Removal of Limited Nodal Disease in Patients Undergoing Radical Prostatectomy: Long-Term Results Confirm a Chance for Cure

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  • Abbreviationsand Acronyms

    ADT androgen deprivationtherapy

    CSS cancer specific survivalPLND pelvic lymph nodedissection

    PSA prostate specific antigen

    Accepted for publication November 13, 2013.* Correspondence: Department of Urology,

    University of Bern, CH-3010 Bern, Switzerland(telephone: 41 31 632 3641; FAX: 41 31 6322180; e-mail: fiona.burkhard@insel.ch).

    For another article on a relatedtopic see page 1439.

    1280 j www.jurology.com00T

    Removal of Limited Nodal Disease in Patients UndergoingRadical Prostatectomy: Long-Term Results Confirm a Chancefor Cure

    Roland Seiler, Urs E. Studer, Konrad Tschan, Pia Bader and Fiona C. Burkhard*

    From the Department of Urology, University of Bern, Bern, Switzerland

    Purpose: In 2003 we reported on the outcomes of 88 patients with node positivedisease who underwent radical prostatectomy and pelvic lymph node dissection(median 21 nodes) between 1989 and 1999. Patients with limited nodal diseaseappeared to have a good chance of long-term survival, even without immediateadjuvant therapy (androgen deprivation therapy and/or radiotherapy). In thisstudy we update the followup in these patients and verify the reported projectedprobability of survival.

    Materials and Methods: The projected 10-year cancer specific survival proba-bility after the initially reported followup of 3.2 years was 60% for these patientswith node positive disease. The outcome has been updated after a medianfollowup of 15.6 years.

    Results: Of the 39 patients with 1 positive node 7 (18%) remained biochemicallyrelapse-free, 11 (28%) showed biochemical relapse only and 21 (54%) experiencedclinical progression. Of these 39 patients 22 (57%) never required deferredandrogen deprivation therapy and 12 (31%) died of prostate cancer. All patientswith 2 (20) or more than 2 (29) positive nodes experienced biochemical relapseand only 5 (10%) of these 49 experienced no clinical progression. Of these49 patients 39 (80%) received deferred androgen deprivation therapy.

    Conclusions: Biochemical relapse is likely in patients with limited nodal diseaseafter radical prostatectomy and pelvic lymph node dissection, but for 46% ofpatients this does not imply death from prostate cancer. Patients with 1 positivenode have a good (75%) 10-year cancer specific survival probability and a 20%chance of remaining biochemical relapse-free even without immediate adjuvanttherapy.

    Key Words: prostatic neoplasms, lymphatic metastasis,prostatectomy, treatment outcome

    PELVIC lymph node dissection inpatients with prostate cancer re-mains the most accurate and reliablestaging procedure for the detection oflymph node metastases. Despite exten-sive research, neither imaging tech-niques1,2 nor lymphoscintigraphy3e5

    are yet able to replace PLND forprostate cancer due to their lowsensitivity. In fact, technetium based

    22-5347/14/1915-1280/0HE JOURNAL OF UROLOGY

    2014 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARC

    lymphoscintigraphy can miss up to30% of diseased nodes.4

    The incidence of nodal metastasisafter radical prostatectomy andPLNDin patients with presumed clinicallylocalized prostate cancer was 20%to 40% in the 1970s and 1980s6,7 andhas decreased more recently to 4%to 10%, depending on patient selec-tion and PLND technique.8,9 There is

    H, INC.

    http://dx.doi.org/10.1016/j.juro.2013.11.029Vol. 191, 1280-1285, May 2014

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    mailto:fiona.burkhard@insel.chhttp://www.jurology.comhttp://dx.doi.org/10.1016/j.juro.2013.11.029
  • SURVIVAL OF PATIENTS WITH NODE POSITIVE DISEASE AFTER RADICAL PROSTATECTOMY 1281

    increasing evidence that a subset of patients mayhave a survival benefit from surgery alone whileothers may profit from multimodal therapy. How-ever, the majority of studies evaluating these ques-tions had a limited followup10,11 and have mainlyincluded patients on immediate ADT.12e15 There-fore, we updated the followup in 88 patients whounderwent radical prostatectomy with PLND be-tween 1989 and 1999, and were diagnosed withlymph nodemetastases at histological evaluation butdid not receive immediate adjuvant therapy (ADTand/or radiotherapy).16

    PATIENTS AND METHODS

    PatientsThe clinicopathological characteristics of the 88 patients(median age 64 years, range 44 to 76) who underwentradical retropubic prostatectomy and PLND between 1989and 1999 are shown in table 1. Despite clinically organconfined prostate cancer as well as negative preoperativeabdominopelvic computerized tomography, bone scan andchest x-ray, all 88 patients had positive lymph nodes onhistopathological evaluation. Overall 39 of these patients(44%) had 1 positive node, 20 (23%) had 2 positive nodesand 29 (33%) had more than 2 positive nodes. More thantwo-thirds of the patients had primary tumors withextraprostatic extension. Median preoperative PSA was11.9 ng/ml (range 0.4 to 172). None of the patients receivedpreoperative treatment for prostate cancer such as ADT orradiotherapy. Patients with pathologically enlargedlymph nodes at preoperative staging or with incompletepreoperative diagnostic evaluation (no computerized to-mography or bone scan) were excluded from this study.The 88 patients were prospectively followed for biochem-ical relapse, clinical progression (defined as documentedbone metastases, visceral metastases, lymphatic progres-sion or local recurrence) and cancer specific survival.

    Surgical Technique and PathologyAll patients underwent open PLND followed by radicalretropubic prostatectomy. Preserving the lymphatics

    Table 1. Clinicopathological characteristics of patients

    Median age at surgery (range) 62 (35e78)Median yrs followup (range, 95% CI) 15.6 (1.1e22.4, 14.7e16.5)No. death from prostate Ca (%) 47 (53)No. death from any cause (%) 14 (16)No. pT stage (%):Organ confined (pT2c or less) 27 (31)Extracapsular extension (pT3a) 14 (16)Invasion of seminal vesicles (pT3b) 45 (51)Invasion of bladder neck, external

    sphincter (pT4)2 (2)

    No. Gleason score (%):6 or Less 24 (27)7 38 (43)8e10 26 (30)

    Median evaluated nodes/pt (range) 21 (6e41)No. pos nodes (%):1 39 (44)2 20 (23)More than 2 29 (33)

    overlying the anterolateral aspect of the external iliacartery, lymph node dissection was performed along theexternal iliac vein, with the caudal limit being the deepcircumflex iliac vein and the femoral canal. All lymphaticvessels from the lower extremities were ligated. Theproximal border was the bifurcation of the common iliacartery. All tissue in the angle between the external andinternal iliac artery was removed. All fatty, connectiveand lymphatic tissue of the obturator fossa along theobturator muscle was removed, leaving only the obturatornerve and vessels. The internal iliac artery and, as far aspossible, the internal iliac vein, were skeletonized. Threedifferent tissue samples on each side, labeled externaliliac, obturator fossa and internal iliac, were sent sepa-rately for histological evaluation. No frozen sections weredone. In 2 patients surgery was aborted after lymph nodedissection because of large palpable lymph node metas-tases and these patients were not included in the study.

    All lymph node specimens removed during surgerywere fixed in neutral buffered 4% formaldehyde for24 hours and placed in acetone to dissolve the fatty tissue.Lymph nodes were meticulously searched for and countedmanually. Each node was cut in 3 mm slices which wereseparately embedded in paraffin, stained with hematox-ylin and eosin, and examined microscopically for thepresence of cancer by pathologists. No immunohisto-chemical staining for keratin or PSA or reversetranscriptase-polymerase chain reaction technology wasused. All tumors and lymph node metastases were stagedaccording to the 6th edition TNM classification.17

    Adjuvant TreatmentNo adjuvant therapy such as hormonal treatment orradiotherapy was recommended in these patients withlymph node positive disease but 4 patients received ADTwithin 6 months after surgery. ADT or radiotherapy wasonly recommended and initiated at the appearance ofsymptoms or if clinically life threatening progressionoccurred (eg bladder outlet obstruction, gross hematuriaor hydronephrosis due to local progression, pain, visceralor bone metastases, or lymphedema caused by lymph nodemetastasis).

    Statistical AnalysesTo estimate biochemical relapse-free, clinical progression-free and cancer specific survival, Kaplan-Meier estimateswere used for all 88 patients. Patients alive at the lastevaluation or relapse-free at the time of death werecensored. The log rank test was used to evaluate differ-ences among the subgroups. Cox proportional hazardsregression models were applied to determine the effect ofthe number of diseased lymph nodes on outcome inmultivariate setting. A significance level of 0.05 was usedfor all tests and all statistical analyses were performedusing SPSS 20.0 software.

    RESULTSAfter a median followup of 15.6 years 81 of the88 patients (92%) had biochemical relapse and65 (74%) showed clinical progression, 90% of whomwithin 5 years after the diagnosis of biochemical

  • Table 2. Outcome of patients with lymph node metastasesfrom prostate cancer after a median followup of 15.6 years

    No. pos nodes 1 2 Greater than 2 TotalsNo. pts 39 20 29 88No. biochemical relapse-free (%) 7 (18) 0 (0) 0 (0) 7 (8)No. biochemical relapse only (%) 11 (28) 3 (15) 2 (7) 16 (18)No. clinical progression (%) 21 (54) 17 (85) 27 (93) 65 (74)No. Ca related deaths (%) 12 (31) 14 (70) 21 (72) 47 (53)

    1282 SURVIVAL OF PATIENTS WITH NODE POSITIVE DISEASE AFTER RADICAL PROSTATECTOMY

    relapse. Of the 88 patients 56 (64%) required ADTdue to clinical progression observed a median of2.9 years (range 0.3 to 14.6) after surgery. Overall61 of the 88 patients (69%) died, including 47 (53%)of prostate cancer and 1