Articles

Platinum Priority – Prostate Cancer
Editorial by Alberto Briganti, Nazareno Suardi, Andrea Gallina, Firas Abdollah and Francesco Montorsi on pp. 459–461 of this issue

Mapping of Pelvic Lymph Node Metastases in Prostate Cancer

By: Steven Joniau a lowast , Laura Van den Bergh b , Evelyne Lerut c , Christophe M. Deroose d , Karin Haustermans b , Raymond Oyen e , Tom Budiharto b , Filip Ameye a , Kris Bogaerts f and Hein Van Poppel a

European Urology, Volume 63 Issue 1, March 2013, Pages 450-458

Published online: 01 March 2013

Keywords: Lymphadenectomy, Lymph node dissection template, Lymph node staging, Prostate cancer

Abstract Full Text Full Text PDF (1,3 MB)

Abstract

Background

Opinions about the optimal lymph node dissection (LND) template in prostate cancer differ. Drainage and dissemination patterns are not necessarily identical.

Objective

To present a precise overview of the lymphatic drainage pattern and to correlate those findings with dissemination patterns. We also investigated the relationship between the number of positive lymph nodes (LN+) and resected lymph nodes (LNs) per region.

Design, setting, and participants

Seventy-four patients with localized prostate adenocarcinoma were prospectively enrolled. Patients did not show suspect LNs on computed tomography scan and had an LN involvement risk of ≥10% but ≤35% (Partin tables) or a cT3 tumor.

Intervention

After intraprostatic technetium-99m nanocolloid injection, patients underwent planar scintigraphy and single-photon emission computed tomography imaging. Then surgery was performed, starting with a sentinel node (SN) procedure and a superextended lymphadenectomy followed by radical prostatectomy.

Outcome measurements and statistical analysis

Distribution of scintigraphically detected SNs and removed SNs per region were registered. The number of LN+, as well as the percentage LN+ of the total number of removed LNs per region, was demonstrated in combining data of all patients. The impact of the extent of LND on N-staging and on the number of LN+ removed was calculated.

Results and limitations

A total of 470 SNs were scintigraphically detected (median: 6; interquartile range [IQR]: 3–9), of which 371 SNs were removed (median: 4; IQR: 2.25–6). In total, 91 LN+ (median: 2; IQR: 1–3) were found in 34 of 74 patients. The predominant site for LN+ was the internal iliac region. An extended LND (eLND) would have correctly staged 32 of 34 patients but would have adequately removed all LN+ in only 26 of 34 patients. When adding the presacral region, these numbers increased to 33 of 34 and 30 of 34 patients, respectively.

Conclusions

Standard eLND would have correctly staged the majority of LN+ patients, but 13% of the LN+ would have been missed. Adding the presacral LNs to the template should be considered to obtain a minimal template with maximal gain.

Note

This manuscript was invited based on the 2011 European Association of Urology meeting in Vienna.

Take Home Message

When prostate cancer disseminates to the nodal basin, a clear hierarchic pattern in nodal spread exists. Based on our findings, the presacral nodes should be added to the standard extended lymph node dissection to obtain a minimal template with maximal gain.

Keywords: Lymphadenectomy, Lymph node dissection template, Lymph node staging, Prostate cancer.

Footnotes

a Department of Urology, University Hospitals Leuven, Leuven, Belgium

b Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium

c Department of Histopathology, University Hospitals Leuven, Leuven, Belgium

d Department of Nuclear Medicine, University Hospitals Leuven, Leuven, Belgium

e Department of Radiology, University Hospitals Leuven, Leuven, Belgium

f L-Biostat, Catholic University of Leuven, Leuven, Belgium

lowast Corresponding author. Department of Urology, UH Leuven Campus Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium. Tel. +32 0 16346687; Fax: +32 0 16346931.

Steven Joniau and Laura Van den Bergh are joint first authors of this paper.

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