Importance of lymph node dissection even in patients with with very low risk of spread to nodes

Most of us know that some surgeons don't remove lymph nodes in every prostatectomy. The guidelines say that if the probability of LN+ (positive nodes) is less than 2% (some say 1%) under the nomograms then no LN dissection is needed. Not all docs agree.

Now there's more evidence.

article: EAU 2011 - More extensive pelvic lymph node dissection is associated with reduced risk of cancer progression in node negative organ confined prostate cancer patients

url: www.urotoday.com/prostate-cancer-1014/eau-2011-more-extensive-pelvic-lymph-node-dissection-is-associated-with-reduced-risk-of-cancer-progression-in-node-negative-organ-confined-prostate-cancer-patients-session-highlights.html Password is required but it's free to set up an account.

This found that even in patients where the lymph nodes were found to be cancer free, removing them still improved the rates of freedom from biochemical recurrence. Moreover, the more nodes removed, the better the outcome. One plausible explanation is that there can be micro-metastases in the lymph nodes which are not seen, but are nonetheless there, and you're better off if they're removed. In this particular study with relatively early stage cancers 10% of the patients had biochemical recurrence after ten years who had MORE than 20 nodes removed; 25% of the patients had recurrence who had LESS than 20 nodes removed.

So ask your surgeon what his plans are for node removal. This is particularly an issue with robotic surgery, where in general doctors are about half as likely to remove and examine the lymph nodes, other things being equal.

Thanks for the post.

It's in line with what I saw presented at our UsTOO meeting when we had a top surgeon come in. The more nodes the better.

Tony

Chris R,
You posted the AUA Brosman report here (18.6 year RP follow up). That report was adamant on lymph node dissection showing extensively better results particularly in intermediate and high risk cases. It did downplay the benefits in G6 cases but there was a reward there too. Just not as extensive as the other risks. But they showed near 75% disease control rates at 15 years for high risk stage 3 and 4.

Tony

reachout - the difference is probably explainable by the nature of the sample. This sample was not entirely low risk patients, it was a mix of patients of different risk levels. They were all PT2, N0, SM-. But some were G4+3=7 and higher. Some had PSA>10. Some may have had other negative features on their pathology such as EPE+, SV+. See below, from the abstract:

The abstract said...

The study included 1,368 consecutive patients with pT2, N0 and surgical margin negative (SM-) CaP treated with extended PLND (ePLND) and RP for clinically localized CaP at a single referral center. All patients underwent an anatomically defined ePLND (including removal of obturator, external iliac and hypogastric nodes). Patients were divided into two groups according to the extent of PLND: <20 and ≥20 lymph nodes removed. Pre-operative as well as pathological variables were available for all patients. BCR at 2, 5 and 8 years after surgery in the overall patient population and in each group was calculated. The association between the extent of PLND and BCR - after accounting for pre-operative PSA and age at surgery, prostate weight and pathological Gleason score - was determined. Overall, mean number of nodes removed was 16.6, and pathological Gleason sum was 6, 3+4 ,4+3 and 8-10 in 56.1, 32.4, 8.4 and 3.1% of patients, respectively. Mean PSA was 7.86 ng/ml and mean prostate weight was 53.2 grams. No patient received any adjuvant treatment.

Post Edited (proscapt) : 4/7/2011 7:54:35 PM (GMT-6)

Here's a good articulation of the contrary view:

www.ncbi.nlm.nih.gov/pmc/articles/PMC2997839/ **FREE**


Should all men having a radical prostatectomy have a pelvic lymph node dissection? No

... said...

However, even if we assume that PLND does have a beneficial cancer control effect, the very low LNI rate in contemporary patients may eliminate any meaningful benefit. Kawakami and colleagues18 examined the CaPSURE database; according to the D’Amico risk classification,19 they reported LNI rates of 0.8, 2.0 and 7.1% for low, intermediate and high-risk PCa patients, respectively. Based on a 10% biochemical-free survival reported by Masterson and colleagues,16 the “number needed to treat” to achieve this beneficial effect in 1 individual is 1250, 500 and 140 PLNDs for low, intermediate, and high-risk patients, respectively. It may be hard to defend performing 1250, 500 or even 140 PLNDs to improve the biochemical recurrence-free rate by 10% in 1 individual. In that light, omitting the PLND appears to represent a much better option.

I'm not saying I buy this line of argument (I don't) but there you have it.

Post Edited (proscapt) : 4/7/2011 8:07:35 PM (GMT-6)

I think I would like to know a lot more about the effects of removing lymphnodes. I know that a lot of breast cancer patients have to wear an arm sleeve and have loss of motion due to node removal.
Does anyone know the effects of removing pelvic nodes? I suspect leg swelling. What may be an acceptable risk for high risk patients may not be for low and intermediate risk ones.
I would be more inclined to get the new IPSO imaging from Sand Lake Imaging, the replacement for Combidex, that uses the Feraleme contrasting agent. I understand it cost $750, which is a smoking deal.
JT

My uro/surgeon and I talked about this very subject once, more than a year ago. He said that he typically only removes what is needed in the lymph nodes, they do a spot check during surgery, and it the closest ones appear "clean", they don't remove any more. Sure this varies on the number and conditon of the particular patient. He said removing all of them, if not needed, isn't  worththe  risk of possible deep infections and complications after the fact. Kind of made sense to me.

David

Post Edited (Purgatory) : 4/7/2011 10:54:07 PM (GMT-6)

My uro/surgeon and I talked about this very subject once, more than a year ago. He said that he typically only removes what is needed in the lymph nodes, they do a spot check during surgery, and it the closest ones appear "clean", they don't remove any more. Sure this varies on the number and conditon of the particular patient. He said removing all of them, if not needed, isn't  worth the  risk of possible deep infections and complications after the fact. Kind of made sense to me.

David

This is exactly what my surgeon did.

Tim

Reachout,
You have to identify the infected nodes because you can't remove all of them. Dr Myers went through this early in his battle, he had some identified nodes surgically removed and had radiation to others. You can specifically target individual nodes with radiation and that works really well, but 1st you have to identify which nodes are affected and which are clear. The other option is wide area radiation to the pelvic region and sometimes to the upper body.
JT

Newporter,
My robotic surgeron told me when he came out to do a guest speaking engagement that if he knew more at the time when he did my surgery that he would have removed more in my case. But he also said that he was glad that I went with a radiation protocol that hit remaining lymph nodes (WPRT or whole pelvic region treatment ~ designed to hit the prostate bed and remaining illiac lymph nodes). And this was after he removed ten in the RALP. Robotic surgery does not limit the ability to remove lymph nodes in fact he said it enhances the ability to find them.

Images of the lymphatic system:
sparkcharts.sparknotes.com/health/generalanatomy/section7.php

Tony

Post Edited (TC-LasVegas) : 4/8/2011 12:42:01 PM (GMT-6)

142,
I don't know, but since this is experimental I doubt that insurance would cover it. The MRI is standard, so insurance may pick up the MRI cost and the $750 would be for the contrast agent. I really don't know.
JT

Today's UroToday news highlights a study that answers several questions about morbidity rates associated with LN removal and dissection:

Complications of pelvic lymphadenectomy in clinically localised prostate cancer: Different techniques in comparison and dependency on the number of removed lymph nodes

www.urotoday.com/prostate-cancer-1014/complications-of-pelvic-lymphadenectomy-in-clinically-localised-prostate-cancer-different-techniques-in-comparison-and-dependency-on-the-number-of-removed-lymph-nodes-abstract.html **FREE ABSTRACT - REGISTRATION REQUIRED**

It contrasts what they call ePLND (extended pelvic lymph node dissection) with SLND (sentinal lymph node dissection, in which a few nodes are taken, examined while the pt is still on the operating table, then more nodes are taken if needed. The SLND has about half the complication rate of the ePLND (11% vs. 21-22%) and so it is recommended as a good compromise between better cancer control and lower side effects.

Tony,

Thank you for the information. I learn something new today.

Regards