Implementation of radioguided surgery in prostate cancer

With the development of new imaging technologies and tracers, the applications of radioguided surgery for prostate cancer are growing rapidly. The current paper aims to give an overview of the recent advances of radioguided surgery in the management of prostate cancer. We performed a literature search to give an overview of the current status of radioguided surgery for prostate cancer. Three modalities of radioguided surgery, the sentinel node procedure, Cerenkov Luminescence / beta-radio-guided surgery and radio-guided salvage surgery in recurrent prostate cancer, were reviewed in detail. Radioguided surgery for prostate cancer has shown promising value in the treatment of primary diagnosed prostate cancer and recurrent loco-regional lymph node positive prostate cancer. Advances have been made into minimal invasive (robot-assisted) laparoscopic surgery. The sentinel node procedure for prostate cancer has been further developed and is currently performed with high diagnostic sensitivity. Cerenkov luminescence imaging is a feasible and encouraging technique for intraoperative margin assessment in prostate cancer. Radioguided surgery in recurrent prostate cancer has shown to be feasible, yielding high sensitivity and specificity for detecting small local recurrences and metastases. With the availability of different new tracers, the road has been paved towards clinically feasible radioguided surgery for prostate cancer. Novel technologies now being developed for minimal invasive surgery are speeding up clinical research. Currently, none of the radioguided surgery techniques mentioned have been accepted as standard of care.

Is the Recommendation of a Pelvic Lymphadenectomy in Conjunction with Radical Prostatectomy in Prostate Cancer Patients Justified? Report from a Multidisciplinary Expert Panel Meeting

INTRODUCTION

Pelvic lymphadenectomy (pLA) in prostate cancer (PCa) is one of the most common uro-oncologic surgical procedures. An increased complication rate is accompanied by unproven oncologic benefit. Extent of pLA and mechanisms of metastasis are discussed controversially. We aimed to explore evidence and knowledge gaps in pLA and mechanisms of metastasis in PCa and to develop further steps to clarify oncologic benefits through an expert panel.

METHODS

A multidisciplinary expert meeting was initiated, compiling available facts on pLA and mechanisms of metastasis in PCa. Questions and hypotheses were formulated. The resulting protocol was modeled on priority and consistency in four anonymized voting rounds using the Delphi method (March 2018-June 2018).

RESULTS

The oncologic benefit of pLA in PCa is still unclear. Results of randomized trials (RCTs) are pending. Extent and techniques of pLA are differently applied and inconsistently recommended by the guidelines as well as the indication for pLA. Different growth rates for the primaries and metastases and different survival curves for lymph node and organ metastasis at diagnosis argue against metastasis originating from positive nodes. However, results from clinical and basic research support this opportunity in PCa.

CONCLUSIONS

The RCTs required to clarify the estimated low oncologic benefit of pLA prove to be difficult because of the great effort (e.g., high case number). Establishing a network of treatment centers for implementation of high-quality cohort studies could be an alternative approach. Future studies with larger panels and international participants based on the presented feasibility should be launched to set this process in motion. Until valid data are available, benefits and harms of pLA should be weighted under consideration of low-invasive techniques (e.g., sentinel pLA).

Rise in Node-Positive Prostate Cancer Incidence in Context of Evolving Use and Extent of Pelvic Lymphadenectomy

BACKGROUND

The incidence of node-positive prostate cancer has risen and might be partially explained by evolving use of lymphadenectomy at a population level. We assessed trends of node-positive prostate cancer in context of extent of lymphadenectomy among men treated surgically for prostate cancer.

PATIENTS AND METHODS

This was a retrospective study using data from a population-based cancer registry to identify men older than 50 years of age diagnosed with prostate cancer from 2010 to 2015 without distant metastases. We considered extent of node dissection as ordinal (1-4, 5-9, 10-14, 15-19, ≥20) and dichotomous (1-14, ≥15) variables. We fit multivariable models to assess trends in receipt of extended lymphadenectomy and then estimated odds of node-positive cancer on the basis of extent of lymphadenectomy.

RESULTS

We identified 280,156 men diagnosed from 2010 to 2015; 5355 men (1.9%) had positive lymph nodes. Incidence of positive nodes increased from 6.4 to 8.4 cases per 100,000 men from 2010 to 2015 (standardized rate ratio, 1.31; 95% confidence interval [CI], 1.20-1.44). Compared with 2010, prostatectomy patients with high-risk (odds ratio [OR], 1.66; 95% CI, 1.42-1.95) and intermediate-risk tumors (OR, 1.66; 95% CI, 1.47-1.88) were more likely to undergo extended lymphadenectomy in 2015. Among high-risk patients, men with ≥20 nodes removed were 7 times more likely to have positive nodes, versus <5 removed (6.1% for 1-4 vs. 32.4% for ≥20; OR, 7.32; 95% CI, 6.16-8.71). After adjusting for extent of dissection, odds of node-positive disease did not increase between 2010 and 2015 (OR, 1.17; 95% CI, 0.98-1.39) among high-risk patients.

CONCLUSION

Increased incidence of node-positive prostate cancer in the United States is partially explained by more frequent use of extended lymphadenectomy.