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The role of pelvic lymph node dissection in prostate cancer: Extended vs standard

Presented by
Dr Karim Touijer, Dr Akshay Sood
EAU 2019
One prospective study presented showed no benefit of extended PLND, whereas a large retrospective study did point to decreased mortality after PLND.

Dr Karim Touijer et al. (Sloan Kettering Cancer Center, USA) presented a single-centre prospective RCT including 1,480 men with intermediate- to high-risk disease to assess outcomes of limited vs extended lymph node dissection in patients undergoing open, laparoscopic, and robotic prostatectomy for localised prostate cancer. No differences were observed in biochemical-free survival comparing the limited and extended dissection groups.

The patients were randomised to limited pelvic lymph node dissection (PLND; obturator fossa, n=723) or extended PLND (obturator, hypogastric, and external iliac dissection, n=757) groups, which had similar demographics including age, preoperative PSA, Gleason Grade, the presence of extracapsular extension, nodal disease, and seminal vesical invasion. The primary endpoint was time to biochemical recurrence. Each surgeon was randomised, committing to limited or extended PLND for a 3-month period. The trial reported similar rates of grade 2/3 complications (12 vs 11%) and no grade 4/5 complications.

To summarise findings, no differences were seen in biochemical-free survival comparing the limited and extended template dissection groups. Subgroup analyses or meta-analysis did not render any statistical differences as well. It should be noted that the median number of nodes removed in this study was pretty much the same in both groups, which suggests a surgical bias towards more extensive lymph node dissection in the limited PLND group. Similarly, patients with higher risk of disease were less likely to be enrolled in the study overall.

On the other hand, there was retrospective evidence that showed somewhat opposite results, that extended PLND was beneficial to patients at high risk for lymph node invasion. Using the USA National Cancer Database (n=406,409 patients), Dr Akshay Sood et al. (Henry Ford Hospital, USA) showed that patients undergoing extended PLND (HR=1.22) had 8% incrementally lower risk of 10-year mortality as compared to patients undergoing none/limited PLND (HR=1.31). These data were highly significant (P<0.0001), albeit retrospective. The conclusion drawn from these two studies is that there may be a trend for benefit of extended PLND for patients with high-risk prostate cancer.

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