Lymph node removal

How common is it to have lymph nodes removed(lymphadenectomy) during RALP for low risk disease? Is it necessary?

I know you are talking about removal during RALP. Thought I would add my 2 cents for the rad. guys.
I'm a G9-10 and chose 3-dimensional CT scan with IMRT. I asked my rad. Onc. If I was getting my lymph nodes zapped as well. She said given my G# plus PSA #'s that the chances were only 7% that the Pca had spread to any of the lymph nodes. She didn't want to over treat. I had a problem with that given that I'm in a high risk category. Thought she would throw everything at it at once. Hopefully, I made the correct decision. Time will tell I guess.
Good luck, bertb

zufus..... Don't want to hijack this thread. But, she showed me several and decided it wasn't worth the added risk. But, I still can't help but think about it.

jym62,

The issue is whether it is worth sampling some lymph nodes to get a pathology report (a procedure that is commonly done for breast cancer). For low risk disease, there is an old formula that has been used called the "Roach" formula with a cut-off at 15%

(2/3*PSA) + (Gleason Score-6)*10

So if your PSA is 5.6, and your Gleason score is 6, your risk of nodal involvement is 3.7%, which is well below the 15% cut-off. Because that formula was validated before the PSA screening era, most think it is way too high - for your case by 4.5 fold to 16-fold, which would mean your revised risk is well under 1%:

Predicting the risk of pelvic node involvement among men with prostate cancer in the contemporary era.
Predicting pelvic lymph node involvement in current-era prostate cancer.

I don't think many surgeons would sample your lymph nodes with that low a risk. But with your insignificant amounts of PC, I think you will have many more years, if not a lifetime, on AS before you have to worry about it.

- Allen

jmy62, have you really looked into IMRT? Given your stats, I think you would be a poster boy for that procedure. Given that I was a G9-10 I didn't have much of a choice. But, I sort of like the No Cut, No Catheter, No Diaper approach.
But to each his own and I wish you the best results.
bertb

jym62,

You might want to get another opinion about coming off AS. I would hate to see you suffer the side effects of any treatment when your cancer is apparently insignificant and indolent. A second opinion from a doctor who has had extensive experience with AS might lead you in a different direction.

On AS programs, there are different criteria for going on AS than for coming off it. For going on AS, some programs want to see no more than 2 cores typically out of 12 cores and no more than 50% in any one core -- this is called "very low risk." However, NCCN (many of the top tertiary care hospitals in the US) has relaxed that to include any low risk. This is based on long-term success with such patients.

As an indicator that it's time to come off AS, there are no major AS programs I know of that doesn't require at least set some GS3+4, and some are moving to GS4+3.

The second biopsy is considered a confirming biopsy. Because you had 24 cores taken, it is not surprising that 3 were positive. That is probably no change from the biopsy you had 15 months earlier. And the fact that your PSA is virtually unchanged from 15 months earlier (well within natural variability), seems to indicate that the cancer remains indolent.

The removal of the lymph glands during surgery is only for diagnostic purposes only. If the cancer has spread there, radiation must be used to get it.

My understanding is that when the nodes turn out to be positive removing them is therapeutic and potentially curative.

Dr. Catalona said that if nodes are positive there is still approximately a 15% chance of cure from removing them and continuing with the prostatectomy.

The following from Hopkins suggests the cure rate is only ~7% or less for men with positive nodes: urology.jhu.edu/newsletter/2013/prostate_cancer_2013_21.php

Since it is not known ahead of time whether the nodes are positive and, in fact, they would usually be much more likely to be clear, the expected improvement for the average patient whose node status is unknown pre-operatively is significantly less than these figures, but it is an improvement nonetheless.

Even though I was low-risk, being 40 years old I knew that if I was not cured my life span was likely to be significantly impacted so I wanted every last incremental improvement in cure probability I could possibly get ("belt and suspenders"). But for some this may be less important.


All the proceeding has to do with unconditional node dissection. The approach Putt refers to is different. Only a few nodes are removed and sent for frozen section before continuing with the operation. This increases risk by lengthening the operation and I believe this is less commonly done nowadays. If you agree to this you are saying in the event your nodes are positive you are willing to sacrifice the 7-15% chance of a cure that would be available by continuing. This clearly makes no sense for the low risk patient as the nodes are unlikely to be positive but they still incur the additional delay of the frozen section.

njs said "My understanding is that when the nodes turn out to be positive removing them is therapeutic and potentially curative."

I'll have to pass this on to my wife and her Oncologist, since she is struggling with last stage lung cancer that has recently exploded into her lymph system in her chest.  Well, maybe I won't.  After a year of various chemo treatments that have not worked out too well, I'll keep it to my self and blow it off as just another example of internet fuzz.

I made my earlier comment because I was NOT a low risk patient.  It had already invaded the SVI's and nerve bundles, which were also removed.  Without node involvement, my Uro thought with followup treatments after surgery I might have a good chance of another 10 years without major mets showing up somewhere.  So far so good.  PSA is playing games but what the h***, I have cancer.............

My surgeon removed one and tested it for cancer. I always wondered why just one. As noted above, some doctors take more than one or none.

jum62 hope this helps...

62
60 at 1st biopsy 11/22/11 one of 12 pos <5% gleason 6(3+3) psa 5.0
active surveillance 15 months
2nd biopsy 2/26/13 3of 24 pos <5% gleason 6(3+3)
psa 3/14/13 5.6

Taken fro the Partin table given your stats.
Probability of Pathologic Stage (%)
PSA = 4.1 – 10.0 ng/ml
Clinical Stage
Gleason score Pathologic stage T1a T1b T1c T2a T2b T2c T3a
2 - 4 Organ-confined disease 84 70 83 71 61 66 43
Established capsular penetration 14 27 15 26 35 29 44
Seminal vesicle involvement 1 2 1 2 4 5 10
Lymph node involvement 0 1 0 0 1 1 1

lymphadema?

Lymphadema is usually associated with breast cancer and changes the cost/benefit analysis of dissection there.
Not so with prostate cancer. Lymphocels and elongated pratt drainage are the S/E mostly associated with Pca. Easily managed is very descriptive of them.

I think Walsh is seriously underestimating the dangers. Taking out additional organs at risk "while we're in there" strikes me as an unnecessary risk. Routine lymphadectomy (PLND) strikes me as a reckless policy, especially for a procedure that is of questionable life-increasing benefit in most cases.

It seems that others at Johns Hopkins disagree with Walsh:
"However, the incidence of node positivity is declining, and accordingly a greater number of lymphadenectomies must be performed to benefit 1 patient. In addition to the associated cost, PLND has the potential for morbidity, including lymphoceles, thromboembolic events, ureteral injury, and neurovascular injury. Patients and physicians should therefore assess the risk to benefit ratio associated with PLND on an individual basis to permit informed treatment decisions."
Complications of Pelvic Lymphadenectomy: Do the Risks Outweigh the Benefits?

The AUA Guidelines recommend against it in most cases:

AUA said...
Pelvic lymph node dissection for clinically localized prostate cancer may not be necessary if the PSA is less than 10.0 ng/mL and the Gleason score is less than or equal to 6.

Although pelvic lymph node dissection is often routinely performed in conjunction with radical prostatectomy, its morbidity, even if limited, must be considered. This is especially true in cases where it offers little additional information. A benefit to standard lymph node dissection has not been conclusively shown. Several studies have shown increased sensitivity; in addition, that there may be a recurrence and survival benefit associated with extended lymph node dissection, especially in intermediate- to high-risk patients, even when all nodes are negative. In extended lymphadenectomy, the area of additional dissection involves the region from the external iliac vein to the internal iliac vein medially, and to the bifurcation of the common iliac artery superiorly, rather than to just the obturator fossa. The benefit accruing to this more extended dissection must be balanced against the potential for increased morbidity, however, making careful patient selection critical.

Measurement of pretreatment PSA level, supplemented with clinical stage and Gleason score information, can identify a subset of patients in whom the incidence of nodal metastases is very low (3% to 5%). Patients with a pretreatment PSA level <10.0 ng/mL and a Gleason score =6 rarely have nodal metastases, and it may be appropriate to omit lymphadenectomy in this group. These observations have been made in several large series of patients.

NCCN said...
The decision to perform PLND should be guided by the probability of nodal metastases.

From Vanderbilt:
"In the setting of this debate, concern over morbidity directly attributable to this procedure is of paramount importance. This review focuses on the complications associated with PLND, including lymphocele, thromboembolic events, ureteral injury, nerve injury, vascular injury, and lymphedema."
www.ncbi.nlm.nih.gov/pubmed/21394597

From Albert Einstein:
"In addition to the associated cost, pelvic lymph node dissection (PLND) has the potential for morbidity. This article focuses on the complications associated with PLND, including lymphocele, thromboembolic events, ureteral injury, nerve injury, vascular injury, and lymphedema."
www.ncbi.nlm.nih.gov/pubmed/22045181

From NYU:
"Extended PLND has complications that increase with extent of dissection... However, for patients with low risk disease, PLND is not necessary and is not recommended, because the chance of metastasis is low."
www.ncbi.nlm.nih.gov/pubmed/21504645

From U of Chicago:
"The benefit of PLND during RARP should be weighed against the elevated risk of lymphocele formation and its potential complications."
www.ncbi.nlm.nih.gov/pubmed/21489117

From Harvard/ Brigham and Women's Hospital:
"A total of 55 complications (15%) occurred: 14 were noted in the intraoperative and 41 in the postoperative period. Of these patients 13 required open surgical intervention for the treatment of a complication. Complications included vascular injury (11 patients), viscus injury (8), genitourinary problems (10), functional/mechanical bowel obstruction (7), lower extremity deep venous thrombosis (5), infection/wound problem (5), lymphedema (5), anesthetic complications (2) and obturator nerve palsy (2). "
www.ncbi.nlm.nih.gov/pubmed/8426411