The role of lymph node dissection in salvage radical prostatectomy for patients with radiation recurrent prostate cancer

Abstract

Purpose: To examine the effect of lymph node dissection on the outcomes of patients who underwent salvage radical prostatectomy (SRP). Material and Methods:We retrospectively reviewed data from radiation-recurrent patients with prostate cancer (PCa) who underwent SRP from 2000-2016. None of the patients had clinical lymph node involvement before SRP. The effect of the number of removed lymph nodes (RLNs) and the number of positive lymph nodes (PLNs) on biochemical recurrence (BCR)-free survival, metastases free survival, and overall survival (OS) was tested in multivariable Cox regression analyses.Results: About 334 patients underwent SRP and pelvic lymph node dissection (PLND). Lymph node involvement was associated with increased risk of BCR (p < .001), metastasis (p < .001), and overall mortality (p = .006). In a multivariable Cox regression analysis, an increased number of RLNs significantly lowered the risk of BCR (hazard ratio [HR] 0.96, p = .01). In patients with positive lymph nodes, a higher number of RLNs and a lower number of PLNs were associated with improved freedom from BCR (HR 0.89, p = .001 and HR 1.34, p = .008, respectively). At a median follow-up of 23.9 months (interquartile range, 4.7-37.7), neither the number of RLNs nor the number of PLNs were associated with OS (p = .69 and p = .34, respectively). Conclusion:Pathologic lymph node involvement increased the risk of BCR, metastasis and overall mortality in radiation-recurrent PCa patients undergoing SRP. TheThis is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

Importance of magnetic resonance imaging and prostate‐specific membrane antigen PET‐CT in patients treated with salvage radical prostatectomy for radiorecurrent prostate cancer

“…29 Notably, we found that with a pT3 disease prevalence of 38% the NPV was strong (92%), which allow considering PSMA-PET/CT as a rule-out test for the nonorgan confined disease in patients with radiorecurrent PCa. Considering detection rates of local recurrence-96% for MRI and 100% for PSMA-PET/CT, both imaging modalities are reliable tools in this setting, which has been also shown previously by Liu et al 30 Our study shows that due to 100% specificity and 100% PPV patients with positive lymph nodes on PSMA-PET/CT should either undergo extended PLND, which may improve survival outcomes, 16 or can forgo SRP due to significant morbidity and lower chance of cure and may be considered for other treatment modalities such as systemic therapy. 7,20 A recent multicenter prospective phase 3 trial 31 reported PSMA-PET sensitivity of 40% and specificity of 95% for lymph node metastases at primary RP.…”

“…Our study shows that due to 100% specificity and 100% PPV patients with positive lymph nodes on PSMA‐PET/CT should either undergo extended PLND, which may improve survival outcomes, 16 or can forgo SRP due to significant morbidity and lower chance of cure and may be considered for other treatment modalities such as systemic therapy 7,20 . A recent multicenter prospective phase 3 trial 31 reported PSMA‐PET sensitivity of 40% and specificity of 95% for lymph node metastases at primary RP.…”

“…Furthermore, several studies reported that nonorgan confided disease and lymph node involvement are significant adverse prognostic features associated with limited survival benefits from local therapy. [13][14][15][16] For example, in our previous study analyzing 334 radiorecurrent PCa patients undergoing SRP, lymph node involvement was associated with significantly reduced BCR-free survival (hazard ratio [HR] 1.75, p = 0.014), metastasis-free survival (HR 3.93, p < 0.001), and overall survival (HR 2.88, p = 0.006). 16 Thus pre-SRP accurate staging and selection of optimal candidates for salvage are presently pivotal unmet needs in radiorecurrent PCa.…”

“…Therefore, identifying patients that would benefit the most from the SRP is crucial to prevent overtreatment and limit treatment‐related toxicities. Furthermore, several studies reported that nonorgan confided disease and lymph node involvement are significant adverse prognostic features associated with limited survival benefits from local therapy 13–16 . For example, in our previous study analyzing 334 radiorecurrent PCa patients undergoing SRP, lymph node involvement was associated with significantly reduced BCR‐free survival (hazard ratio [HR] 1.75, p = 0.014), metastasis‐free survival (HR 3.93, p < 0.001), and overall survival (HR 2.88, p = 0.006) 16 .…”

The Role of Salvage Radical Prostatectomy in Patients with Radiation-Resistant Prostate Cancer

“…Furthermore, those who did undergo PLND were noted to have increased CSS, with the lymph node count showing a direct correlation with increasing CSS up to seven nodes [51]. In a separate retrospective multicenter cohort, pathologic nodal involvement was found to be associated with an increased risk of BCR, the development of metastasis, and decreased OS among patients undergoing salvage RP for radio-recurrent prostate cancer [52]. Given these prognostic and potential therapeutic benefits, performing PLND at the time of salvage RP should be standard of practice when possible.…”