 20 minutes. No major bleeding or complications occurred. The number of nodes was similar to that in our retropubic prostatectomy series because of the limited lymphadenectomy that we usually performed. Fecal incontinence and potency results were almost the same as in patients without lymphadenectomy. Although urinary continence was not good at catheter removal on day 7, patients became dry in 1 to 6 months.

CONCLUSIONS

This method resolves the major disadvantage of perineal prostatectomy. Radical perineal prostatectomy with lymphadenectomy via the same incision is feasible and reproducible.

Randomized prospective evaluation of extended versus limited lymph node dissection in patients with clinically localized prostate cancer

PURPOSE

The low rate of pelvic node metastasis in most contemporary series of patients undergoing radical prostatectomy for carcinoma of the prostate has been attributed to earlier and better patient selection than historical series. Alternatively, it has been suggested that the limited dissection commonly performed misses nodal metastasis in a substantial number of patients. To assess the value of an extended node dissection in detecting nodal metastasis, we performed a randomized prospective study.

MATERIALS AND METHODS

A total of 123 patients undergoing radical prostatectomy were randomized to an extended node dissection on the right versus the left side of the pelvis with the other side being a limited dissection. The extended dissection included removal of all external iliac nodes to a point above the bifurcation of the common iliac artery, the obturator nodes and the presacral nodes. The limited dissection included only the nodes along the external iliac vein and obturator nerve.

RESULTS

Mean patient age was 61 years. Clinical stage was T1c in 88 patients (72%), T2a in 26 (21%), T2b in 7 (6%) and T3 in 2 (1%). Mean preoperative prostate specific antigen was 7.4 ng./ml. Pelvic lymph node metastasis was histologically confirmed in 8 patients (6.5%). Positive nodes were found on the side of the extended dissection in 4 patients, on the side of the limited dissection in 3 and on both sides in 1. Complications possibly attributable to the node dissection included lymphocele in 4 patients, lower extremity edema in 5, deep venous thrombosis in 2, ureteral injury in 1 and pelvic abscess in 1. These complications occurred 3 times more often on the side of the extended dissection (p = 0.08).

CONCLUSIONS

Extended node dissection in contemporary series of patients undergoing radical prostatectomy identifies few with nodal metastases not found by a more limited dissection. A trend toward an increased risk of complications attributable to the lymphadenectomy occurs with an extended dissection.

Is a limited lymph node dissection an adequate staging procedure for prostate cancer?

PURPOSE

Generally lymph node dissection is only considered a staging procedure for prostate cancer. Therefore, the need for meticulous lymph node dissection is often questioned and only sampling is suggested. We performed a prospective study to identify the pattern of lymph node metastasis in prostate cancer and determine how extensive lymph node dissection must be not to under stage cases.

MATERIALS AND METHODS

All patients with clinically organ confined prostate cancer, no prior hormonal treatment, negative preoperative staging computerized tomography and bone scan, who underwent radical prostatectomy between 1989 and 1999, were evaluated prospectively as to the number and location of lymph node metastasis. A meticulous lymph node dissection was performed along the external iliac vein, obturator nerve and internal iliac (hypogastric) vessels. Nodes from each location and side were submitted separately for histological evaluation.

RESULTS

In 365 patients with a median serum prostate specific antigen of 11.9 ng./ml. (range 0.4 to 172) the median number of nodes removed was 21 (range 6 to 50). Lymph nodes were positive in 88 (24%) patients and the median number of positive nodes was 2 (range 1 to 19). Internal iliac lymph nodes were positive in 51 (58%) of the 88 patients, including 34 with additional positive lymph nodes along the external iliac vein and/or obturator nerve. Internal iliac lymph nodes alone were positive in 17 (19%) of 88 patients.

CONCLUSIONS

There were significant numbers of lymph node metastases at all 3 different areas of lymphadenectomy. Positive lymph nodes were found along the internal iliac artery in more than half (58%) of the patients and exclusively in 19%. Therefore, we consider lymph node dissection along the internal iliac (hypogastric) vessels essential for representative staging. Without this dissection a fifth of node positive cases would have been under staged and diseased nodes would have remained in more than half of the cases.

[Non-metastatic prostate cancer treated with exclusive radiotherapy: prognosis of patients according to lymph node radiologic or surgical assessment method. Multivariate retrospective analysis]

PURPOSE

To compare retrospectively the outcome of localized prostate cancers treated by curative external radiotherapy in which the negative lymphatic status was either surgically or radiologically assessed.

METHODS AND MATERIALS

From January 1986 to December 1995, 112 patients with localized prostate cancers were found to have no evidence of lymphatic disease in the pelvis. N0 status was assessed either surgically (61 patients, group pN-) or after a CT scan procedure (51 patients, group cN0). The treatment consisted of conventional external radiotherapy using a four-fields box technique to a total dose of 65 Gy. The pelvis was never irradiated.

RESULTS

The two groups did not statistically differ according to age, PSA level, Gleason score, T stage and hormonal therapy. Actuarial NED survival rates were 80% and 60% at five and ten years respectively. At ten years, the actuarial NED survival rates were 78% and 34% in the pN- and cN0 groups respectively (p = 0.003). The multivariate analysis corroborated the positive impact of lymphatic dissection before radiotherapy on disease free survival of T1-T2 patients, but not for T3 stages.

CONCLUSIONS

This retrospective study suggests the inability of CT scan to accurately evaluate the lymph node status in carcinoma of the prostate. Systematic ilio-obturator nodal dissection is strongly recommended in early stages before curative radiotherapy. Only pN-patients should be included in high dose conformal irradiation trials.

Should laparoscopy be the standard approach used for pelvic lymph node dissection?

Involvement of the pelvic lymph nodes in patients with prostate cancer worsens the overall prognosis of this common disease entity. Prior radiographic staging techniques, including fine-needle aspiration, are limited by a poor sensitivity and are not reliable. The gold standard for the evaluation of pelvic lymph nodes in men with prostate cancer involves performing a lymphadenectomy. Historically, this procedure was performed using an open surgical technique. Unfortunately, this invasive procedure is associated with significant morbidity. In response, modern surgical technology has provided newer, less invasive techniques, including laparoscopic pelvic lymphadenectomy (LPLND). Improved detection of localized prostate cancer through the institution of screening protocols and early detection programs has decreased the number of patients presenting with lymph node involvement. Various clinical indicators, including prostate-specific antigen, grade, and stage, have been used to improve the selection of "high-risk" patients that are appropriate candidates for pelvic lymph node dissection. The technique of LPLND is a valid option in the armamentarium for staging of prostate cancer. The laparoscopic approach provides the same staging accuracy as the open surgical technique and is superior with respect to morbidity. LPLND is limited to patients who present with a high risk of advanced prostate cancer. In addition, the urologist must accept the additional training, financial expense, and "learning curve" associated with this technique.

Volume-weighted mean nuclear volume predicts tumor biology of clinically organ-confined prostate cancer

BACKGROUND

Estimates of volume-weighted mean nuclear volume (MNV) are the only means by which unbiased estimates of three-dimensional parameters can be obtained from a single two-dimensional section, with stereological methods. The present study was conducted to elucidate the role of MNV in predicting tumor biology for patients treated with radical prostatectomy.

METHODS

A retrospective prognostic study of 71 patients with T1/T2 disease, treated with radical prostatectomy alone, was performed. MNV was estimated using biopsy specimens based on a stereological method, and was compared with other preoperative clinical variables. For patients with prostate-specific antigen (PSA) failure, we determined the correlation of MNV with PSA doubling time (PSA DT) which was calculated using PSA values obtained with an ultrasensitive assay.

RESULTS

Mean MNVs for pathologically organ-confined and non-organ-confined tumors were 198.9 and 236.3 microm3, respectively; this difference was significant (P = 0.0364). Univariate analysis showed that PSA, MNV, and Gleason score were significant predictors of prognosis (P = 0.0126, 0.0148, and 0.0375, respectively). Multivariate analysis revealed that MNV and preoperative PSA were powerful independent predictors of prognosis (P = 0.0160 and P = 0.0147, respectively), but the Gleason score was not correlated with prognosis (P = 0.4120). For patients with PSA failure, PSA DT was significantly correlated with MNV (r = -0.597, P = 0.0099). When these patients were classified using median PSA DT at 6 months into two groups, MNV was significantly greater in PSA rapid-riser group than in the slow-riser group (P = 0.0008), but no differences were observed between these groups in PSA, the Gleason score, or cancer volume.

CONCLUSIONS

The findings of the present study suggest that MNV is a powerful predictor of PSA failure for patients with clinically organ-confined disease treated with radical prostatectomy. More importantly, they suggest that MNV can be a useful new parameter for prediction of tumor biology for patients with PSA failure after radical prostatectomy.

Per-operative frozen section examination of pelvic nodes is unnecessary for the majority of clinically localized prostate cancers in the prostate-specific antigen era

BACKGROUND

The incidence of unsuspected lymph node metastasis seems to be decreasing in the prostate-specific antigen (PSA) era. It remains controversial as to whether routine pelvic lymph node dissection and per-operative frozen section examination should be performed. In addition, it is still unclear whether an aggressive approach to local disease by surgery or irradiation confers survival benefits on stage D1 patients.

METHODS

Eighty-eight consecutive patients with clinically localized prostate cancer who underwent pelvic lymph node dissection prior to radical prostatectomy during the period between 1985 and 1998 were analyzed. The incidence of lymph node metastases after 1992 was compared with that before 1992. Sensitivity and specificity of frozen section examination was assessed. Progression-free survival and cause-specific survival curves of node-positive patients who underwent radical prostatectomy were estimated by the Kaplan-Meier method.

RESULTS

Six of 17 patients (35.3%) treated before 1992 and five of 71 patients (7.0%) treated after 1992 showed unsuspected lymph node metastasis (P = 0.0059). Eight of 11 node-positive patients underwent radical prostatectomy and two have so far demonstrated clinical progression and cancer death with a median follow-up period of 63 months. The 5 year progression-free rate and the cause-specific survival rate for these patients were 71.4 and 85.7%, respectively. Sensitivity of frozen section examination for micrometastasis and gross-metastasis cases, respectively, was 3/6 (50%) and 4/4 (100%), while specificity was 85/85 (100%).

CONCLUSIONS

The incidence of unsuspected lymph node metastases has been significantly decreased in the PSA era. Frozen section examination of pelvic nodes can be omitted and radical prostatectomy is an acceptable choice of treatment in patients without macroscopically apparent nodal metastases.

No difference in biochemical failure rates with or without pelvic lymph node dissection during radical prostatectomy in low-risk patients

OBJECTIVES

To detect the short-term differences in biochemical relapse-free rates between patients with and without pelvic lymph node dissection (PLND). Recently, a trend has begun to omit PLND in patients undergoing radical prostatectomy considered at low risk of pelvic lymph node metastases.

METHODS

The records of 1152 consecutive radical prostatectomy cases were reviewed. A total of 575 patients with favorable tumor characteristics (prostate-specific antigen [PSA] 10 ng/mL or less, Gleason score 6 or less, and clinical Stage T1 or T2) who were not receiving adjuvant or neoadjuvant therapy were divided into two groups according to whether PLND was performed (PLND group, n = 372) or omitted (no PLND group, n = 203). Proportional hazards were used to analyze the effect of age, race, family history, stage, biopsy Gleason score, initial PSA, PLND, and pathologic findings on the likelihood of biochemical failure. Biochemical failure-free survival for each group was estimated by Kaplan-Meier analysis. The mean follow-up was 38 months (range 1 to 141).

RESULTS

The actuarial 4-year biochemical relapse-free rate for the PLND versus no PLND groups was 91% and 97%, respectively (P = 0.16). On multivariate analysis, PLND was not an independent predictor of outcome (P = 0.24).

CONCLUSIONS

The results of our study indicate that the omission of PLND in patients with favorable tumor characteristics does not adversely affect biochemical relapse rates.

Salvage radical prostatectomy after radiation therapy and brachytherapy

Local recurrence after any type of radiation therapy presents the clinician with a significant challenge. If there is no evidence of metastatic disease, patients can be offered a potentially curative salvage prostatectomy. To qualify for such surgery, patients should be at least 12 months from the completion of radiation and have at least a 10-year life expectancy; ideally, they will have a serum prostate specific antigen concentration <10 ng/mL and a Gleason score of 7 or less. Perioperative complications are substantial, with urinary incontinence rates of 40% to 50% and rectal injury rates of 10% to 15%. Long-term disease-free survival rates of 30% to 40% can be expected.

The use of artificial intelligence technology to predict lymph node spread in men with clinically localized prostate carcinoma

BACKGROUND

The current study assesses artificial intelligence methods to identify prostate carcinoma patients at low risk for lymph node spread. If patients can be assigned accurately to a low risk group, unnecessary lymph node dissections can be avoided, thereby reducing morbidity and costs.

METHODS

A rule-derivation technology for simple decision-tree analysis was trained and validated using patient data from a large database (4,133 patients) to derive low risk cutoff values for Gleason sum and prostate specific antigen (PSA) level. An empiric analysis was used to derive a low risk cutoff value for clinical TNM stage. These cutoff values then were applied to 2 additional, smaller databases (227 and 330 patients, respectively) from separate institutions.

RESULTS

The decision-tree protocol derived cutoff values of < or = 6 for Gleason sum and < or = 10.6 ng/mL for PSA. The empiric analysis yielded a clinical TNM stage low risk cutoff value of < or = T2a. When these cutoff values were applied to the larger database, 44% of patients were classified as being at low risk for lymph node metastases (0.8% false-negative rate). When the same cutoff values were applied to the smaller databases, between 11 and 43% of patients were classified as low risk with a false-negative rate of between 0.0 and 0.7%.

CONCLUSIONS

The results of the current study indicate that a population of prostate carcinoma patients at low risk for lymph node metastases can be identified accurately using a simple decision algorithm that considers preoperative PSA, Gleason sum, and clinical TNM stage. The risk of lymph node metastases in these patients is < or = 1%; therefore, pelvic lymph node dissection may be avoided safely. The implications of these findings in surgical and nonsurgical treatment are significant.

Evaluation of a decision-support system for preoperative staging of prostate cancer

The usefulness and effectiveness of a decision-support system for preoperative staging of prostate cancers (PCES) were evaluated. The study population consisted of 43 consecutive patients with the preoperative diagnosis of prostate cancer who underwent surgical operation. Results obtained using the PCES were compared with staging by four urology attending physicians and five urology residents. The effect of PCES consultation on the physicians' staging of prostate cancer was also evaluated. To confirm the usefulness of the clinical findings of prostate-specific antigen, prostate-specific antigen density, prostate volume, and abnormal Gleason score in the PCES, their receiver operating characteristic (ROC) curves for diagnosis of advanced prostate cancer were plotted. The values of the areas under the curves were 0.772, 0.800, 0.531, and 0.752. The stage of prostate cancer was correctly determined by the PCES for 38 of the 43 patients, yielding 88.4% preoperative diagnostic accuracy. The PCES was significantly more accurate than two of the attending physicians and all residents. PCES consultation improved the residents' staging accuracy to approximately that of the attending physicians. The effect of PCES consultation on the residents' staging was significantly (p < 0.001) greater than the effect on the physicians' staging. The PCES may be useful in the preoperative staging of prostate cancers, especially during residency. The system's accuracy in determining the stage of advanced prostate cancer may make it possible to avoid unneccesary surgical operations.

Incidence of lymph node metastasis and its impact on long-term prognosis in clinically localized prostate cancer

BACKGROUND

Pelvic lymph node dissection (PLND) is an important staging method for men with clinically localized prostate cancer. We report our experience with staging PLND and the impact of lymph node metastasis on long-term prognosis.

METHODS

One hundred forty-eight consecutive patients who underwent staging PLND for clinically localized prostate cancer were retrospectively studied. Patients were evaluated for the presence and number of lymph node metastases, treatment (prostatectomy vs. radiotherapy), and endocrine therapy, and analyzed with respect to disease progression and survival. The mean follow-up period was 52.9 months (range, 2.3 to 165.8 months).

RESULTS

Thirty-two patients (21.6%) had pelvic lymph node metastases, the incidence of which markedly decreased from 32.3% in 1982 to 1987 to 6.7% in 1994 to 1997. The intervals to disease progression and cancer death were significantly shorter in patients with positive lymph nodes (P < 0.001). In stage D1 disease, patients who underwent a radical prostatectomy tended to be free of progression longer than those receiving radiotherapy or conservative therapy (P = 0.0546). Other factors, such as early endocrine therapy, the extent of lymph node involvement and the Gleason score of the primary tumor did not predict disease progression or survival.

CONCLUSION

These data suggest a decreasing trend in the incidence of lymph node metastasis in the PSA era. Although longer disease-free intervals were observed in radical prostatectomy-treated patients, the impact of an aggressive approach to stage D1 disease awaits further studies.

Systematic sextant biopsies improve preoperative prediction of pelvic lymph node metastases in patients with clinically localized prostatic carcinoma

PURPOSE

An algorithm including the results of systematic sextant biopsies was statistically developed and evaluated to predict the probability of pelvic lymph node metastases in patients with clinically localized carcinoma of the prostate.

MATERIALS AND METHODS

Clinical stage, serum prostate specific antigen concentration, Gleason score, number of positive biopsies, number of biopsies containing any Gleason grade 4 or 5 cancer and number of biopsies predominated by Gleason grade 4 or 5 cancer were recorded in 345 patients undergoing pelvic lymph node dissection and correlated with the incidence of lymph node metastases. Multivariate logistic regression, and classification and regression trees analyses were performed.

RESULTS

In univariate analysis all variables had a statistically significant influence on lymph node status. Logistic regression showed that the amount and distribution of undifferentiated Gleason grade 4 and 5 cancer in the biopsies were the best predictors of lymphatic spread followed by serum prostate specific antigen. Classification and regression trees analysis classified 79.9% of patients who had 3 or fewer biopsies with Gleason grade 4 or 5 cancer and no biopsies predominated by undifferentiated cancer as a low risk group. In this group positive lymph nodes occurred in only 2.2% (95% confidence interval 0.8 to 4.7%).

CONCLUSIONS

Including the results of systematic sextant biopsies substantially enhances the predictive accuracy of algorithms that define the probability of lymph node metastases in prostatic cancer. Patients thus defined as having no lymphatic spread could potentially be spared pelvic lymph node dissection before definitive local treatment.

Lymphangiography combined with biopsy and computer tomography to detect lymph node metastases in localized prostate cancer

To evaluate the efficacy of lymphangiography combined with fine needle aspiration biopsy and computer tomography (CT) for lymph node staging in clinically localized prostate cancer. Prospective evaluation of nodal involvement was carried out using standard bipedal lymphangiography combined with fine needle aspiration biopsy (FNAB) in 70 patients (aged 47 to 75 years, mean age 63 years) with apparently locally confined prostate cancer before intended radical prostatectomy. Sixty-four patients also underwent computer tomography. Seventeen withdrew the decision to undergo a radical prostatectomy, leaving 53 patients with pathologic examination of the lymph nodes eligible for analysis. Lymph node metastases were diagnosed in 8 patients (8/53 = 15.1%). Three were diagnosed preoperatively by FNAB, 3 peroperatively by lymph node dissection and frozen section biopsy and an additional 2 at the final pathologic assessment. The sensitivity, specificity, positive and negative predictive values for lymphangiography and lymphangiography combined with FNAB in predicting nodal disease, based on the analysis of the 53 patients with known pathologic results, were 0.63, 0.76, 0.31, 0.92 and 0.38, 1.00, 1.00, 0.90, respectively. The corresponding values for CT staging were 0.25, 0.98, 0.67 and 0.87, respectively. The efficacy of bipedal lymphangiography alone or combined with FNAB or CT alone for assessment of nodal metastases is too low to be worthwhile for lymph node staging in localized prostate cancer patients with expected low or intermediate probability of nodal disease.

Results of laparoscopic pelvic lymphadenectomy in patients at high risk for nodal metastases from prostate cancer

BACKGROUND

Laparoscopic pelvic lymphadenectomy (LPLND) can be performed safely and with minimal morbidity in the staging of prostate cancer. Its utility in evaluating patients at high risk for metastatic disease before primarily nonsurgical treatment modalities was evaluated.

METHODS

Twenty-four consecutive patients who underwent LPLND between June 1993 and July 1996 were studied. These patients were considered poor surgical candidates based on several risk factors, as follows: elevation of serum PSA >20 in 19 patients (79%); elevation of serum acid phosphatase in 4 patients (17%); digital rectal examination findings indicative of extraprostatic extension or seminal vesical involvement in 14 patients (58%); and poorly differentiated tumors on prostate biopsy in 19 patients (79%). Nineteen patients (79%) had two or more of these risk factors. Median PSA for the entire series of patients was 35.2 ng/mL (range 7.9 to 133 ng/mL), and median Gleason score was 7 (range 5 to 9). Preoperative CT or MRI was negative for pelvic lymph node metastases in 17 of 23 patients (79%), and bone scan was negative in all 24 patients.

RESULTS

Unilateral (n = 2) or bilateral (n = 22) LPLND was performed in all patients. Six patients (25%) had lymph node metastases detected laparoscopically. Five of the six patients had palpable extraprostatic extension (T3a/b) or invasion of a seminal vesical (T3c), and in four of these patients the site of the metastatic lymph nodes was ipsilateral to the palpable prostate abnormality. None of the risk factors was independently predictive of lymph node metastases within this series of patients. An average of 10.8 +/- 6.5 lymph nodes was removed at a mean operative time of 174 +/- 10 minutes for patients undergoing bilateral LPLND. Estimated blood loss was minimal for 20 of 22 patients (92%) undergoing LPLND alone, and there were no complications requiring open exploration. Mean postoperative hospital stay was 1.2 +/- 0.5 days for patients undergoing LPLND alone.

CONCLUSIONS

LPLND can be used efficiently to identify patients with nodal metastases from select high-risk patients. This, in turn, can exclude such patients from noncurative local and regional therapy.