Indications, Extent, and Benefits of Pelvic Lymph Node Dissection for Patients with Bladder and Prostate Cancer

Serum extracellular vesicles derived hsa-miR-320d as an indicator for progression of clear cell renal cell carcinoma

BACKGROUND

Renal cell carcinoma (RCC) is a prevalent malignancy with a rising incidence in developing countries. Clear cell renal cell carcinoma (ccRCC) constitutes 70% of RCC cases and is prone to metastasis and recurrence, yet lacks a liquid biomarker for surveillance. Extracellular vesicles (EVs) have shown promise as biomarkers in various malignancies. In this study, we investigated the potential of serum EV-derived miRNAs as a biomarker for ccRCC metastasis and recurrence.

MATERIALS AND METHODS

Patients diagnosed with ccRCC between 2017 and 2020 were recruited in this study. In the discovery phase, high throughput small RNA sequencing was used to analyze RNA extracted from serum EVs derived from localized ccRCC (LccRCC) and advanced ccRCC (AccRCC). In the validation phase, qPCR was employed for quantitative detection of candidate biomarkers. Migration and invasion assays were performed on ccRCC cell line OSRC2.

RESULTS

Serum EVs derived hsa-miR-320d was significantly up-regulated in patients with AccRCC than in patients with LccRCC (p < 0.01). In addition, Serum EVs derived hsa-miR-320d was also significantly up-regulated in patients who experienced recurrence or metastasis (p < 0.01). Besides, hsa-miR-320d enhances the pro-metastatic phenotype of ccRCC cells in vitro.

CONCLUSIONS

Serum EVs derived hsa-miR-320d as a liquid biomarker exhibits significant potential for identifying the recurrence or metastasis of ccRCC, as well as hsa-miR-320d promotes ccRCC cells migration and invasion.

Contemporary use trends and effect on survival of pelvic lymph node dissection for non-muscle-invasive bladder cancer

Background

Patients diagnosed with non-muscle-invasive bladder cancer (NMIBC) who are at a very high risk of disease progression and failure of Bacillus Calmette-Guerin treatment are recommended to undergo immediate radical cystectomy (RC). The role and optimal degree of pelvic lymph node dissection (PLND) during RC for NMIBC patients, however, have not been well investigated.

Patients and methods

The Surveillance, Epidemiology, and End Results (SEER) database was used to identify patients. Overall survival (OS) was assessed with the Kaplan–Meier technique. Multivariable Cox regression analysis was conducted to determine independent factors of OS.

Results

A total of 1,701 patients were identified in the SEER database from 2004 to 2015. Any level of PLND (>0 lymph nodes examined) was performed in 1,092 patients (64.2%). The median number of lymph nodes examined was 8 (interquartile range, 0–20) in T1, 0 (interquartile range, 0–11) in Ta, and 0 (interquartile range, 0–14) in Tia patients. Compared with non-PLND, any level of PLND improved OS in T1 but not in Ta or Tis patients. Compared to limited (1–9 lymph nodes examined) and non-PLND, extensive PLND (lymph nodes examined ≥10) resulted in better OS only in T1 patients (all p < 0.001, adjusted significance level = 0.017). PLND was identified as a independent protective factor for OS.

Conclusion

Based on the SEER database, we found that PLND during RC led to better OS and extensive PLND was associated with better OS in T1 but not in Ta or Tis patients. The implementation of PLND was insufficient both in population proportions and scope.

Effect of lymph node dissection on stage-specific survival in patients with upper urinary tract urothelial carcinoma treated with nephroureterectomy

Background

We aimed to estimate the stage-specific impact of lymph node dissection (LND) on survival for upper urinary tract urothelial carcinoma (UTUC) patients treated with nephroureterectomy (NU).

Methods

Overall, 7278 UTUC patients undergoing NU within the SEER database from 2004 to 2015 were identified. Kaplan-Meier plots illustrated overall survival (OS) and cancer-specific survival (CSS) rates according to LND status. Multivariable Cox regression analyses assessed the effect of LND on OS and CSS rates stratified by pathological tumor stage.

Results

LND was performed in 26.9% of patients, and in 18.6, 23.3, 31.2 and 45.9% for pT1, pT2, pT3 and pT4 patients, respectively (P <  0.001). In multivariable Cox regression analyses, LND was associated with a higher OS or CSS in UTUC patients with pT3 and pT4 disease (all P <  0.05), but failed to achieve independent predictor status in patients with pT1 and pT2 disease (all P > 0.05). LND with 1 to 3 regional lymph nodes removed was prone to a higher OS or CSS only in pT4 compared to no LND (both P <  0.01). LND with 4 or more regional lymph nodes removed predisposed to a higher OS or CSS in pT3 or pT4 (all P <  0.05).

Conclusions

The beneficial effect of LND especially LND with 4 or more regional lymph nodes removed on survival was evident in pT3/4 patients. LND can be considered for pT3 and pT4, for pT1/2 remains to be seen, both of which will be verified by further prospective studies.

Increased Paxillin expression in prostate cancer is associated with advanced pathological features, lymph node metastases and biochemical recurrence

Purpose Paxillin regulates cell-cell adhesion, and altered Paxillin expression has been associated with human carcinogenesis. This study analyzed the association between Paxillin expression in prostate cancer (PCa) tissues with clinicopathological features, lymph node metastasis and biochemical PCa recurrence.

Methods A total of 386 tissue specimens from PCa patients who received radical prostatectomy and 60 tissue specimens from benign prostatic hyperplasia (BPH) cases were collected to construct tissue microarrays, which were subsequently immunostained for Paxillin expression. Thirty positive lymph node tissue specimens and 10 healthy prostate tissue specimens were randomly selected for Paxillin immunostaining.

Results The association between Paxillin expression, lymph node metastasis and biochemical PCa recurrence was analyzed. Paxillin expression was significantly higher in PCa than both normal and BPH tissues (P<0.001) and was correlated with preoperative prostate-specific antigen level, Gleason score, clinical tumor stage, lymph node metastasis, positive surgical margin, extracapsular extension and seminal vesicle invasion (P<0.05 for all). Logistic regression analysis showed that Paxillin and Gleason score were independent risk factors for PCa lymph node metastasis (P<0.05). The receiver operating characteristic (ROC) curve indicated that Paxillin expression (AUC=0.723) more accurately predicted PCa lymph node metastasis than Gleason score (AUC=0.692). Kaplan-Meier curve analysis showed that increased Paxillin expression was associated with shortened biochemical-free survival (BFS) after radical prostatectomy (P<0.001).

Conclusion Paxillin was significantly upregulated in PCa compared with BPH and normal tissues and associated with lymph node metastasis and shortened BFS of PCa. Further study will investigate the underlying molecular mechanism and the role of Paxillin in PCa.

Upregulation of Talin-1 expression associates with advanced pathological features and predicts lymph node metastases and biochemical recurrence of prostate cancer

Talin-1 functions to regulate cell-cell adhesion, and its altered expression was reported to be associated with human carcinogenesis.A total of 280 tissue specimens from prostate cancer (PCa) patients who underwent radical prostatectomy, 75 cases of benign prostatic hyperplasia (BPH) tissue, and 6 cases of normal prostate tissue specimens were collected for construction of tissue microarray and subsequently subjected to immunohistochemical staining of Talin-1 expression.Talin-1 expression was significantly higher in PCa than both normal and BPH tissues (P <0.001). Talin-1 expression in PCa tissues was associated with preoperative prostate-specific antigen (PSA) level, Gleason score, tumor stage, lymph node metastasis, positive surgical margin, extracapsular extension and seminal vesicle invasion (all P <0.05). Logistic regression analysis showed that Talin-1 and Gleason score were independent risk factors for lymph node metastasis of PCa (P <0.001). Receiver operating characteristic (ROC) curve indicated that Talin-1 expression (AUC = 0.766) had a better accuracy to predict PCa lymph node metastasis than Gleason score (AUC = 0.697), whereas their combination could further enhance the prediction accuracy (AUC = 0.803). Kaplan-Meier curve analysis showed that increased Talin-1 expression was associated with shortened biochemical-free survival of PCa patients after radical prostatectomy (P <0.001).These findings suggested that Talin-1 protein was significantly upregulated in PCa tissues compared with that of BPH tissue and Talin-1 expression was an independent predictor for lymph node metastasis and biochemical recurrence of PCa. Further study will investigate the underlying molecular mechanism and the role of Talin-1 in PCa.

The role of extended pelvic lymphadenectomy with radical prostatectomy for high-risk prostate cancer

INTRODUCTION

The role of pelvic lymph node dissection (PLND) during radical prostatectomy (RP) for prostate cancer (PCa) is controversial. Despite extensive research in both patterns of lymphatic drainage and the clinical effect of lymph node involvement, the exact role of PLND in PCa is yet to be defined.

METHODS

A systematic search of the MEDLINE database was performed, and all relevant articles were reviewed in depth.

RESULTS

We included 84 relevant articles in our review and subdivided the information into the following categories: preoperative patient evaluation, procedure/extent of dissection, complications, and robotic surgery era. Most authors agree that the greatest benefit is seen in patients with high-risk PCa undergoing RP. Multiple imaging modalities have been evaluated for assistance in patient selection, but the use of preoperative nomograms appears to be the most helpful selection tool. The role of limited PLND vs. extended PLND (e-PLND) is yet to be defined, though many authors agree that e-PLND is preferred in the setting of high-risk PCa. Although PLND is associated with a higher incidence of complications, especially lymphocele formation, it is unclear whether e-PLND leads to more complications than limited PLND. The introduction of minimally invasive surgery may have had a negative effect on implementation of PLND in the appropriate patients undergoing RP.

CONCLUSION

Despite a lack of prospective, randomized trials evaluating PLND in RP, there does appear to be a consistent benefit in patients with high-risk disease.

Lymphotropic nanoparticle-enhanced MRI in prostate cancer: value and therapeutic potential

Nodal staging in prostate cancer is suboptimal both with respect to current imaging modalities and pelvic lymph node dissection, and thus other techniques are being explored. Lymphotropic nanoparticle-enhanced MRI, also called magnetic resonance lymphography (MRL), is a technique that has shown high sensitivity (65-92 %) and excellent specificity (93-98 %) in detecting prostate cancer lymph node metastases. This technique aids in the detection of metastases in non-enlarged small nodes. MRL has been useful in determining the location and pathways of spread in nodal chains. Knowledge of the location of lymph node involvement is important for decisions regarding appropriate therapeutic options, such as image-guided therapy.. A geographic miss in radiotherapy can be avoided with the use of MRL-guided focal therapy. This paper provides an overview of current literature, lessons learned, and new therapeutic options with nanoparticle-enhanced MRI.

National trends in the utilization of robotic-assisted radical cystectomy: an analysis using the Nationwide Inpatient Sample

OBJECTIVES

To determine temporal and regional trends in utilization of robotic-assisted radical cystectomy (RARC) in the United States and to explore factors associated with utilization of robotic assistance.

MATERIALS AND METHODS

Using 2009 to 2011 data from the Nationwide Inpatient Sample, we identified radical cystectomy cases that were performed using either open or robotic assistance and applied Nationwide Inpatient Sample discharge weights to determine national incidence. Univariable and multivariable logistic regressions were performed to assess regional trends and characteristics associated with having RARC. Descriptive analysis was performed using the chi-square test, the Student t test, and the Mann-Whitney U test.

RESULTS

Of the 29,719 radical cystectomy patients, 3,733 were RARC (12.6%). Although there was no change in the proportion of RARC performed annually (P = 0.702). Length of stay was 1 day longer for open cystectomy than RARC (P<0.001). On multivariate regression, patients whose primary payer was Medicaid were less likely than private insurance patients to undergo RARC (odds ratio = 0.60, P = 0.074). Additionally, patients in the south were at 50% reduced odds of undergoing RARC (odds ratio = 0.49, P = 0.044). Median hospital costs were $5,000 greater for RARC (P<0.001).

CONCLUSIONS

Regional variation in utilization should be monitored to ensure equal access to new technology and to assess potential overuse of new technology. Although RARC is associated with higher median hospital costs, further studies to assess its benefits are warranted.

Molecular and functional imaging for detection of lymph node metastases in prostate cancer

Knowledge on lymph node metastases is crucial for the prognosis and treatment of prostate cancer patients. Conventional anatomic imaging often fails to differentiate benign from metastatic lymph nodes. Pelvic lymph node dissection is an invasive technique and underestimates the extent of lymph node metastases. Therefore, there is a need for more accurate non-invasive diagnostic techniques. Molecular and functional imaging has been subject of research for the last decades, in this respect. Therefore, in this article the value of imaging techniques to detect lymph node metastases is reviewed. These techniques include scintigraphy, sentinel node imaging, positron emission tomography/computed tomography (PET/CT), diffusion weighted magnetic resonance imaging (DWI MRI) and magnetic resonance lymphography (MRL). Knowledge on pathway and size of lymph node metastases has increased with molecular and functional imaging. Furthermore, improved detection and localization of lymph node metastases will enable (focal) treatment of the positive nodes only.

Clinical and pathological nodal staging score for urothelial carcinoma of the bladder: an external validation

PURPOSE

Radical cystectomy (RC) and pelvic lymph node dissection (LND) are standard treatments for muscle-invasive urothelial carcinoma of the bladder. Lymph node staging is a prerequisite for clinical decision-making regarding adjuvant chemotherapy and follow-up regimens. Recently, the clinical and pathological nodal staging scores (cNSS and pNSS) were developed. Prior to RC, cNSS determines the minimum number of lymph nodes required to be dissected; pNSS quantifies the accuracy of negative nodal staging based on pT stage and dissected LNs. cNSS and pNSS have not been externally validated, and their relevance for prediction of cancer-specific mortality (CSM) has not been assessed.

METHODS

In this retrospective study of 2,483 RC patients from eight German centers, we externally validated cNSS and pNSS and determined their prediction of CSM. All patients underwent RC and LND. Median follow-up was 44 months. cNSS and pNSS sensitivities were evaluated using the original beta-binominal models. Adjusted proportional hazards models were calculated for pN0 patients to assess the predictive value of cNSS and pNSS for CSM.

RESULTS

cNSS and pNSS both pass external validation. Adjusted for other clinical parameters, cNSS can predict outcome after RC. pNSS has no independent impact on prediction of CSM. The retrospective design is the major limitation of the study.

CONCLUSIONS

In the present external validation, we confirm the validity of both cNSS and pNSS. cNSS is an independent predictor of CSM, thus rendering it useful as a tool for planning the extent of LND.

Laparoscopic radical prostatectomy plus extended lymph nodes dissection for cases with non-extra node metastatic prostate cancer: 5-year experience in a single Chinese institution

OBJECTIVE

To investigate the functional and oncologic outcomes of patients with locally advanced or lymph node metastatic prostate cancer (PCa) treated by laparoscopic radical prostatectomy (LRP) in a single Chinese institution.

METHODS

From June 2004 to June 2011, a total of 152 cases including 105 locally advanced PCa and 47 lymph node metastatic PCa who were treated by LRP with extended lymph node dissection (ePLND) were enrolled in this study. Surgical records, urinary continence, complications, and oncologic outcomes were presented.

RESULTS

The mean operation time and bleeding were 240 min and 110 ml, respectively. After 12-87 months (median 48 m) of follow-up, 91.4 and 94.7 % of the patients were urinary continence at 6 and 12 m, respectively. Eighty biochemical recurrent diseases were observed. The 3- and 5-year biochemical progression-free survival rates were 59.2 and 47.3 %, respectively. Multivariate analysis showed that Gleason score (HR: 1.66, 95 % CI: 1.05-2.64, P = 0.031), pathological stage (HR: 1.64, 95 % CI: 1.2-2.23, P = 0.002), and surgical margin status (HR: 1.75, 95 % CI: 1.04-2.95, P = 0.035) were independent predictive factors for subsequent biochemical relapse. The 3- and 5-year overall and cancer-specific survival rates were 90.2, 86.0 and 95.8, 92.3 %, respectively. There were no significant differences in biochemical recurrence-free (42.6 vs. 49.5 %, P = 0.491), overall (83.4 vs. 87.3 % P = 0.503), and cancer-specific survival rates (92.3 vs. 94.9 %, P = 0.801) between lymph node-positive and -negative PCa.

CONCLUSION

With favorable functional and oncologic outcomes in this cohort of 152 patients, we concluded that LRP plus ePLND is feasible for patients with locally advanced non-extra node metastatic PCa.

Role of lymphadenectomy in the management of urothelial carcinoma of the bladder and the upper urinary tract

The role of lymphadenectomy has been controversial in urological malignancies. Urothelial carcinoma of the bladder and upper urinary tract has a high potential to spread through the lymphatic network compared with other malignancies, including renal cell carcinoma or prostate cancer. In urothelial carcinoma of the bladder, lymphadenectomy of pelvic nodes had been considered as the standard procedure when radical cystectomy was carried out. Recently, many investigators have examined the influence of its extent, and the majority of the studies have supported the beneficial role of extended lymphadenectomy in accurate staging or in improving patient survival. Although randomized controlled trials are required to establish a greater level of evidence, more urological surgeons have already noticed the necessity for extended lymphadenectomy in bladder cancer. In contrast to bladder cancer, there have been far fewer studies on urothelial carcinoma of the upper urinary tract. This might be because of the smaller number of the patients with urothelial carcinoma of the upper urinary tract and the lack of understanding of regional nodes. However, studies of lymph node mapping and the retrospective analyses with respect to the benefit of lymphadenectomy have been carried out in urothelial carcinoma of the upper urinary tract by some investigators, although the results are still controversial. However, the results from multi-institutional studies by high volume centers have supported the beneficial role of lymphadenectomy in urothelial carcinoma of the upper urinary tract, as it has been proposed in bladder cancer. Thus, lymphadenectomy for urothelial carcinoma of the bladder and the upper urinary tract might have a potential role in staging and improving the oncological outcomes.

Retropubic radical prostatectomy: Clinicopathological observations and outcome analysis of 428 consecutive patients

AIM

We report the outcome analysis of retropubic radical prostatectomy (RRP) performed in 428 patients in terms of pathological findings, complications, and survival.

MATERIALS AND METHODS

Systematically recorded case reports forms of consecutive 428 RRPs done over a 14-year period were analyzed using the SPSS 14 software. Secondary analysis was done to evaluate era specific (pre and post 2002) changes in clinical features and survivals.

RESULTS

Seven-year overall survival (OAS), cancer-specific survival (CSS), and event-free survival (EFS) was 83.2%, 82.8%, and 69.8% respectively in our series. Era-specific survival showed higher CSS post 2002, and there was an increase in presentation with organ-confined disease. Univariate and multivariate analysis showed statistically significant impact on era specific outcome. With the improvement in techniques decrease in complications rate and increase in quality of life was noted.

CONCLUSIONS

Our series spanning over decade demonstrates that RRP is viable option to offer cure to organ-confined carcinoma prostate. Further, there is evidence of stage migration and improvements in outcome in post 2002 patients. Although our series is modest in number, the success rates and outcome data matches those reported in the literature.

The history and anatomy of urologic lymphadenectomy

The history of urologic lymphadenectomy is rich and diverse. Our current understanding of its use and benefits is a product of the hard work of numerous physicians and scientists from many nations. Standard dissection templates for the various urologic malignancies are based on a complete understanding of the anatomy of the lymphatic system, which has developed immensely since Hippocrates first described the white blood of the lymphatic system while performing an axillary dissection. It is hoped that the next 100 years will bring even greater comprehension of its value and utility.

Stage-specific impact of pelvic lymph node dissection on survival in patients with non-metastatic bladder cancer treated with radical cystectomy

OBJECTIVE

To examine the effect of stage-specific pelvic lymph node dissection (PLND) on cancer-specific (CSM) and overall mortality (OM) rates at radical cystectomy (RC) for bladder cancer.

METHODS

Overall, 11,183 patients were treated with RC within the Surveillance, Epidemiology, and End Results database. Univariable and multivariable Cox regression analyses tested the effect of PLND on CSM and OM rates, after stratifying according to pathological tumour stage.

RESULTS

Overall, PLND was omitted in 25% of patients, and in 50, 35, 27, 16 and 23% of patients with respectively pTa/is, pT1, pT2, pT3 and pT4 disease (P < 0.001). For the same stages, the 10-year CSM-free rates for patients undergoing PLND compared with those with no PLND were, respectively, 80 vs 71.9% (P = 0.02), 81.7 vs 70.0% (P < 0.001), 71.5 vs 56.1% (P = 0.001), 43.7 vs 38.8% (P = 0.006), and 35.1 vs 32.0% (P = 0.1). In multivariable analyses, PLND omission was associated with a higher CSM in patients with pTa/is, pT1 and pT2 disease (all P ≤ 0.01), but failed to achieve independent predictor status in patients with pT3 and pT4 disease (both P ≥ 0.05). Omitting PLND predisposed to a higher OM across all tumour stages (all P ≤ 0.03).

CONCLUSIONS

Our results indicate that PLND was more frequently omitted in patients with organ-confined disease. The beneficial effect of PLND on cancer control outcomes was more evident in these patients than in those with pT3 or pT4 disease. PLND at RC should always be considered, regardless of tumour stage.

The importance of pelvic lymph node dissection in the elderly population: implications for interpreting the 2010 National Comprehensive Cancer Network practice guidelines for bladder cancer treatment

PURPOSE

National Comprehensive Cancer Network practice guidelines indicate that pelvic lymph node dissection can be omitted at radical cystectomy in elderly patients. We examined the pelvic lymph node dissection rate in patients 80 years old or older and the impact of pelvic lymph node dissection on cancer specific and overall mortality in these patients.

MATERIALS AND METHODS

We examined the records of 11,183 patients treated with radical cystectomy in 17 Surveillance, Epidemiology and End Results registries. We performed univariate and multivariate Cox regression analysis to test the effect of pelvic lymph node dissection on cancer specific and overall mortality.

RESULTS

Overall pelvic lymph node dissection was omitted in 25% of patients, including 24.2% younger than 80 years and 30.8% 80 years old or older (p <0.001). The 5-year rate of freedom from cancer specific mortality for pelvic lymph node dissection vs no pelvic lymph node dissection was 62.5% vs 59.9% in patients younger than 80 years, and 50.0% vs 46.1% in those 80 years old or older (p = 0.01 and 0.005, respectively). The 5-year rate of freedom from overall mortality for the same categories was 48.8% vs 43.9% and 28.3% vs 24.7% (p <0.001 and 0.01, respectively). On multivariate analysis omitting pelvic lymph node dissection was associated with a 1.3-fold higher cancer specific rate at ages less than 80 and 80 years or greater (each p <0.001). Omitting pelvic lymph node dissection was also associated with a 1.3-fold higher overall mortality rate, including 1.3 at ages less than 80 years and 1.2-fold at ages 80 years or greater (each p ≤0.005).

CONCLUSIONS

Results indicate that pelvic lymph node dissection was more often omitted in patients 80 years old or older than in those younger than 80 years. However, the protective effect of pelvic lymph node dissection on cancer specific and overall mortality was virtually the same in the 2 age categories. Thus, advanced age should not be a limiting factor for performing pelvic lymph node dissection at radical cystectomy.

Fusion of high b-value diffusion-weighted and T2-weighted MR images improves identification of lymph nodes in the pelvis

Accurate identification of lymph nodes facilitates nodal assessment by size, morphological or MR lymphographic criteria. We compared the MR detection of lymph nodes in patients with pelvic cancers using T2-weighted imaging, and fusion of diffusion-weighted imaging (DWI) and T2-weighted imaging. Twenty patients with pelvic tumours underwent 5-mm axial T2-weighted and DWI (b-values 0-750 s/mm(2)) on a 1.5T system. Fusion images of b = 750 s/mm(2) diffusion-weighted MR and T2-weighted images were created. Two radiologists evaluated in consensus the T2-weighted images and fusion images independently. For each image set, the location and diameter of pelvic nodes were recorded, and nodal visibility was scored using a 4-point scale (0-3). Nodal visualisation was compared using Relative to an Identified Distribution (RIDIT) analysis. The mean RIDIT score describes the probability that a randomly selected node will be better visualised relative to the other image set. One hundred fourteen pelvic nodes (mean 5.9 mm; 2-10 mm) were identified on T2-weighted images and 161 nodes (mean 4.3 mm; 2-10 mm) on fusion images. Using fusion images, 47 additional nodes were detected compared with T2-weighted images alone (eight external iliac, 24 inguinal, 12 obturator, two peri-rectal, one presacral). Nodes detected only on fusion images were 2-9 mm (mean 3.7 mm). Nodal visualisation was better using fusion images compared with T2-weighted images (mean RIDIT score 0.689 vs 0.302). Fusion of diffusion-weighted MR with T2-weighted images improves identification of pelvic lymph nodes compared with T2-weighted images alone. The improved nodal identification may aid treatment planning and further nodal characterisation.

[Prostate cancer: an update]

2009 Has been a year of high profile publishing about prostate cancer (PCa): To call in the first instance the S3 guideline and the ERSPC. The ERSPC especially as the basis for that in addition to the detection of prostate cancer, the treatment must be differentiated; overtreatment in particular may be avoided through the implementation of active surveillance protocols. In radical prostatectomy (RPx), increasingly the therapeutic value of lymphadenectomy is detected. Current issues in radiation oncology concern the efficacy and indications of brachytherapy, dose escalation with external beam radiotherapy and the differential indication of adjuvant vs. salvage radiotherapy after RPx. Similarly, the indication for salvage RPx after primary radiotherapy. To mention in systemic therapy are the GnRH antagonists, the so-called super-antiandrogens and the different approaches to immunotherapy of prostate cancer.

Radicai Prostatectomy: Local Recurrence and Persistence of Disease. Is it Possible to Hypothesize any Responsibility of the Surgeon?

Radical prostatectomy (RP) represents the most frequently chosen therapeutic option for treating newly diagnosed localized prostate cancer. Cancer recurrence after surgery is linked to biologic variables. But are these the only ones that must be considered to give an explanation of a possible local or distal recurrence, or can it also admit the possibility that an incorrectly conducted surgery has a negative role in the unfavorable evolution after PR? Prostate cancer recurrence, as a matter of fact, is related also to surgical technique. The PR, by definition is a surgical, potentially complicated act. Surgery outcomes depend on a whole serires of factors: the surgeon's ability, and the way the surgical procedure is conducted, play an essential role. Here we evaluate the role of biological and surgical factors on biochemical recurrence.

Predicting biochemical recurrence-free survival for patients with positive pelvic lymph nodes at radical prostatectomy

PURPOSE

We evaluated predictors of freedom from biochemical recurrence in patients with pelvic lymph node metastasis at radical prostatectomy.

MATERIALS AND METHODS

Of 207 patients with lymph node metastasis treated with radical prostatectomy and bilateral pelvic lymph node dissection 45 received adjuvant androgen deprivation therapy and 162 did not. Cox proportional hazards regression models were used to investigate predictors of biochemical recurrence after radical prostatectomy. Recurrence probability was estimated using the Kaplan-Meier method.

RESULTS

A median of 13 lymph nodes were removed. Of the patients 122 had 1, 44 had 2 and 41 had 3 or greater positive lymph nodes. Of patients without androgen deprivation therapy 103 had 1, 35 had 2 and 24 had 3 or greater positive lymph nodes while 69 experienced biochemical recurrence. Median time to recurrence in patients with 1, 2 and 3 or greater lymph nodes was 59, 13 and 3 months, respectively. Only specimen Gleason score and the number of positive lymph nodes were independent predictors of biochemical recurrence. Recurrence-free probability 2 years after prostatectomy in men without androgen deprivation with 1 positive lymph node and a prostatectomy Gleason score of 7 or less was 79% vs 29% in those with Gleason score 8 or greater and 2 or more positive lymph nodes.

CONCLUSIONS

Prognosis in patients with lymph node metastasis depends on the number of positive lymph nodes and primary tumor Gleason grade. Of all patients with lymph node metastasis 80% had 1 or 2 positive nodes. A large subset of those patients had a favorable prognosis. Full bilateral pelvic lymph node dissection should be done in patients with intermediate and high risk cancer to identify those likely to benefit from metastatic node removal.

Pelvic lymph nodes: distribution and nodal tumour burden of urothelial bladder cancer

Aims

To evaluate the number of lymph nodes and the lymph node tumour burden in different anatomical pelvic regions to better asses the impact of variations in the extent of lymphadenectomy on reported LN parameters and pelvic tumour clearance.

Methods

162 patients with lymph-node-positive urothelial carcinoma of the bladder were treated by cystectomy and extended pelvic lymphadenectomy. Various lymph node parameters were determined separately for the three pelvic regions (external iliac, obturator and internal iliac).

Results

Of 4080 evaluated lymph nodes (median 25 per patient, range 8–55) 39%, 35% and 26% (p<0.05) were found in the external iliac, obturator and internal iliac region, respectively. The distribution of the 625 lymph node metastases (median two per patient, range 1–35) was not significantly different between the regions (external iliac 33%, obturator 38%, internal iliac 29%). However, the median diameter of largest metastasis and total diameter of all metastases were smallest in the internal iliac region (external iliac 0.85 cm, 1.1 cm; obturator 0.8 cm, 1.0 cm; internal iliac 0.6 cm, 0.8 cm; p<0.03, p<0.05; for median diameter of largest metastasis and total diameter of all metastases, respectively). Metastases in only one region were found in 33% of patients (external iliac 13%, obturator 10%, internal iliac 10%); these three groups showed no significant difference in survival. No difference was detected in lymph node parameters between genders.

Conclusions

Lymph node counts and retrieval of metastases depends on the extent of pelvic lymphadenectomy. Dissection not including the internal iliac region misses 26% of all pelvic lymph nodes, 29% of metastases, and understages a substantial number of patients as pN0 (10%).