Pathological and oncologic outcomes for men with positive lymph nodes at radical prostatectomy: The Johns Hopkins Hospital 30-year experience

Japanese expert consensus on the standardization of robot-assisted pelvic lymph node dissection in urological surgery: Extent of pelvic lymph node and surgical technique

Pelvic lymph node dissection (PLND) is important for accurate staging and prognosis of prostate and/or bladder cancer. Several guidelines recommend extended PLND for patients with these cancers. However, the therapeutic benefits of extended PLND are unclear. One major reason is that the extent of PLND is not clearly defined. Thus, the working group for standardization of robot-assisted PLND, including nine experienced urologists for PLND in Japan, was launched in January 2023 by the Japanese Society of Endourology and Robotics. This study summarized the discussions to define the individual extent of PLND in urological surgery in a consensus meeting among these experienced urologists. The consensus meeting determined the extent of PLND based on arteries (veins) and anatomical membrane structures rather than a vague concept or approach toward PLND. This concept is expected to allow surgeons to implement the same extent of PLND. Finally, after a total of 10 online web conferences were held, we determined the extent of PLND for the obturator lymph node (LN) area, the internal iliac LN area, the external and common iliac LN area, and the presacral LN area according to the above rules. The extent of PLND suggested here currently does not have a clear therapeutic rationale. Therefore, the extent of our proposed PLND is by no means mandatory. We hope our definition of the extent of PLND will be supported by further evidence of therapeutic benefits for urologic cancers.

Japanese clinical practice guidelines for prostate cancer 2023

This fourth edition of the Japanese Clinical Practice Guidelines for Prostate Cancer 2023 is compiled. It was revised under the leadership of the Japanese Urological Association, with members selected from multiple academic societies and related organizations (Japan Radiological Society, Japanese Society for Radiation Oncology, the Department of EBM and guidelines, Japan Council for Quality Health Care (Minds), Japanese Society of Pathology, and the patient group (NPO Prostate Cancer Patients Association)), in accordance with the Minds Manual for Guideline Development (2020 ver. 3.0). The most important feature of this revision is the adoption of systematic reviews (SRs) in determining recommendations for 14 clinical questions (CQs). Qualitative SRs for these questions were conducted, and the final recommendations were made based on the results through the votes of 24 members of the guideline development group. Five algorithms based on these results were also created. Contents not covered by the SRs, which are considered textbook material, have been described in the general statement. In the general statement, a literature search for 14 areas was conducted; then, based on the general statement and CQs of the Japanese Clinical Practice Guidelines for Prostate Cancer 2016, the findings revealed after the 2016 guidelines were mainly described. This article provides an overview of these guidelines.

Current status and therapeutic value of extended pelvic lymph node dissection during radical prostatectomy for prostate cancer

Pelvic lymph node dissection (PLND) is important for accurate staging and prognosis of prostate cancer. Several guidelines recommend extended pelvic lymph node dissection (ePLND) for patients with non-low-risk prostate cancer. However, the therapeutic benefits of ePLND are unclear. Therefore, we reviewed the literature regarding the therapeutic value of PLND for prostate cancer. Although some reports showed that ePLND improves postoperative biochemical recurrence and postoperative overall survival compared with limited lymph node dissection, other reports show no benefits. Overall, the current evidence supporting ePLND is poor. The extent of PLND varied among studies concerning the therapeutic value of ePLND, and study design issues such as patient background and length of follow-up period were different. Some reports demonstrated potential therapeutic value for ePLND when adjusting for patient background. Focusing on patients with high-grade prostate cancer may be important in demonstrating the therapeutic benefits of ePLND. Although the incidence of major adverse events related to ePLND was low, the possibility of adverse events such as lymphedema and lymphocele formation should be considered. In the future, we hope that evidence for optimal selection criteria for ePLND and the extent of ePLND will become more definitive and evidence for the therapeutic value of ePLND will be developed.

Prognostication in Lymph Node-Positive Prostate Cancer with No PSA Persistence After Radical Prostatectomy

BACKGROUND

This study aimed to create a prognostic model to predict disease recurrence among patients with lymph node involvement but no prostate-specific antigen (PSA) persistence and to explore its clinical utility.

METHODS

The study analyzed patients with lymph node involvement after pelvic lymph node dissection with radical prostatectomy in whom no PSA persistence was observed between 2006 and 2019 at 33 institutions. Prognostic factors for recurrence-free survival (RFS) were analyzed by the Cox proportional hazards model.

RESULTS

Among 231 patients, 127 experienced disease recurrence. The factors prognostic for RFS were PSA level at diagnosis (≥ 20 vs. < 20 ng/mL: hazard ratio [HR], 1.66; 95% confidence interval [CI], 1.09-2.52; P = 0.017), International Society of Urological Pathology grade group at radical prostatectomy (RP) specimen (group ≥ 4 vs. ≤ 3: HR, 1.63; 95% CI 1.12-2.37; P = 0.010), pathologic T-stage (pT3b/4 vs. pT2/3a: HR, 1.70; 95% CI 1.20-2.42; P = 0.0031), and surgical margin status (positive vs. negative: HR, 1.60; 95% CI 1.13-2.28; P = 0.0086). The prognostic model using four parameters were associated with RFS and metastasis-free survival.

CONCLUSION

The prognostic model in combination with postoperative PSA value and number of lymph nodes is clinically useful for discussing treatment choice with patients.

Identifying low cancer-specific mortality risk lymph node-positive radical prostatectomy patients

OBJECTIVES

To identify low cancer-specific mortality (CSM) risk lymph node-positive (pN1) radical prostatectomy (RP) patients.

METHODS

Within Surveillance, Epidemiology and End Results database (2010-2015) pN1 RP patients were identified. Kaplan-Meier plots and multivariable Cox-regression (MCR) models were used. Pathological characteristics were used to identify patients at lowest CSM risk.

RESULTS

Overall, 2197 pN1 RP patients were identified. Overall, 5-year cancer-specific survival (CSS) rate was 93.3%. In MCR models ISUP GG1-2 (hazard ratio [HR]: 0.12, p < 0.001), GG3 (HR: 0.14, p < 0.001), GG4 (HR: 0.35, p = 0.002), pT2 (HR: 0.27, p = 0.012), pT3a (HR: 0.28, p = 0.003), pT3b (HR: 0.39, p = 0.009), and 1-2 positive lymph nodes (HR: 0.64, p = 0.04) independently predicted lower CSM. Pathological characteristics subgroups with the most protective hazard ratios were used to identify low-risk (ISUP GG1-3 and pT2-3a and 1-2 positive lymph nodes) patients versus others (ISUP GG4-5 or pT3b-4 or ≥3 positive lymph nodes). In Kaplan-Meier analyses, 5-year CSS rates were 99.3% for low-risk (n = 480, 21.8%) versus 91.8% (p < 0.001) for others (n = 1717, 78.2%).

CONCLUSIONS

Lymph node-positive RP patients exhibit variable CSS rates. Within this heterogeneous group, those at very low risk of CSM may be identified based on pathological characteristics, namely ISUP GG1-3, pT2-3a, and 1-2 positive lymph nodes. Such stratification scheme might be of value for individual patients counseling, as well as in design of clinical trials.

Cancer-Specific Mortality Differences in Specimen-Confined Radical Prostatectomy Patients According to Lymph Node Invasion

PURPOSE

To test cancer-specific mortality (CSM) differences in specimen-confined (pT2) prostate cancer (PCa) at radical prostatectomy (RP) with lymph node dissection (LND) according to lymph node invasion (LNI).

METHODS

RP + LND pT2 PCa patients were identified (surveillance, epidemiology, and end results 2010-2015). CSM-FS rates were tested in Kaplan-Meier plots and multivariable Cox-regression (MCR) models. Sensitivity analyses respectively addressing patients with 6 or more lymph nodes analyzed and pT2 pN1 patients were performed.

RESULTS

Overall, 32,258 patients with pT2 PCa at RP + LND were identified. Of these, 448 (1.4%) patients harbored LNI. Five-year CSM-free estimates were 99.6% for pN0 vs. 96.4% for pN1 (P < .001). In MCR models, pN1 (HR: 3.4, P < .001) independently predicted higher CSM. In sensitivity analyses addressing patients with 6 or more lymph nodes analyzed (n = 15,437), 328 (2.1%) pN1 patients were identified. In this subgroup, 5-year CSM-free estimates were 99.6% for pN0 vs. 96.3% for pN1 (P < .001) and, in MCR models, pN1 independently predicted higher CSM (HR: 4.4, P < .001). In sensitivity analyses addressing pT2 pN1 patients, 5-year CSM-free estimates were 99.3, 100 and 84.8% for ISUP GG 1-3 vs. 4 vs. 5, respectively (P < .001).

CONCLUSIONS

In patients with pT2 PCa a small proportion harbor LNI (1.4%-2.1%). In such patients, CSM rate is higher (HR 3.4-4.4, P < .001). This higher CSM risk seems to virtually exclusively apply to ISUP GG5 patients (84.8% 5-year CSM-free rate).

Oncologic Outcomes of Lymph Node Dissection at Salvage Radical Prostatectomy

BACKGROUND

Lymph node invasion (LNI) represents a poor prognostic factor after primary radical prostatectomy (RP) for prostate cancer (PCa). However, the impact of LNI on oncologic outcomes in salvage radical prostatectomy (SRP) patients is unknown.

OBJECTIVE

To investigate the impact of lymph node dissection (LND) and pathological lymph node status (pNX vs. pN0 vs. pN1) on long-term oncologic outcomes of SRP patients.

PATIENTS AND METHODS

Patients who underwent SRP for recurrent PCa between 2000 and 2021 were identified from 12 high-volume centers. Kaplan-Meier analyses and multivariable Cox regression models were used. Endpoints were biochemical recurrence (BCR), overall survival (OS), and cancer-specific survival (CSS).

RESULTS

Of 853 SRP patients, 87% (n = 727) underwent LND, and 21% (n = 151) harbored LNI. The median follow-up was 27 months. The mean number of removed lymph nodes was 13 in the LND cohort. At 72 months after SRP, BCR-free survival was 54% vs. 47% vs. 7.2% for patients with pNX vs. pN0 vs. pN1 (p < 0.001), respectively. At 120 months after SRP, OS rates were 89% vs. 81% vs. 41% (p < 0.001), and CSS rates were 94% vs. 96% vs. 82% (p = 0.02) for patients with pNX vs. pN0 vs. pN1, respectively. In multivariable Cox regression analyses, pN1 status was independently associated with BCR (HR: 1.77, p < 0.001) and death (HR: 2.89, p < 0.001).

CONCLUSIONS

In SRP patients, LNI represents an independent poor prognostic factor. However, the oncologic benefit of LND in SRP remains debatable. These findings underline the need for a cautious LND indication in SRP patients as well as strict postoperative monitoring of SRP patients with LNI.

Comparison of therapeutic features and oncologic outcome in patients with pN1 prostate cancer among robot-assisted, laparoscopic, or open radical prostatectomy

OBJECTIVES

To compare the therapeutic features and oncological outcomes of robot-assisted radical prostatectomy (RARP) with those of open radical prostatectomy (ORP) or laparoscopic radical prostatectomy (LRP) in lymph node (LN) positive prostate cancer patients in a retrospective observational multi-institutional study.

PATIENTS AND METHODS

We evaluated the clinical results of 561 patients across 33 institutions who underwent RARP, LRP, or ORP and who were diagnosed with LN-positive prostate cancer during RP with pelvic LN dissection (PLND). We determined the following survival outcomes: metastasis-free survival, overall survival, cancer-specific survival, and biochemical recurrence-free survival. The Kaplan-Meier method, log-rank test, and Cox proportional hazards regression model were used to evaluate the effect of treatment on oncological outcomes. Statistical significance was set at P < 0.05.

RESULTS

There was no significant difference for any of the survival outcomes between the three surgical groups. However, RARP achieved a greater LN yield compared to that of ORP or LRP. When the extent of PLND was limited to the obturator LNs, the number of removed LNs (RLNs) was comparable between the three surgical groups. However, higher numbers of RLNs were achieved with RARP compared to the number of RLNs with ORP (P < 0.001) when PLND was extended to the external and/or internal iliac LNs.

CONCLUSION

RARP, LRP, and ORP provided equal surgical outcomes for pN1 prostate cancer, and the prognosis was relatively good for all procedures. Increased numbers of RLNs may not necessarily affect the oncological outcome.

Prediction of pelvic lymph node metastases and PSMA PET positive pelvic lymph nodes with multiparametric MRI and clinical information in primary staging of prostate cancer

Purpose

To compare the accuracy of multiparametric MRI (mpMRI), ⁶⁸Ga-PSMA PET and the Briganti 2019 nomogram in the prediction of metastatic pelvic lymph nodes (PLN) in prostate cancer, to assess the accuracy of mpMRI and the Briganti nomogram in prediction of PET positive PLN and to investigate the added value of quantitative mpMRI parameters to the Briganti nomogram.

Method

This retrospective IRB-approved study included 41 patients with prostate cancer undergoing mpMRI and ⁶⁸Ga-PSMA PET/CT or MR prior to prostatectomy and pelvic lymph node dissection. A board-certified radiologist assessed the index lesion on diffusion-weighted (Apparent Diffusion Coefficient, ADC; mean/volume), T2-weighted (capsular contact length, lesion volume/maximal diameters) and contrast-enhanced (iAUC, k_ep, K^trans, v_e) sequences. The probability for metastatic pelvic lymph nodes was calculated using the Briganti 2019 nomogram. PET examinations were evaluated by two board-certified nuclear medicine physicians.

Results

The Briganti 2019 nomogram performed superiorly (AUC: 0.89) compared to quantitative mpMRI parameters (AUCs: 0.47-0.73) and ⁶⁸Ga-PSMA-11 PET (AUC: 0.82) in the prediction of PLN metastases and superiorly (AUC: 0.77) in the prediction of PSMA PET positive PLN compared to MRI parameters (AUCs: 0.49-0.73). The addition of mean ADC and ADC volume from mpMRI improved the Briganti model by a fraction of new information of 0.21.

Conclusions

The Briganti 2019 nomogram performed superiorly in the prediction of metastatic and PSMA PET positive PLN, but the addition of parameters from mpMRI can further improve its accuracy. The combined model could be used to stratify patients requiring ePLND or PSMA PET.

Utility of diffusion weighted imaging-based radiomics nomogram to predict pelvic lymph nodes metastasis in prostate cancer

Background

Preoperative pelvic lymph node metastasis (PLNM) prediction can help clinicians determine whether to perform pelvic lymph node dissection (PLND). The purpose of this research is to explore the feasibility of diffusion-weighted imaging (DWI)-based radiomics for preoperative PLNM prediction in PCa patients at the nodal level.

Methods

The preoperative MR images of 1116 pathologically confirmed lymph nodes (LNs) from 84 PCa patients were enrolled. The subjects were divided into a primary cohort (67 patients with 192 positive and 716 negative LNs) and a held-out cohort (17 patients with 43 positive and 165 negative LNs) at a 4:1 ratio. Two preoperative pelvic lymph node metastasis (PLNM) prediction models were constructed based on automatic LN segmentation with quantitative radiological LN features alone (Model 1) and combining radiological and radiomics features (Model 2) via multiple logistic regression. The visual assessments of junior (Model 3) and senior (Model 4) radiologists were compared.

Results

No significant difference was found between the area under the curve (AUCs) of Models 1 and 2 (0.89 vs. 0.90; P = 0.573) in the held-out cohort. Model 2 showed the highest AUC (0.83, 95% CI 0.76, 0.89) for PLNM prediction in the LN subgroup with a short diameter ≤ 10 mm compared with Model 1 (0.78, 95% CI 0.70, 0.84), Model 3 (0.66, 95% CI 0.52, 0.77), and Model 4 (0.74, 95% CI 0.66, 0.88). The nomograms of Models 1 and 2 yielded C-index values of 0.804 and 0.910, respectively, in the held-out cohort. The C-index of the nomogram analysis (0.91) and decision curve analysis (DCA) curves confirmed the clinical usefulness and benefit of Model 2.

Conclusions

A DWI-based radiomics nomogram incorporating the LN radiomics signature with quantitative radiological features is promising for PLNM prediction in PCa patients, particularly for normal-sized LNM.

Pathologically Node-Positive Prostate Cancer: Casting for Cure When the Die Is Cast?

The postoperative management of men with lymph node involved prostate cancer (pN+) remains a challenge as there is a general lack of randomized trial data and a range of management strategies. Retrospective studies suggest a variable clinic course for patients with pN+ prostate cancer. Some men progress rapidly to metastatic disease despite further therapies, whereas other men can have a period of prolonged quiescence without adjuvant androgen deprivation therapy (ADT) or radiation therapy (RT). For men who have undergone radical prostatectomy, randomized trial data indicate that the addition of ADT in pN+ disease extends metastasis-free, prostate cancer-specific, and overall survival. Additional retrospective studies suggest that adding RT is potentially beneficial in this setting, improving overall and cancer-specific survival especially in men with certain pathologic parameters. Conversely, men with lower disease burden in their lymph nodes have longer times to progression and may be candidates for observation and salvage therapy as opposed to adjuvant ADT/RT.

Histological comparison between predictive value of preoperative 3-T multiparametric MRI and 68 Ga-PSMA PET/CT scan for pathological outcomes at radical prostatectomy and pelvic lymph node dissection for prostate cancer

OBJECTIVE

To evaluate the ability of preoperative multiparametric magnetic resonance imaging (mpMRI) and a gallium-68 prostate-specific membrane antigen positron emission tomography/computed tomography (⁶⁸ Ga-PSMA PET/CT) scan to predict pathological outcomes and also identify a group of men with a <5% risk of histological pelvic lymph node metastasis (LNM) at pelvic lymph node dissection (PLND) performed during a robot-assisted laparoscopic radical prostatectomy (RALP) for prostate cancer. We then aimed to compare these results to known risk calculators for LNM, including the Cancer of the Prostate Risk Assessment (CAPRA) score, Memorial Sloan Kettering Cancer Centre (MSKCC) and Briganti nomograms.

PATIENTS AND METHODS

Between July 2014 and September 2019 only men who had both a preoperative mpMRI and staging ⁶⁸ Ga-PSMA PET/CT at our institution followed by a RALP with PLND referred to a single specialist uropathology laboratory were considered for inclusion. The data were collected retrospectively prior to February 2019 and in a prospective manner thereafter. A model was built to allocate probabilities of the men with a negative ⁶⁸ Ga-PSMA PET/CT scan having a <5% risk of histologically LNM at RALP based on the preoperative radiological staging.

RESULTS

A total of 233 consecutive men met the inclusion criteria of which 58 men (24.9%) had a LNM identified on PLND histology. The median (range) International Society of Urological Pathology (ISUP) Grade was 5 (1-5) and the median (range) prostate-specific antigen level was 7.4 (1.5-72) ng/mL. The median (range) number of resected lymph nodes was 16 (1-53) and the median (range) number of positive nodes identified on histology was 2 (1-22). Seminal vesicle invasion on mpMRI was more common in node-positive men than in the absence of LNM (31% vs 12%). The maximum standardised uptake value of the primary tumour on ⁶⁸ Ga-PSMA PET/CT was higher in men with LNM (median 9.2 vs 7.2, P = 0.02). Suspected LNM were identified in 42/233 (18.0%) men with ⁶⁸ Ga-PSMA PET/CT compared with 22/233 (9.4%) men with mpMRI (P = 0.023). The positive and negative predictive value for ⁶⁸ Ga-PSMA PET/CT was 66.7% and 84.3% respectively, compared to 59.1% and 78.7% for mpMRI. A predictive model showed only two men (4.2%) with a negative preoperative ⁶⁸ Ga-PSMA PET/CT would be positive for a histological LNM if they are ISUP Grade < 5 and Prostate Imaging-Reporting and Data System (PI-RADS) <5; or ISUP Grade 5 with PI-RADS < 4. An inspection of three additional variables: CAPRA score, MSKCC and Briganti nomograms did not improve the predictive probability for this group. However, of the 61 men with ISUP Grade 4-5 malignancy and also a PI-RADS 5 mpMRI, 20 (32.8%) men had a microscopic LNM despite a negative preoperative ⁶⁸ Ga-PSMA PET/CT.

CONCLUSION

Preoperative ⁶⁸ Ga-PSMA/PET CT was more sensitive in identifying histological pelvic LNM than 3-T mpMRI. Men with a negative ⁶⁸ Ga-PSMA PET/CT have a lower risk of LNM than predicted with CAPRA scores or MSKCC and Briganti nomograms. We identified that the combination of a negative preoperative ⁶⁸ Ga-PSMA PET/CT, ISUP biopsy Grade <5 and PI-RADS <5 prostate mpMRI, or an ISUP Grade 5 with PI-RADS <4 on mpMRI was associated with a <5% risk of a LNM. The addition of CAPRA scores, MSKCC and Briganti nomograms did not improve the predictive probability within this model. Conversely, men with ISUP Grade 4-5 malignancy associated with a PI-RADS 5 prostate mpMRI had a >30% risk of microscopic LNM despite a negative preoperative ⁶⁸ Ga-PSMA PET/CT and this high-risk group would appear suitable for an extended PLND at the time of a radical prostatectomy.

Positive node burden rather than the number of removed nodes impacts survival in patients with node-positive prostate cancer

BACKGROUND

The value of pelvic lymphadenectomy during radical prostatectomy (RP) remains controversial. This study aims to test the effects of the number of removed lymph nodes (RLN), positive nodes (pLN), and pLN ratio (pLNR) on cancer-specific survival (CSS) in patients with node-positive prostate cancer (PCa).

METHODS

A total of 2458 patients with a greater than 5% probability of lymph node invasion according to the updated Briganti nomogram who harboured pathologically confirmed positive nodes in the Surveillance, Epidemiology, and End Results database between 2004 and 2015 were identified. Multivariable Cox regression with forward stepwise selection was performed to identify independent risk factors for CSS. Maximally selected rank statistics were used to determine the most informative cut-off value for pLN and pLNR.

RESULTS

The median pLN counts and RLN in the study were two (interquartile range [IQR] 1- 3) and 18 (IQR 15-23), respectively. The RLN counts could not predict CSS, while the higher pLN and pLNR were associated with worse CSS (hazard ratio [HR], 1.11; p < 0.001 and HR, 1.01; p < 0.001, respectively). Patients with ≤ 2 pLN or pLNR ≤ 20% had significantly better CSS than those with pLN > 2 or pLNR > 20% (HR, 1.38 (1.08-1.77); p = 0.009; HR, 1.77 (1.41-2.22); p < 0.001, respectively).

CONCLUSIONS

In patients with node-positive PCa, pelvic lymphadenectomy provides important information for staging, prognosis, and guiding after RP therapy; however, it does not play a therapeutic role. The pLN counts and pLNR were independent predictors of CSS.

Applied anatomy of pelvic lymph nodes and its clinical significance for prostate cancer:a single-center cadaveric study

Background

Pelvic lymph node dissection (PLND) is one of the most important steps in radical prostatectomy (RP). Not only can PLND provide accurate clinical staging to guide treatment after prostatectomy but PLND can also improve the prognosis of patients by eradicating micro-metastases. However, reports of the number of pelvic lymph nodes have generally come from incomplete dissection during surgery, there is no anatomic study that assesses the number and variability of lymph nodes. Our objective is to assess the utility of adopting the lymph node count as a metric of surgical quality for the extent of lymph node dissection during RP for prostate cancer by conducting a dissection study of pelvic lymph nodes in adult male cadavers.

Methods

All 30 adult male cadavers underwent pelvic lymph node dissection (PLND), and the lymph nodes in each of the 9 dissection zones were enumerated and analyzed.

Results

A total of 1267 lymph nodes were obtained. The number of lymph nodes obtained by limited PLND was 4–22 (14.1 ± 4.5), the number obtained by standard PLND was 16–35 (25.9 ± 5.6), the number obtained by extended PLND was 17–44 (30.0 ± 7.0), and the number obtained by super-extended PLDN was 24–60 (42.2 ± 9.7).

Conclusions

There are substantial inter-individual differences in the number of lymph nodes in the pelvic cavity. These results have demonstrated the rationality and feasibility of adopting lymph node count as a surrogate for evaluating the utility of PLND in radical prostatectomy, but these results need to be further explored.

Considering the role of radical prostatectomy in 21st century prostate cancer care

The practice of radical prostatectomy for treating prostate cancer has evolved remarkably since its general introduction around 1900. Initially described using a perineal approach, the procedure was later popularized using a retropubic one, after it was first described as such in 1948. The open surgical method has now largely been abandoned in favour of the minimally invasive robot-assisted method, which was first described in 2000. Until 1980, the procedure was hazardous, often accompanied by massive blood loss and poor outcomes. For patients in whom surgery is indicated, prostatectomy is increasingly being used as the first step in a multitherapeutic approach in advanced local, and even early metastatic, disease. However, contemporary molecular insights have enabled many men to safely avoid surgical intervention when the disease is phenotypically indolent and use of active surveillance programmes continues to expand worldwide. In 2020, surgery is not recommended in those men with low-grade, low-volume Gleason 6 prostate cancer; previously these men - a large cohort of ~40% of men with newly diagnosed prostate cancer - were offered surgery in large numbers, with little clinical benefit and considerable adverse effects. Radical prostatectomy is appropriate for men with intermediate-risk and high-risk disease (Gleason score 7-9 or Grade Groups 2-5) in whom radical prostatectomy prevents further metastatic seeding of potentially lethal clones of prostate cancer cells. Small series have suggested that it might be appropriate to offer radical prostatectomy to men presenting with small metastatic burden (nodal and or bone) as part of a multimodal therapeutic approach. Furthermore, surgical treatment of prostate cancer has been reported in cohorts of octogenarian men in good health with minimal comorbidities, when 20 years ago such men were rarely treated surgically even when diagnosed with localized high-risk disease. As medical therapies for prostate cancer continue to increase, the use of surgery might seem to be less relevant; however, the changing demographics of prostate cancer means that radical prostatectomy remains an important and useful option in many men, with a changing indication.

Pelvic lymph node dissection and its extent on survival benefit in prostate cancer patients with a risk of lymph node invasion >5%: a propensity score matching analysis from SEER database

Pelvic lymph node dissection (PLND) represents the gold standard for nodal staging in PCa and is recommended for patients with a probability of lymph node invasion (LNI) >5%. However, the therapeutic role of PLND and its extent remains a debate. In this study, data of 20,668 patients treated with radical prostatectomy (RP) with and without PLND from SEER database between 2010 and 2015 were retrospectively analyzed. All patients had a risk of LNI >5% according to 2012-Briganti nomogram. Propensity score matching (PSM) was performed to balance baseline characteristics between patients with and without PLND. Kaplan-Meier curves and Cox regression were used to evaluate the impacts of the PLND and its extent on cancer-specific survival (CSS) and overall survival (OS). In overall cohort, patients with PLND were associated with more aggressive clinicopathologic characteristics and had poorer survival compared to those without PLND (5-year CSS rate: 98.4% vs. 99.7%, p < 0.001; 5-year OS rate: 96.3% vs. 97.8%, p < 0.001). In the post-PSM cohort, no significant difference in survival was found between patients with and without PLND (5-year CSS rate: 99.4% vs. 99.7%, p = 0.479; 5-year OS rate: 97.3% vs. 97.8%, p = 0.204). In addition, the extent of PLND had no impact on prognosis (all p > 0.05). Subgroup analyses reported similar negative findings. In conclusion, neither PLND nor its extent was associated with survival in North American patients with a risk of LNI >5%. The cut-off point of 5% probability of LNI might be too low to show benefits in survival in patients underwent PLND.

Sentinel node evaluation in prostate cancer

Sentinel lymph node (SLN) based pelvic lymph node dissection (PLND) in prostate cancer (PCa) is appealing over the time, cost and morbidity classically attributed to conventional PLND during radical prostatectomy. The initial report of feasibility of the SLN concept in prostate cancer was nearly 20 years ago. However, PLND based on the SLN concept, either SLN biopsy of a single node or targeted SLN dissection of multiple nodes, is still considered investigational in PCa. To better appreciate the challenges, and potential solutions, associated with SLN-based PLND in PCa, this review will discuss the rationale behind PLND in PCa and evaluate current SLN efforts in the most commonly diagnosed malignancy in men in the US.

Post prostatectomy outcomes of patients with high-risk prostate cancer treated with neoadjuvant androgen blockade

BACKGROUND

Patients with high-risk prostate cancer have an increased likelihood of experiencing a relapse following radical prostatectomy (RP). We previously conducted three neoadjuvant androgen-deprivation therapy (ADT) trials prior to RP in unfavorable intermediate and high-risk disease.

METHODS

In this analysis, we report on the post-RP outcomes of a subset of patients enrolled on these studies. We conducted a pooled analysis of patients with available follow-up data treated on three neoadjuvant trials at three institutions. All patients received intense ADT prior to RP. The primary endpoint was time to biochemical recurrence (BCR). BCR was defined as a PSA ≥ 0.2 ng/mL or treatment with radiation or androgen-deprivation therapy for a rising PSA < 0.2 ng/mL.

RESULTS

Overall, 72 patients were included of whom the majority had a Gleason score ≥ 8 (n = 46, 63.9%). Following neoadjuvant therapy, 55.7% of patients (n = 39/70) had pT3 disease, 40% (n = 28) had seminal vesicle invasion, 12.9% (n = 9) had positive margins, and 11.4% (n = 8) had lymph node involvement. Overall, 11 (15.7%) had tumor measuring ≤ 0.5 cm, which included four patients (5.7%) with a pathologic complete response and seven (10.0%) with residual tumor measuring 0.1-0.5 cm. Compared to pretreatment clinical staging, 10 patients (14.3%) had pathologic T downstaging at RP. The median follow-up was 3.4 years. Overall, the 3-year BCR-free rate was 70% (95% CI 57%, 90%). Of the 15 patients with either residual tumor ≤ 0.5 cm or pathologic T downstaging, no patient experienced a recurrence.

CONCLUSION

In this exploratory pooled clinical trials analysis, we highlight that neoadjuvant therapy prior to RP in unfavorable intermediate and high-risk patients may potentially have a positive impact on recurrence rates. Larger studies with longer follow-up periods are warranted to evaluate the impact of neoadjuvant hormone therapy on pathologic and long-term outcomes.

Predicting survival in node‐positive prostate cancer after open, laparoscopic or robotic radical prostatectomy: A competing risk analysis of a multi‐institutional database

Objectives

To investigate cancer‐specific mortality and other‐cause mortality in prostate cancer patients with nodal metastases.

Methods

The study included 411 patients treated with radical prostatectomy and pelvic lymph node dissection for prostate cancer with lymph node metastases at 10 tertiary care centers between 1995 and 2014. Kaplan–Meier analyses were used to assess cancer‐specific mortality‐free survival rates at 8 years' follow up in the overall population, and after stratifying patients according to clinical and pathological parameters. Uni‐ and multivariable competing risk Cox regression analyses were used to assess cancer‐specific mortality and other‐cause mortality. Finally, cumulative‐incidence plots were generated for cancer‐specific mortality and other‐cause mortality after stratifying patients according to the number of positive lymph nodes and the median age at surgery, according to the competing risks method.

Results

Men with prostate‐specific antigen ≤40 ng/mL and those with one to three positive lymph nodes showed higher cancer‐specific mortality‐free survival estimates as compared with their counterparts with prostate‐specific antigen >40 ng/mL and >3 metastatic lymph nodes, respectively (all P < 0.001). At multivariable Cox regression analyses, preoperative prostate‐specific antigen >40 ng/mL, >3 lymph node metastases and pathological Gleason score 8–10 were all independent predictors of cancer‐specific mortality (all P‐values ≤0.001). On competing risk analysis, when patients were stratified according to the number of positive lymph nodes (namely, ≤3 vs >3), the 8‐year cancer‐specific mortality rates were 27.4% versus 44.8% for patients aged <65 years, and 15.2% versus 52.6% for patients aged ≥65 years, respectively.

Conclusions

Three positive lymph nodes represent the best prognostic cut‐off in node‐positive prostate cancer patients. In those individuals with >3 positive lymph nodes, the overall mortality rate is completely related to prostate cancer in young patients.

Lymph node staging in prostate cancer: perspective for the pathologist

Pelvic lymph node dissection (PLND) currently represents the gold standard method for nodal staging in the setting of localised prostate cancer and may also have a therapeutic benefit in certain patients. The histopathological evaluation of PLND specimens plays a critical role in accurate lymph node staging, however there is currently a lack of consensus regarding the optimum approach and no quality parameters are in place. In addition, there are no guidelines as to the handling of less commonly encountered nodal specimens such as those identified within the anterior fat pad. This summary provides an overview of pertinent issues regarding lymph node staging in prostate cancer, with a focus on the histopathological evaluation of resected nodal specimens. We hope that this review will further the discussion on how to achieve a more standardised approach to the processing and reporting of PLND specimens in the setting of prostate cancer.

Single Positive Lymph Node Prostate Cancer Can Be Treated Surgically without Recurrence

Purpose/Objectives

To investigate pN1 prostate cancer (PCa) patients treated surgically without immediate adjuvant treatment.

Materials and Methods

We analyzed the database of 2316 patients at our institution who underwent robot-assisted radical prostatectomy (RARP)/radical prostatectomy (RP) between July 2005 and November 2012. 87 patients with pN1 PCa and received no neoadjuvant and immediate adjuvant therapy were included in the study. Included pN1 PCa patients were followed up for median of 60 months. Biochemical recurrence (BCR)-free survival, metastasis-free survival (MFS), cancer specific survival (CSS), and overall survival (OS) rates were determined by using Kaplan-Meier analysis. Cox regression analysis was performed to investigate the impact of prostate-specific antigen (PSA) level, Gleason score, extraprostatic extension, seminal vesicle invasion, perineural invasion, lymphovascular invasion, positive surgical margin, tumor volume, early post-operative PSA(6 weeks), PSA nadir, lymph node yield, and number of pathologically positive lymph nodes on survival.

Results

The 5-year OS rate of patients was 86.1%, while the CSS rate was 89.6%. The metastasis-free and BCR-free survival rates were 71% and 19.1%, respectively, and each was significantly correlated with the number of positive lymph nodes on log rank tests (p = 0.004 and p = 0.039, respectively). The presence of 2 or more pathologically positive LNs (HR:2.20; 95% CI 1.30–3.72; p = 0.003) and a Gleason score ≥8 (HR: 2.40;95% CI: 1.32–4.38; p = 0.04) were significant negative predictors of BCR free survival on multivariable regression analysis. Furthermore, the presence of 2 or more positive lymph nodes (HR: 1.06; 95% CI 1.01–1.11; p = 0.029) were significant negative predictors of metastasis-free survival on multivariable regression analysis. Additionally, in the patients who had no BCR without adjuvant treatment 9 patients out of 10 (90%) had single positive LN and 5 patients out of 10 (50%) had Gleason score 7. Therefore, single positive LN, and Gleason scores ≤7 have significantly low risk of disease progression.

Conclusions

pN1 PCa patients have heterogenous clinical courses. Patients with single positive LN, and Gleason scores ≤7 have low risk of recurrence. Close observation with delayed adjuvant hormone therapy can be considered in these patients.

The role of radical prostatectomy in high-risk localized, node-positive and metastatic prostate cancer

A lack of quality evidence comparing management strategies confounds complex treatment decisions for patients with high-risk prostate cancers. No randomized trial comparing surgery to radiation has been successfully completed. Despite inherent selection biases, however, observational and registry data suggest improved outcomes for patients initially managed with prostatectomy. As consensus shifts away from aggressive treatment for low-risk disease and toward multimodal treatment of locally advanced and metastatic disease, there is renewed interest in surgery for local control in patients presenting with high-risk localized, node-positive and minimally metastatic disease. The objective of this review is to examine the evidence evaluating clinical outcomes of patients with high-risk clinically localized, node-positive and metastatic prostate cancer treated with radical prostatectomy.

Risk Stratification of pN+ Prostate Cancer after Radical Prostatectomy from a Large Single Institutional Series with Long-Term Followup

PURPOSE

Lymph node positive (pN+) prostate cancer after radical prostatectomy has wide variability in long-term oncologic outcomes. We present a large institutional series with extended followup to create an oncologic risk stratification system that clarifies the prognostic heterogeneity for patients with pN+ disease after radical prostatectomy.

MATERIALS AND METHODS

Men with pN+ prostate cancer after radical prostatectomy during 1987 to 2012 were included in the study. Regression models were created to identify significant predictors of biochemical recurrence, metastasis, cancer specific mortality and overall mortality. A cancer specific mortality risk score was then created and internally validated to stratify patients in terms of risk of cancer specific mortality.

RESULTS

For our cohort of 1,011 men with a median followup of 17.6 years the 20-year rate of cancer specific mortality was 31%. On multivariate Cox regression modeling 3 or more positive nodes (HR 1.75, p=0.003), pathological Gleason score 7 vs 6 (HR 1.74, p=0.04) and 8-10 vs 6 (HR 2.63, p=0.001), and positive surgical margins (HR 1.96, p=0.001) were significantly associated with increased cancer specific mortality, while adjuvant radiotherapy (HR 0.40, p=0.008) was associated with decreased cancer specific mortality. A cancer specific mortality risk score was then created using these 4 variables to stratify patients with markedly different prognoses, yielding 20-year cancer specific mortality rates of 19.1% vs 34% vs 46% (p <0.001) for low, intermediate and high risk categories, respectively.

CONCLUSIONS

The prognosis of patients with pN+ prostate cancer varied significantly after radical prostatectomy. A risk score created using the number of positive nodes, pathological Gleason score, margin status and adjuvant radiotherapy status successfully separated patients into low, intermediate and high risk groups.

Update on histopathological evaluation of lymphadenectomy specimens from prostate cancer patients

BACKGROUND

Metastases to lymph nodes (LNs) represent an unfavorable prognostic factor in patients with prostate cancer (PCa). Histological examination represents the gold standard in the evaluation of the lymphadenectomy (LND) specimens for the presence of secondary deposits.

METHODS AND RESULTS

The metastatic detection rate can vary according to the approach adopted in the microscopic analysis of the LNs, which includes frozen-section examination, total inclusion of the tissue with and without whole-mount sections, serial sectioning, and the application of immunohistochemistry. The assessment of the sentinel LN, the search for micrometastases, and the evaluation of atypical LN metastatic sites further contribute to the detection of the metastatic spread.

CONCLUSION

In this review, an update on the histopathological evaluation of LND specimens in patients with PCa is given, and focus is made on their clinical and prognostic significance.

Survival Outcomes in Men Undergoing Radical Prostatectomy After Primary Radiation Treatment for Adenocarcinoma of the Prostate

PURPOSE

Salvage radical prostatectomy (SRP) is a treatment modality for patients with radio-recurrent prostate cancer but is currently underutilized. We analyzed the survival outcomes in patients receiving SRP for radio-recurrent prostate cancer. The secondary outcome was effect of lymph node dissection on survival following SRP.

MATERIALS AND METHODS

The Surveillance, Epidemiology, and End Results (SEER) 18 registry was used to identify patients that underwent radical prostatectomy between 1988 and 2010. Search identified 2628 patients with prostate cancer that underwent surgery after radiation. Following exclusion, 364 patients remained. Endpoints included overall survival (OS) and cancer-specific survival (CSS). Effect of pelvic lymph node dissection (PLND) status and number of nodes retrieved were also studied. Kaplan-Meier analysis, log-rank tests, and Cox-proportional hazard models were used, and P < .05 was considered to be significant.

RESULTS

OS was 77.5% at 10 years and 37.3% at 20 years; CSS was 88.6% at 10 years and 72.7% at 20 years. The hazard of mortality was higher in men who did not undergo PLND with a hazard ratio of 1.4 for OS (P = .2) and 2.7 for CSS (P = .01). No significant increase in OS or CC was seen with increasing number of lymph nodes retrieved. Some limitations are inherent to the SEER database and include the lack of hormone manipulation status and PSA data.

CONCLUSIONS

Excellent long-term survival can be achieved with SRP. PLND improves CSS but increasing nodal yield does not significantly improve survival. Small sample sizes limit the overall power of this study.

[Oncological outcomes of prostate cancer surgery]

OBJECTIVE

Review of the oncological results of the radical prostatectomy as initial treatment of prostate cancer, according to the surgical approach and the risk stratification using D'Amico risk groups.

MATERIALS AND METHODS

Review of literature using Medline databases and MedScience based on scientific relevance. Research focused on the oncological results of the radical prostatectomy in series and meta-analysis published since 10 years, taking into consideration the surgical approach if mentioned.

RESULTS

The characteristics of the operated tumor highly impact the local control authenticated by the pathologic stage and the rates of positive surgical margins (PSM), in addition to the survival and the biochemical recurrence. Surgical technique adapted according to the tumor treated, was a constant challenge to the urologist, who counter balance between the oncological control and the conservation of urinary and sexual function by conditioning the type of radical prostatectomy. Results of radical prostatectomy acceptable in terms of PSM and survival are not influenced by the surgical approach but by the degree of surgical experience.

CONCLUSION

Results of radical prostatectomy show the efficient local control of prostate cancer, taking into consideration the oncological rules and indications validated by multidisciplinary meetings, based on the national (CCAFU) and European oncological guidelines. Tendency is going toward considering radical prostatectomy indicated for patients with higher risk of disease progression, so integrating surgery in a multidisciplinary personalized approach.

A Phase I Dosing Study of Ferumoxytol for MR Lymphography at 3 T in Patients With Prostate Cancer

OBJECTIVE

The objective of our study was to determine the optimal dose of ferumoxytol for performing MR lymphography (MRL) at 3 T in patients with prostate cancer.

SUBJECTS AND METHODS

This phase I trial enrolled patients undergoing radical prostatectomy (RP) with bilateral pelvic lymph node dissection (PLND). Three groups of five patients each (total of 15 patients) received IV ferumoxytol before RP with bilateral PLND at each of the following doses of iron: 4, 6, and 7.5 mg Fe/kg. Patients underwent abdominopelvic MRI at 3 T before and 24 hours after ferumoxytol injection using T2- and T2*-weighted sequences. Normalized signal intensity (SI) and normalized SD changes from baseline to 24 hours after injection within visible lymph nodes were calculated for each dose level. Linear mixed effects models were used to estimate the effects of dose on the percentage SI change and log-transformed SD change within visible lymph nodes to determine the optimal dose of ferumoxytol for achieving uniform low SI in normal nodes.

RESULTS

One patient who was excluded from the study group had a mild allergic reaction requiring treatment after approximately 2.5 mg Fe/kg ferumoxytol injection whereupon the injection was interrupted. The 15 study group patients tolerated ferumoxytol at all dose levels. The mean percentage SI change in 13 patients with no evidence of lymph metastasis was -36.4%, -45.4%, and -65.1% for 4, 6, and 7.5 mg Fe/kg doses, respectively (p = 0.041).

CONCLUSION

A dose level of 7.5 mg Fe/kg ferumoxytol was safe and effective in deenhancing benign lymph nodes. This dose therefore can be the starting point for future phase II studies regarding the efficacy of ferumoxytol for MRL.

Adverse pathology and undetectable ultrasensitive prostate-specific antigen after radical prostatectomy: is adjuvant radiation warranted?

OBJECTIVES

To determine if men with adverse pathology but undetectable ultrasensitive (<0.01 ng/mL) PSA are at high-risk for biochemical recurrence (BCR), or if there is a subset of patients at low-risk for whom the benefit of adjuvant radiation therapy might be limited.

PATIENTS AND METHODS

We evaluated 411 patients treated with RP from 2001 to 2013 without adjuvant radiation who had an undetectable (<0.01 ng/mL) PSA level after RP but with adverse pathology [positive surgical margins (PSMs), extraprostatic extension (EPE), and/or seminal vesicle invasion (SVI)]. Multivariable Cox regression analyses tested the relationship between pathological characteristics and BCR to identify groups of men at highest risk of early BCR.

RESULTS

On multivariable analysis, only pathological Gleason 7 (4 + 3), Gleason ≥8, and SVI independently predicted BCR (P = 0.019, P < 0.001, and P = 0.001, respectively), although on two-way analysis men with Gleason 7 (4 + 3) did not have significantly higher rates of BCR compared with patients with Gleason ≤6 (log-rank, P = 0.074). Men with either Gleason ≥8 (with PSMs or EPE) or SVI (15% of the cohort) defined a high-risk group vs men without these characteristics (3-year BCR risk of 50.4% vs 11.9%, log-rank, P < 0.001).

CONCLUSIONS

Among men with adverse pathology but an undetectable (<0.01 ng/mL) PSA level after RP, the benefits of adjuvant radiation are probably limited except for men with Gleason 8-10 (with PSMs or EPE) or SVI who are at high-risk of early BCR.