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lymph node dissection during RARP - yay or nay?

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Posted 5/14/2017 7:37 AM (GMT 0)

Gemlin said...
As a bonus it also have a direct therapeutic effect.


I think most UROs in Europe will agree with that. However, Fossati was asked to clarify if he could find evidence for that so it could be used in the European guidelines. This year he published his review: The Benefits and Harms of Different Extents of Lymph Node Dissection During Radical Prostatectomy for Prostate Cancer: A Systematic Review.

He concludes:

Fossati said...
Although representing the most accurate staging procedure, PLND and its extension are associated with worse intraoperative and perioperative outcomes, whereas a direct therapeutic effect is still not evident from the current literature.

.... the review suggests that lymph node removal may not have any direct benefit on cancer outcomes and may instead result in more complications. Nevertheless, the procedure remains justified because it enables accurate assessment of cancer spread.


So it is the most accurate staging procedure, but you as the patient may have to suffer from lymphedema for the rest of your life. I had no lymph node removal and think PSA tests and PSMA PET/CTs can provide a staging that is good enough for me.

George
Posted 5/14/2017 1:28 PM (GMT 0)
I had 14 nodes remove during my surgery, none had cancer. It was an relief to get the result since the MRI did show some suspicious nodes and the URO recommended ePLND.
There are studies showing that removing lymph nodes during PC surgery can significantly improve survival in patients with LN invasion. For instance this one More Extensive Pelvic Lymph Node Dissection Improves Survival in Patients with Node-positive Prostate Cancer
For those who are considering ePLND, the risks must of course be weighed against the benefits.
Posted 5/14/2017 2:51 PM (GMT 0)
Gemlin,

Fossati screened 3840 articles for his review, I guess this included the study by Abdollah.

Regarding the study you mentioned there were letters to the editor:
/www.ncbi.nlm.nih.gov/pubmed/25801051
Bogdanovic: "Because of its design, the study by Abdollah et al has not proved the therapeutic role of ePLND in patients with LNI. In our opinion, the paper should be entitled ‘‘The role of adjuvant radiation therapy in node-positive prostate cancer patients receiving hormonal treatment following radical prostatectomy with ePLND’’, because aRT was the sole difference in the treatment of the study patients with a proven effect on CSM"

/www.ncbi.nlm.nih.gov/pubmed/25282364
Froehner: "Only randomized trials may reliably determine the therapeutic efficacy of extended lymph node dissection in this setting"

www.europeanurology.com/article/S0302-2838(14)00678-2/abstract
Stief: "They conclude from their data that patients with lymph node metastases due to prostate cancer benefit from extensive lymphadenectomy versus a more limited lymph node dissection. I regret to say that their data do not support their conclusions."

So I prefer the findings of Fossati wink

George
Posted 5/15/2017 2:16 AM (GMT 0)
George- the Fossati article was published between our consult with Dr. Karnes at Mayo (at which he recommended ePLND) and the time of my husband's surgery.

I could only access the abstract yet it seemed clear to me that the authors concluded there was little/no therapeutic benefit to ePLND, especially considering the risks.

I wrote to Dr. Karnes and asked him if the article caused him to reconsider his recommendation for my husband. He responded that the article only pertained to LN- patients and didn't change his recommendation.

I didn't totally understand his response but I thought if I could read the full article, I might better understand.

If removing invaded lymph nodes during RP surgery had no therapeutic benefit how could there be evidence of benefit of treatment of identified malignant nodes found with recurrent PCa via RT or salvage lymphadenectomy? While removal of invaded nodes likely won't lead to cure, it seems to delay progression.
Posted 5/15/2017 8:01 AM (GMT 0)
Unfortunately, not so encouraging, an article about the natural course of the disease wrote: "Some patients with lymph node-positive prostate cancer have the chance to be cured by surgery. The majority of patients have recurrent disease either in the pelvis combined with distant metastases, or have distant metastases only. Local adjuvant therapy (e.g. radiation therapy) could hardly improve their outcome."
But again, the main reason for ePLND is the accurate staging and prognosis which cannot be matched by any other available procedure.
Posted 5/15/2017 2:25 PM (GMT 0)
Gremlin,
What article are you quoting please?
The statement doesn't address the effect of slowing the progression of the disease by ePLND nor the possible relative efficacy of dealing with invaded nodes by surgical removal during RP vs sLND or by RT down the road.
Posted 5/15/2017 3:24 PM (GMT 0)
Allen's article on Lymph Node tracking and treatment cited above, is , as all things he writes , extremely well done.
It is fair to say, however, that this is a PCA area , unlike others he addresses, where he is not able to be definitive.
Whether one surgically removes or radiates, the chance of actually killing all cancer in the lymph nodes is highly uncertain, and the side effects can be substantial.
When you add to those issues the odds that once the cancer has accumulated in the nodes that it has not gone micro metastatic outside the nodes it makes node treatment even more problematical.
I would say that based on the combined odds of not killing all nodal cancer and it already being beyond the nodes, any nodal treatment should be conservatively, not aggressively, approached.
Posted 5/15/2017 7:20 PM (GMT 0)
Annie,

Fossati writes: " lymph node removal may not have any direct benefit on cancer outcomes". If he writes may he means may. So the lymph node removal may just as well have a benefit for your husband.

"....how could there be evidence of benefit of treatment of identified malignant nodes found with recurrent PCa via RT or salvage lymphadenectomy?"

Yes, there is also no high level evidence that treatment of these node delays the disease. However, I mentioned quite a number of smaller, non-high-level-evidence studies that made me believe that it delays progression. Since treating these nodes with SBRT apparently has almost no side effects I do this and do not wait for high level evidence. This I will most probably not get for the rest of my life.

George
Posted 5/16/2017 1:11 AM (GMT 0)
thanks for all of your responses.

allen, the two nomograms above gave us very different probabilities, so which one do you suggest going by?

for reference, the MSKCC nomogram put his risk at 5%, and the european one puts it at 17%!
Posted 5/16/2017 4:34 AM (GMT 0)
pwallace-

Yes -different databases give different results. Also European data is likely to be different from US data, especially about this. You can see why the American study put the bar at 2.6% and the European study put the bar at 7%. (Europeans generally present with more progressed disease.)

However, where they do agree is on the recommendation for you - the risk exceeds those bars in either case.

As Staying Tuned rightly warns, this must be approached cautiously. I think it's really important they use Indocyanine Green intraoperatively for fluorescent detection. However, even with that, complete dissection is impossible. Lymph nodes are nearly invisible and may be very small; they also hide in fat pads around the prostate where they are nearly impossible to locate; and drainage patterns are haphazard and unique to the individual. In one study where they used a radioactive PSMA-based indicator and a gamma-detector to find them intraoperatively, they found that about a quarter were missed with the fluorescent indicator, and this was by doctors experienced at ePLND in Europe.
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