Lymphadenectomy in high-risk prostate cancer

[Palex80]

Hey! I am asking for a friend here. He is planning a trial and would like to have some feedback on worldwide practice.
In your experience, do urologists perform lymphadenectomy in high-risk cN0 prostate cancer (provided the high-risk cancer was known before surgery - based on GS, PSA, cT3) when performing radical prostatectomy as primary treatment.

Thank you!

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[medgator]

Hey! I am asking for a friend here. He is planning a trial and would like to have some feedback on worldwide practice.
In your experience, do urologists perform lymphadenectomy in high-risk cN0 prostate cancer (provided the high-risk cancer was known before surgery - based on GS, PSA, cT3) when performing radical prostatectomy as primary treatment.

Thank you!

Hit or miss. Just saw a G9 pt post op who had G7 prior to surgery on biopsies so no LAD was done. Some urologists will do it on almost every pt

 

[DoctwoB]

A lot of places do it based on nomograms if >5% LNI. Which in the era of surveillance means most patients.

 

[TheWallnerus]

I’ve seen the chair of a big name place not remove SVs in intermediate risk. Very hit and miss indeed.

 

[thecarbonionangle]

The quality is highly variable. I have heard of a lot of “lymphadenectomies” with like two LN on each side

 

[CaesarRO]

The quality is highly variable. I have heard of a lot of “lymphadenectomies” with like two LN on each side

This was my first thought. Does 1-2 nodes per side count?

 

[Chartreuse Wombat]

Will the global economic downturn affect prostate cancer care? Pelvic lymphadenectomy as an example - PubMed

Will the global economic downturn affect prostate cancer care? Pelvic lymphadenectomy as an example

pubmed.ncbi.nlm.nih.gov

 

[StIGMA]

The quality is highly variable. I have heard of a lot of “lymphadenectomies” with like two LN on each side

Definitely a difference in what's really a sampling vs. dissection. >20 median nodes removed in some Mayo series (they are known for being more extensive)

 

[Reaganite]

Oh they always do lymphadenectomies...the pathologists just didn't do a good job looking for nodes .

 

[Palex80]

This was my first thought. Does 1-2 nodes per side count?

True, I did not specify that. No, I am referring to a systematic lympahademectomy (not necessarily extended field).

 

[TheWallnerus]

True, I did not specify that. No, I am referring to a systematic lympahademectomy (not necessarily extended field).

Has a surgeon’s lymph node count ever been associated with improved… survival?

If a surgeon finds a positive node, do they continue on with the prostatectomy? I guess they probably don’t send for frozen intra op unless they find a very suspicious node.

 

[Palex80]

Has a surgeon’s lymph node count ever been associated with improved… survival?

Nope! That's why perhaps a trial will be good!

If a surgeon finds a positive node, do they continue on with the prostatectomy? I guess they probably don’t send for frozen intra op unless they find a very suspicious node.

Indeed, previously they stopped. But current guidelines say that they should carry on.

 

[ramsesthenice]

Nope! That's why perhaps a trial will be good!

Indeed, previously they stopped. But current guidelines say that they should carry on.

What about going the other way? Sentinel sampling looks very good for GYN tumors. Given the anatomic similarities, it would make sense for prostate too. There is a decent literature suggesting it should work in prostate as well as an extended dissection though nothing randomized that I can recall off hand.

 

[TheWallnerus]

Indeed, previously they stopped. But current guidelines say that they should carry on.

Really. Urologists curing Stage IV prostate cancer now via scalpel?! Delusions of grandeur. I thought we were the only specialty that cures Stage IV!

 

[TheWallnerus]

What about going the other way? Sentinel sampling looks very good for GYN tumors. Given the anatomic similarities, it would make sense for prostate too. There is a decent literature suggesting it should work in prostate as well as an extended dissection though nothing randomized that I can recall off hand.

I’m totally not down with saying cancers behave similarly because they come from similar parts of the body, fwiw

I thought there was a pretty clear reason the staging systems have put prostate cancer that has spread to nodes in a stage IV (ie “incurable”) posture…

 

[communitydoc13]

curing Stage IV prostate cancer now via scalpel

Cure is a dirty word when it comes to prostate cancer. I'm sure you've seen Gleason 6 disease resected to negative margins and return 15-20 years later. I never talk about cure.

But the local treatment probably helps most the patients who have the lowest chances of cure (up to high metastatic burden disease of course).

I see 1-2 nodes per pelvic side often. Sometimes it's helpful (maybe), cause I think a positive pelvic node means something, and when everyone is confused because we are following the patients with ultrasensitive PSA assays now (what does a PSA of 0.04 really mean?) a positive node may drive me to early salvage.

 

[medgator]

Cure is a dirty word when it comes to prostate cancer. I'm sure you've seen Gleason 6 disease resected to negative margins and return 15-20 years later. I never talk about cure.

But the local treatment probably helps most the patients who have the lowest chances of cure (up to high metastatic burden disease of course).

I see 1-2 nodes per pelvic side often. Sometimes it's helpful (maybe), cause I think a positive pelvic node means something, and when everyone is confused because we are following the patients with ultrasensitive PSA assays now (what does a PSA of 0.04 really mean?) a positive node may drive me to early salvage.

You never "cure" htn or niddm either. You manage it as a chronic disease. Non visceral stage iv prostate can be similar in many cases

 

[TheWallnerus]

Cure is a dirty word when it comes to prostate cancer. I'm sure you've seen Gleason 6 disease resected to negative margins and return 15-20 years later. I never talk about cure.

But the local treatment probably helps most the patients who have the lowest chances of cure (up to high metastatic burden disease of course).

I see 1-2 nodes per pelvic side often. Sometimes it's helpful (maybe), cause I think a positive pelvic node means something, and when everyone is confused because we are following the patients with ultrasensitive PSA assays now (what does a PSA of 0.04 really mean?) a positive node may drive me to early salvage.

Really? I talk about cure all the time. Of course no man can predict the future but any time (almost every time) I am irradiating a prostate it’s for curative intent. And I tell the patient I am attempting to cure them too.

 

[communitydoc13]

Really? I talk about cure all the time. Of course no man can predict the future but any time (almost every time) I am irradiating a prostate it’s for curative intent. And I tell the patient I am attempting to cure them too.

Yeah, that's reasonable IMO just not my MO. When you plug in a 65 yo with Gleason 3+4=7 in 5/12 cores with PSA 10, T1c disease into the MSKCC pre-surgical nomogram, its gonna spit out a roughly 60% chance of biochemical control at 10 years. This is gonna be roughly mimicked by XRT.

I don't want the patient thinking in the cure/not cure paradigm, cause there's a pretty damn high chance that we will be dealing with biochemical failure in 10 years and I want them prepared for that.

I do let them know that the risk of them dying of the prostate cancer is very very low with treatment (low without).

 

[TheWallnerus]

Yeah, that's reasonable IMO just not my MO. When you plug in a 65 yo with Gleason 3+4=7 in 5/12 cores with PSA 10, T1c disease into the MSKCC pre-surgical nomogram, its gonna spit out a roughly 60% chance of biochemical control at 10 years. This is gonna be roughly mimicked by XRT.

I don't want the patient thinking in the cure/not cure paradigm, cause there's a pretty damn high chance that we will be dealing with biochemical failure in 10 years and I want them prepared for that.

I do let them know that the risk of them dying of the prostate cancer is very very low with treatment (low without).

Well huh. I didn’t seek out a philosophical discussion today but here it is. I would argue it is your MO to cure when irradiating prostate to high BED; that is the rad onc’s teleology, there is no other in that circumstance. (We even have to mark “curative” or “palliative” on most Rx sheets still too.) What’s in my brain comes out my mouth and in to my patients’ ears. “To cut is to cure,” say certain other doctors. Even when cutting away cancer they say this. If we had to not state why we are doing something due to the fact that there’s a non zero chance we won’t accomplish what we have set out do, no one could ever say what they’re about to attempt to do, or doing, as there are zero universal certainties.

 

[communitydoc13]

the rad onc’s teleology

I hate binaries. Just in my personality (creates problems with coding). My professional teleology is to treat to extend life, preserve QOL and sometimes improve QOL.

When the intention is to extend life and the statistics regarding life expectancy become poorly defined and exceed years, I call the treatment "curative" for billing purposes. But I'm rarely using the word cure with patients.

One of the great disservices that we've done with patients is to create a false binary at 5 years regarding being a "cancer survivor". Of course, you are a survivor from the day of diagnosis until death. Many ER+ breast cancer patients are at as much risk regarding their cancer moving past 5 years as before that milestone. (It is likely that vast majority of small cell lung CA patients are in fact "cured" at this time point, however their competing risks, including the risk of additional malignancy, are remarkably high).

 

[evilbooyaa]

Yeah, that's reasonable IMO just not my MO. When you plug in a 65 yo with Gleason 3+4=7 in 5/12 cores with PSA 10, T1c disease into the MSKCC pre-surgical nomogram, its gonna spit out a roughly 60% chance of biochemical control at 10 years. This is gonna be roughly mimicked by XRT.

I don't want the patient thinking in the cure/not cure paradigm, cause there's a pretty damn high chance that we will be dealing with biochemical failure in 10 years and I want them prepared for that.

I do let them know that the risk of them dying of the prostate cancer is very very low with treatment (low without).

You just described someone who would be cured 60% of the time.... Hell I call GBM patients curative intent if we're going to 60/30.

I hate binaries. Just in my personality (creates problems with coding). My professional teleology is to treat to extend life, preserve QOL and sometimes improve QOL.

When the intention is to extend life and the statistics regarding life expectancy become poorly defined and exceed years, I call the treatment "curative" for billing purposes. But I'm rarely using the word cure with patients.

One of the great disservices that we've done with patients is to create a false binary at 5 years regarding being a "cancer survivor". Of course, you are a survivor from the day of diagnosis until death. Many ER+ breast cancer patients are at as much risk regarding their cancer moving past 5 years as before that milestone. (It is likely that vast majority of small cell lung CA patients are in fact "cured" at this time point, however their competing risks, including the risk of additional malignancy, are remarkably high).

I get more of what you're saying here - the time frame for breast and prostate before we all have a deep exhale and "get to use the C word" is longer than most. And have anecdotes about recurrences > 10, at 12, 15, 20 years from th etime of initial therapy.

To OP - They are usually not 'dissections' more of 1-4 LNs on each side. There is NO advantage of a more significant disesction. It's not even prognostic beyond "yup, they are N+". You take some LNs just to ensure, as best as you can, that paitnet isn't pN+.

In an ideal world (to me), a frozen section showing N+ would stop the rest of the prostatectomy with a referral to radiation.

I don't really know if SLN has ever been evaluated in prostate but I agree with it in concept.

 

[DoctwoB]

Oh they always do lymphadenectomies...the pathologists just didn't do a good job looking for nodes .

You joke, but it’s not wrong. There’s good evidence that if you send the same sample eg (pelvic lymph nodes) in more specimens (left and right external and common illiacs) they find more nodes.

 

[DoctwoB]

Has a surgeon’s lymph node count ever been associated with improved… survival?

If a surgeon finds a positive node, do they continue on with the prostatectomy? I guess they probably don’t send for frozen intra op unless they find a very suspicious node.

Lot of retrospective data linking lymph node yields with recurrence free survival in bladder, less so in prostate. Randomized trial in bladder of limited V extended showed no significant difference but trend towards better in extended. ditto with prostate (data immature)

 

[TheWallnerus]

Lot of retrospective data linking lymph node yields with recurrence free survival in bladder, less so in prostate. Randomized trial in bladder of limited V extended showed no significant difference but trend towards better in extended. ditto with prostate (data immature)

"Has a surgeon’s lymph node count ever been associated with improved… survival?" (in prostate obv)

You could have just said "no"

 

[DoctwoB]

You just described someone who would be cured 60% of the time.... Hell I call GBM patients curative intent if we're going to 60/30.



I get more of what you're saying here - the time frame for breast and prostate before we all have a deep exhale and "get to use the C word" is longer than most. And have anecdotes about recurrences > 10, at 12, 15, 20 years from th etime of initial therapy.

To OP - They are usually not 'dissections' more of 1-4 LNs on each side. There is NO advantage of a more significant disesction. It's not even prognostic beyond "yup, they are N+". You take some LNs just to ensure, as best as you can, that paitnet isn't pN+.

In an ideal world (to me), a frozen section showing N+ would stop the rest of the prostatectomy with a referral to radiation.

I don't really know if SLN has ever been evaluated in prostate but I agree with it in concept.

Not sure why a frozen node should stop a surgery. 15-30% of pN+ disease will not recur after surgery and never need additional lines of therapy. By doing laparoscopy and placing ports you’ve done a big chunk of the surgical morbidity. You’re also adding 15-20 min of anesthesia per case by waiting for frozen with your thumb up your a**. Of those who will progress, plenty of data (stampede, Belgian registry, Chinese RCT) that local therarapy improved their outcomes. And while you could argue about less morbid xrt, you can also argue for lower local failure/future surgery rates after prostatectomy.

 

[TheWallnerus]

15-30% of pN+ disease will not recur after surgery and never need additional lines of therapy.

You referring pN+ disease for: 1) nothing 2) RT 3) ADT 4) RT+ADT?

 

[medgator]

You referring pN+ disease for: 1) nothing 2) RT 3) ADT 4) RT+ADT?

Have seen one high volume GU pick #1 before, more than once

 

[communitydoc13]

You referring pN+ disease for: 1) nothing 2) RT 3) ADT 4) RT+ADT?

What's the right thing to do here?

If PSA undetectable, usually I wait. If detectable by ultrasensitive assay, I will usually treat with RT and ADT.

Agree that fine to complete prostatectomy with positive node.

 

[TheWallnerus]

What's the right thing to do here

Was there data at ASTRO this year trying to answer this question

I’m still an adjuvant guy here vs salvagr

 

[communitydoc13]

Well NRG-GU008 is a salvage trial in the pN+ post-prostatectomy setting

 

[medgator]

What's the right thing to do here?

If PSA undetectable, usually I wait. If detectable by ultrasensitive assay, I will usually treat with RT and ADT.

Agree that fine to complete prostatectomy with positive node.

I thought all N+ at least get some ADT after?

 

[communitydoc13]

I thought all N+ at least get some ADT after?

I have not been doing/seeing this. Agree with the GU008 model (except for including apa instead of just abi but I digress). They will usually become detectable and I do not wait for 0.2. Any bump on US assay would prompt treatment on this study and in my clinic.

I have waited a small amount after initial detection on US assay (case by case and per patient preference) as PSMA PET going to have terrible sensitivity with a PSA below 0.1.

 

[DoctwoB]

What's the right thing to do here?

If PSA undetectable, usually I wait. If detectable by ultrasensitive assay, I will usually treat with RT and ADT.

Agree that fine to complete prostatectomy with positive node.

That is my approach as well. If PSA is reasonably elevated (i.e .5 and not 0.03) and patient hasn't had one already I'll also get a PSMA PET scan

 

[DoctwoB]

I thought all N+ at least get some ADT after?

They do if you believe the messing trial. Immediate versus deferred androgen deprivation treatment in patients with node-positive prostate cancer after radical prostatectomy and pelvic lymphadenectomy

The problem is that trial compared lifelong ADT vs. waiting to symptomatic or radiographic progression on standard imaging without any thought given to PSA dynamics, which is how most of us would manage these patients currently (if not immediately providing adjuvant therapy, which is also reasonable)

 

[TheWallnerus]

They do if you believe the messing trial. Immediate versus deferred androgen deprivation treatment in patients with node-positive prostate cancer after radical prostatectomy and pelvic lymphadenectomy

The problem is that trial compared lifelong ADT vs. waiting to symptomatic or radiographic progression on standard imaging without any thought given to PSA dynamics, which is how most of us would manage these patients currently (if not immediately providing adjuvant therapy, which is also reasonable)

Messing is kind of anathema in #radonc world