Determinants of Long-term Survival of Patients With Locally Advanced Prostate Cancer

The Role of Extensive Pelvic Lymph Node Dissection

M Moschini; N Fossati; F Abdollah; G Gandaglia; V Cucchiara; P Dell'Oglio; S Luzzago; SF Shariat; F Dehò; A Salonia; F Montorsi; A Briganti

Disclosures

Prostate Cancer Prostatic Dis. 2016;19(1):63-67. 

In This Article

Abstract and Introduction

Abstract

Background: The therapeutic effect of pelvic lymph node dissection (PLND) during radical prostatectomy (RP) due to prostate cancer (PCa) is still under debate. We aimed at assessing the impact of more extensive PLND on cancer-specific mortality (CSM) in patients treated with surgery for locally advanced PCa.

Methods: We examined data of 1586 pT3-T4 PCa patients treated with RP and extended PLND between 1987 and 2012 at a tertiary referral care center. Univariable and multivariable Cox regression analyses tested the relationship between the number of nodes removed and CSM rate, after adjusting for potential confounders. Survival estimates were based on the multivariable models.

Results: The average number of nodes removed was 19 (median: 17; interquartile range: 11–23). Mean and median follow-up were 80 and 72 months, respectively. At multivariable analyses, Gleason score 8–10 (hazard ratio (HR): 2.5) and a higher number of positive nodes (HR: 1.06) were independently associated with higher CSM rate (all P<0.05). Conversely, higher number of removed LNs (HR: 0.94) and adjuvant radiotherapy (HR: 0.54) were independent predictors of lower CSM rates (all P≤0.03).

Conclusions: In pT3-T4 PCa patients, removal of a higher number of LNs during RP was associated with higher cancer-specific survival rates. This supports the role of more extensive PLNDs in this patient group. Further prospective studies are needed to validate our findings.

Introduction

Prostate cancer (PCa) represents the most common non-cutaneous malignancy for men, with 233 000 new cases and 29 480 deaths in the United States only in 2014.[1] Although the introduction of PSA testing have led to a stage migration in the diagnosis of PCa,[2] approximately one-third of patients are still diagnosed with adverse pathological characteristics at the time of radical prostatectomy (RP).[3,4] These patients are considered at higher risk of cancer recurrence[5] over time and a multi-modal approach is often required to achieve optimal cancer outcomes. However, despite a multimodal approach, good survival outcomes are not invariably achieved.[6–8] Moreover, these patients harbor higher risk of evident[9] or occult[10] nodal metastases. In this context, while an extended pelvic lymph node dissection (ePLND) has now been accepted as the gold standard for staging purposes, its beneficial effect on oncological outcomes has not been elucidated yet owing to the lack of available prospective randomized trials. Several retrospective series have indeed reported conflicting results on the beneficial effect of meticulous PLND and very few have examined the association between adequate PLND and hard clinical end points. Moreover, not all series focused on the appropriate patient population, that is, men with adequate life expectancy assessed at long term and with higher risk of cancer progression and death. Following these considerations, no therapeutic impact of ePLND has ever been shown in patients with advanced local stage. This could be pivotal considering the increased risk to incur in evident[9] or occult[10] node metastases in this patient's category. To address this issue, we tested the relationship between the number of removed lymph nodes (RLNs) and cancer-specific mortality (CSM) in pT3-pT4 patients treated with RP.

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