Diagnostic benefit
- Identification of metastatic disease
- The number of involved nodes, tumor volume within the nodes, and capsular perforation provide critical information
- Enables us to decide whether we should administer adjuvant chemotherapy
Therapeutic benefit
- Improve regional control and progression free survival (PFS)
- Provides a possibility for cure
According to the European Association of Urology (EAU) the cutoff to perform PLND is 5%, while according to the National Comprehensive Cancer Network (NCCN) the cutoff is 2%. In the European (Briganti) nomogram, the percentage of positive cores represents the foremost predictor of lymph node involvement (LNI).
A systematic review demonstrated that there is no benefit in performing any PLND during radical prostatectomy (RP) for any oncological outcome, including survival.[1] However, it is generally accepted that extended PLND (EPLND) provides important information for staging and prognosis. It is recommended in patients with unfavorable intermediate or with high risk disease. However, EPLNDS has twice the complication and lymphocele rate, and 1.7 days longer hospital stay. The Briganti or MSKCC nomograms should be used, and a cutoff above 5%, is an indication to perform nodal sampling.
The standard PLND includes the external and internal iliac nodes and the obturator nodes. Omitting the internal iliac nodes has caused physicians to miss 19% of patients with LNI and 58% of the positive nodes. [2]. In a systematic review published in 2017, including 66 studies with a total of 275000 patients, no significant differences were observed among groups for survival. More extensive PLND has shown to be correlated to a greater prospect of complications.[1]
In node positive patients it has been shown, both in patients treated with surgery and radiotherapy, that addition of hormonal therapy immediately after the treatment decreased mortality.
Dr. Evans concluded his talk by stating that nowadays, the 5% cutoff in the various nomograms should help choose the appropriate patients for PLND. EPLND will detect a higher number of ILN but will also result in a higher complication rate. Importantly, survival improvement with EPLND has not been proven.
Speaker: Christopher Evans, MD, FACS, Chair, Department of Urology, Professor, UC Davis, Sacramento, California, US
Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at The 15th Meeting of the EAU Section of Oncological Urology ESOU18 - January 26-28, 2018 - Amsterdam, The Netherlands
References:
- Eur Urol 2017; 72: 84-109
- Bader et al. J Urol 168: 514-518, 2002