Standard Versus Limited Pelvic Lymph Node Dissection for Prostate Cancer in Patients With a Predicted Probability of Nodal Metastasis Greater Than 1%
Abstract
Purpose:
We determined the yield of standard vs limited pelvic lymphadenectomy in patients with a predicted risk of lymph node metastasis greater than 1% according to the Partin tables predicted probability of pathological stage. We also determined the feasibility of laparoscopic standard pelvic lymph node dissection.
Materials and Methods:
Of 1,269 patients with clinically localized prostate cancer undergoing radical prostatectomy, 648 had a Partin’s table predicted probability of lymph node invasion greater than 1%. Of the 648 patients 177 underwent limited pelvic lymph node dissection performed laparoscopically (group 1), and 471 underwent standard pelvic lymph node dissection performed open (367) or laparoscopically (104) (group 2). Templates of limited pelvic lymph node dissection included the external iliac lymph nodes whereas standard pelvic lymph node dissection included the external iliac, obturator and hypogastric lymph nodes. Multivariate logistic regression analyses were performed to compare the node positivity rate between groups 1 and 2.
Results:
On multivariate logistic regression analysis controlling for prostate specific antigen, biopsy Gleason sum, clinical stage and surgical approach, the odds of node positivity were 7.15-fold higher (95% CI 2.49–20.5, p <0.001) for standard vs limited pelvic lymph node dissection. The median (mean) number of nodes retrieved was 9 (10) and 14 (15) after limited and standard pelvic lymph node dissection, respectively (p <0.001). A similar impact was observed in patients treated laparoscopically with standard vs limited pelvic lymph node dissection (odds ratio 15.6, 95% CI 3.7–66.4, p <0.001).
Conclusions:
Standard lymph node dissection yields positive nodes more frequently and retrieves a higher total nodal count than the often performed pelvic lymph node dissection limited to the external iliac nodes. Standard pelvic lymph node dissection is feasible through a transperitoneal laparoscopic approach.
References
- 1 : Eliminating the need for bilateral pelvic lymphadenectomy in select patients with prostate cancer. J Urol1994; 151: 1315. Link, Google Scholar
- 2 : Pelvic lymphadenectomy can be omitted in selected patients with carcinoma of the prostate: development of a system of patient selection. Urology1995; 45: 270. Google Scholar
- 3 : Carcinoma of the prostate and lymphatic metastases. J Urol1974; 111: 65. Link, Google Scholar
- 4 : Prostatic carcinoma: incidence and location of unsuspected lymphatic metastases. J Urol1976; 115: 89. Link, Google Scholar
- 5 : Disease progression and survival of patients with positive lymph nodes after radical prostatectomy: Is there a chance of cure?. J Urol2003; 169: 849. Link, Google Scholar
- 6 : Prognosis of patients with lymph node positive prostate cancer following radical prostatectomy: long-term results. J Urol2004; 172: 2252. Link, Google Scholar
- 7 : Anatomical extent of lymph node dissection: impact on men with clinically localized prostate cancer. J Urol2004; 172: 1840. Link, Google Scholar
- 8 : Combination of prostate-specific antigen, clinical stage, and Gleason score to predict pathological stage of localized prostate cancer: A multi-institutional update. JAMA1997; 277: 1445. Google Scholar
- 9 : Extended experience with surgical treatment of stage D1 adenocarcinoma of prostate: Significant influences of immediate adjuvant hormonal treatment (orchiectomy) on outcome. Urology1989; 33: 27. Google Scholar
- 10 : Lower incidence of unsuspected lymph node metastases in 521 consecutive patients with clinically localized prostate cancer. J Urol1992; 147: 1574. Link, Google Scholar
- 11 : Long-term biochemical disease-free and cancer-specific survival following anatomic radical retropubic prostatectomy: The 15-year Johns Hopkins experience. Urol Clin North Am2001; 28: 555. Google Scholar
- 12 : Multicenter radioimmunoscintigraphic evaluation of patients with prostate carcinoma using indium-111 capromab pendetide. Cancer1998; 83: 739. Google Scholar
- 13 : Limited efficacy of preoperative computed tomographic scanning for the evaluation of lymph node metastasis in patients before radical prostatectomy. Urology1996; 48: 428. Google Scholar
- 14 : A preoperative nomogram identifying decreased risk of positive pelvic lymph nodes in patients with prostate cancer. J Urol2003; 170: 1798. Link, Google Scholar
- 15 : Laparoscopic radical prostatectomy: oncological evaluation after 1,000 cases at Montsouris Institute. J Urol2003; 169: 1261. Link, Google Scholar
- 16 : Endoscopic extraperitoneal radical prostatectomy: oncological and functional results after 700 procedures. J Urol2005; 174: 1271. Link, Google Scholar
- 17 : Prospective analysis of prostate-specific markers in pelvic lymph nodes of patients with high-risk prostate cancer. J Natl Cancer Inst1997; 89: 1498. Google Scholar
- 18 : Implications of prostate micrometastases in pelvic lymph nodes: an archival tissue study. Urology1996; 47: 370. Google Scholar
- 19 : Transperitoneal or extraperitoneal approach for laparoscopic radical prostatectomy: a false debate over a real challenge. J Urol2004; 171: 714. Link, Google Scholar
- 20 : Noninvasive detection of clinically occult lymph-node metastases in prostate cancer. N Engl J Med2003; 348: 2491. Google Scholar
Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan-Kettering Cancer Center, New York, New York
