1 / 25

Lymphadenectomy in the surgical treatment of prostate cancer - does it influence survival?

Lymphadenectomy in the surgical treatment of prostate cancer - does it influence survival?. Oliver Hakenberg Urologische Klinik und Poliklinik Universitätsklinikum Rostock. Incidence and mortality of prostate cancer in Europe 1998. Davidson & Gabbay, WHO Report 2007. Pelvic lymphadenectomy.

chynna
Download Presentation

Lymphadenectomy in the surgical treatment of prostate cancer - does it influence survival?

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Lymphadenectomy in the surgical treatment of prostate cancer - does it influence survival? Oliver Hakenberg Urologische Klinik und Poliklinik Universitätsklinikum Rostock

  2. Incidence and mortality of prostate cancer in Europe 1998 Davidson & Gabbay, WHO Report 2007

  3. Pelvic lymphadenectomy • Node-positive prostate cancer is a systemic disease • Surgery should be aborted if pelvic lymph nodes are positive

  4. trends in risk stratification of surgically treated prostate cancer (CaPSURE) Cooperberg et al, J Urol 2003, 170, S21ff

  5. temporal trends in RPE • Retrospective study • n=37 centres 5291 patients Stage shift PSA-recurrence = 36% Chun & Djavan et al, Eur Urol 2007, 52, 1067-75

  6. Lymphadenectomy - pros and cons • Pro • A significant percentage of patients will harbour N+ disease • Better staging with LAE • LAE in limited N+ will be curative • Con • Overtreatment in most patients • Associated with morbidity • No influence on outcome

  7. Incidence of pN+ in RPE Burckhardt et al, Eur Urol, 2002 Allaf et al, J Urol 2004 Masterson et al, J Urol 2006 Briganti et al, Urology 2007 Weckermann & Wawroschek et al, J Urol 2007

  8. Partin tables for the preoperative predictionof pathologic stage

  9. Difference in Gleason Score: original vs. reference pathology

  10. n=2.295 Mayo % organ confined Line of equality Predicted % organ confined by Partin tables Validation of the Partin tables for the prediction of an organ-confined cancer Blute et al. J Urol 164, 2000

  11. Sentinel nodes and radio-guided surgery Jeschke et al, J Urol 2005 Weckermann & Wawroschek et al, J Urol 2007

  12. Lymphocelesclinical series

  13. Lymphocelesby imaging studies • 33% with ultrasound • 27% with ultrasound • 61% with CT scanning Hakenberg et al, Eur Urol 2005 Spring et al, Radiology 1981 Solberg et al, Scand J Urol Nephrol 2003

  14. n= 446 consecutive RPEs • pelvic U/S and venous duplex sonography on days 0, 8 and 21 • 146 pelvic lymphoceles (size 1-20 cm) - 32.7% • 18.7% day 8, 27.9% day 21 • only 26 with venous thromboses, 13/26 with measurable reduction in venous flow • 73 patients with venous thromboses - 16.4% • 7.2% day 8, 10.5% day 21. • 3 patients with distal thromboses (calf muscles) were diagnosed preoperatively • majority of thromboses was distal and small • DVTs: day 8 n=4, day 21 n=10 • pulmonary emboli: day 8 n=2, day 21 n=2 • A reduction in venous flow was seen only in patients with lymphoceles Hakenberg et al, Eur Urol 2005

  15. Extent of PLND • Limited (standard) = obturator fossa • Modified = + internal iliac artery • Extended = + common iliac artery

  16. Standard PLND underestimates nodal disease • n = 100 standard vs n= 103 extended PLND Heidenreich et al, 2002

  17. Standard PLND underestimates nodal diseaselaparoscopic RPE Stone et al, 1997 Touijer & Guilloneau, 2006

  18. pN+ disease in Bernen= 365-463 consecutive RPE patients, 50.6% pT2 Bader et al, J Urol, 2002 Bader et al, J Urol, 2003 Burckhardt et al, Eur Urol, 2002

  19. But…contemporaray RPE • n= 123 • Limited vs extended PLND on either side • PSA 7.4 ng/ml, 72% cT1c • Extended: 4 pN+ • Limited: 3 pN+ Clark et al, 2003

  20. Extent of PLND and pN+ yield • n= 858 • PSA 5.8 ng/ml • 55% pT1c, 41% pT2 • 14 nodes (mean) • 10.3% pN+ • 2-10 nodes: 5.6% pN+ • 20-40 nodes: 17.6% pN+ • no of nodes examined predicted for pN+: p<0.001 • < 10 nodes examined: 0% probability of pN+ • > 28 nodes: 90% probability of detecting pN+ Briganti et al, Urology 2007

  21. Volume of N+ disease and progression Cheng et al, Am J Surg Pathol 1998 Daneshmand et al, J Urol 2004 Golimkbu et al, Urology 1987

  22. Influence of PLND with limited N+ -disease on PFS Allaf et al, J Urol 2004

  23. Influence on survival?

  24. Influence on survival?

  25. Conclusions • PLND carries morbidity • many positive nodes are outside obturator fossa • the more nodes removed the more likely the detection of positive nodes • no influence of limited PLND on survival • influence of extended PLND on PFS is unclear but likely • extent of PLAD should depend on case and case mix • low risk PCa (Gleason < 7 and PSA < 10 ng/ml) does not need PLAD

More Related