lymph node dissection during RARP - yay or nay?

lymph node dissection during robot-assisted radical prostatectomy -- where do you all stand on this?

do the benefits outweigh the risks?

Gemlin said...
I personally think it is worth the risks when being intermediate/high risk PCa patient...

Absolutely. With no lymph node excision I would be in a reactive treatment mode and basically waiting for a biochemical re-occurrence. Since I had a positive node, I was put on a proactive treatment track.

I do have lymphodema in both legs and my torso but that is mostly controlled with a pneumatic compression garment/device and my legs ache almost all of the time but I consider that a fair trade.

It depends on your risk level. If your nomogram risk is >2% (some say 2.6% is a better cutoff), many urologists would do it. Other urologists disagree. PLND, a very limited dissection of pelvic lymph nodes that is often done in the US, is not really very good at detecting the presence of cancerous LNs. Even extended PLND (ePLND) is of questionable value, and risk of lymphocele and lymphedema (which can be serious) are much higher. ePLND is seldom done in the US, except at a few institutions that specialize in it (like Mayo). It is more common in Europe.

Here is a discussion of the controversies:

We're still not very good at finding cancerous pelvic lymph nodes

What's it going to hurt? Every surgical procedure does some hurting. I think you should take surgery very seriously.

Please don't take the risk of lymphedema lightly. When it effects you it is generally pretty bad and there is little that can be done to completely relieve it. Please look at John-TX remarks. My wife suffers from lymphedema in one arm from the lymph node removal during breast cancer surgery. She wears a full length compression sleeve 24/7/365. If she goes a few days without the sleeve her arm swells to nearly double. In Georgia 9 months of the year the sleeve is a real pain due to the temperature. She also has two physical therapy sessions each month to minimize the effect. She has done this for six years and will do so forever.

I would question that if your are high enough risk to have all the nodes resected, why wouldn't you consider a radiation form of treatment and have the nodes radiated? After all, if the surgery finds the nodes positive you will have the radiation on top of the surgery. More risk and worse side effects. The radiation will present less risk and does not pose the possibility of lymphedema as the nodes are left intact and functional. I also understand that it is nearly impossible to remove all the nodes as they can be difficult to see and find. Plus if cancer is in the ducts and not the nodes, node removal would not solve the problem.

All of my treatment has been at a world class cancer center, MD Anderson in Houston. My urologist/surgeon removed 44 nodes so obviously he suspected the horse had already left the barn. Only one node was positive and that was only one mm in size.

pwallace-
if you look at the link I provided, there is a link to a nomogram you can use.

Thanks for alerting me to the broken link!

On the following nomogram, they recommend a cut-off of 7% risk of nodal involvement before lymph nodes ought to be sampled. In their trials with that cut-off, it predicted 91% of the patients with nodal involvement.

www.europeanurology.com/cms/attachment/2090693045/2075851227

To use it, use a straight-edge to find the number of points on the top assigned to each of the 5 risk factors. Then add the 5 numbers together to get "total points." Then use the straight edge to see on the bottom two lines which probability is associated with your total points. For example, if your total points = 80, then the probability of lymph node invasion = 0.07 = 7%

Here's a full report on how they came up with this nomogram, if you want all the gory details:

www.europeanurology.com/article/S0302-2838(17)30280-4/fulltext

Re read post by JNF,

A recommendation worth considering

My urologist that did a fellowship at MD Anderson said that for GS6 lymph node dissection is rarely warranted. But anything above that he does take lymph nodes.

I'd be interested in knowing what the nomogram says.

I'd also be unable to tell a surgeon to not take lymph nodes with that pathology no matter what a chart says. But that's me.

I'd use the information from the lymph nodes to determine my next move...or lack of.

Rightly or wrongly....I know that's what I would do....if I were doing surgery.


I believe I read that the risk of lymphedema is greater with breast cancer than with prostate cancer. Don't quote me on that...but the information is out there somewhere. Might be worth a look to see.

I thought the idea of node excision was to check if any cancer was extra-capsule. Why your surgeon only removed two is a puzzle to me.

My husband's surgeon felt that since the MRI showed his tumor was small and contained that taking out lymph nodes was not what he wanted to do. He explained that he could take out a number of lymph nodes but if you don't get the ones that might have cancer then what good is it? It is like finding a needle in a haystack. If he takes out 20 and they are clear and the very one with cancer is right next to it but didn't get taken what has that accomplished? Plus you have the potential for the side effects of that action. We will always be looking over our shoulder for cancer to return but we plan on not letting it limit us living our lives.

fiddlecanoe said...
I find this confusing and would be happy if someone could explain. When I had surgery, two lymph nodes were removed, and both were negative. Is the point of removing the nodes to remove cancer, to detect spread, or both? Is ePLND the same as removing nodes for examination? Usually when people report the number of nodes removed during surgery, it is a lot more than the two I had removed. Why more or less?

It is generally accepted by European uro's that eLND provides important information for staging and prognosis which cannot be matched by any other currently available procedure, CT, MRI, PET, ... As a bonus it also have a direct therapeutic effect.
As Tall Allen wrote it is common i Europe but not in US. TA wrote: "ePLND is seldom done in the US, except at a few institutions that specialize in it (like Mayo). It is more common in Europe."