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293 LYMPH NODE DENSITY PREDICTS SURVIVAL OF PATIENTS WITH NODAL METASTASES AND PROSTATE CANCER ONLY IN PRESENCE OF MORE EXTENSIVE NODAL DISSECTION. IMPORTANCE OF ACCURATE STAGING
Vol. 185, No. 4S, Supplement, Sunday, May 15 , 2011
THE JOURNAL OF UROLOGY姞
CONCLUSIONS: In high-risk prostate cancer patients, neither cut-off of removed lymph nodes is a significant predictor of CSS, while a cut-off of at least 21 removed nodes predicts a significantly improved OS. Source of Funding: None
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293 LYMPH NODE DENSITY PREDICTS SURVIVAL OF PATIENTS WITH NODAL METASTASES AND PROSTATE CANCER ONLY IN PRESENCE OF MORE EXTENSIVE NODAL DISSECTION. IMPORTANCE OF ACCURATE STAGING Alberto Briganti*, Andrea Gallina, Nazareno Suardi, Umberto Capitanio, Manuela Tutolo, Marco Bianchi, Dario Di Trapani, Ettore Di Trapani, Luigi Filippo Da Pozzo, Renzo Colombo, Patrizio Rigatti, Francesco Montorsi, Milan, Italy
292 RADIO-GUIDED SENTINEL LYMPH NODE DISSECTION IN OVER 1,200 CASES WITH PROSTATE CANCER: RATE OF LYMPH NODE POSITIVE PATIENTS DEPENDING ON PREOPERATIVE PROGNOSTIC FACTORS Alexander Winter*, Rolf-Peter Henke, Friedhelm Wawroschek, Oldenburg, Germany INTRODUCTION AND OBJECTIVES: The pelvic lymphadenectomy (PLND) is currently the most reliable staging method for the detection of lymph node (LN) metastases in clinically localized prostate cancer. Any limitation of the dissection area decreased the sensitivity of detection of metastases. Therefore the European (EAU) guidelines recommend an extended or sentinel-guided PLND (SLND) at least for patients with intermediate or high risk disease. Based on this we analyzed the rate of LN positive (LN⫹) patients detected by SLND depending on preoperative prognostic factors and opposed them to nomogram data and the EAU guidelines. METHODS: We included 1,233 patients who had received a SLND and a radical retropubic prostatectomy (01/2005 – 12/2009). The average number of removed LN was determined. The rate of LN⫹ patients was analysed total, for low risk (PSA ⬍10, Gleason-Score (G.-S.) ⬍6 / ⱕT2a), intermediate risk (PSA 10 ⬍20 and/or G.-S. 7 and/or T2b) and high risk (PSA ⬎20 and/or G.-S. 8 –10 and/or ⱖT2c) prostate cancer. The results were compared with the partin tables and the recommendations of the EAU guidelines (no PLND: PSA ⬍20 / G.-S. ⬍6 / ⱕT2). RESULTS: An average of 10 LN was removed. 17.4% of the patients had LN metastases. The rate of LN⫹ patients were distributed as follows: low risk (n⫽436) 3.2%, intermediate risk (n⫽446) 14.8% and high risk prostate cancer (n⫽351) 38.2%. According to the partin tables one would have expected much less LN⫹ patients particularly in the low and high risk situation (Table 1). According to the EAU guideline 6.1% LN⫹ patients would not have been detected. In the cT2 tumors of this collective even 12.1% patients with LN metastases would not have been found. CONCLUSIONS: Because of their high sensitivity the SLND is regarded as optional to the extended PLND in the EAU guidelines. In our collective in all risk situations more LN⫹ patients were detected by SLND than expected according to the partin tables. In view of 12.1% LN⫹ patients in cT2 tumors which are not provide for a PLND in the EAU guidelines we consider the SLND even in such cases. The SLND offers a relative low expenditure and a minimal morbidity, without having to expect a significantly reduced detection of metastases. Rate of LN⫹ patients depending of preoperative prognostic factors Preoperative parameters Partin tables SLND PSA 6.1–10 / G.-S. ⬍⫽6 / T2a 0% 11% PSA ⬎10 / G.-S. 7 / T2b
29%
31%
PSA ⬎10 / G.-S. 8–10 / T2c
26%
75%
Source of Funding: None
INTRODUCTION AND OBJECTIVES: Lymph node density (LND) has previously been shown to be a significant predictor of survival in patients with prostate cancer and lymph node invasion (LNI) treated with radical prostatectomy (RP) and pelvic lymph node dissection (PLND). However, such association might be strongly related to the extent of PLND, since less extensive dissection are associated with high rates of non-detected nodal metastases. We hypothesized that LND may be influenced by the extent of PLND and it might not predict survival in patients with more limited PLND due to a less accurate nodal staging. METHODS: The study included 689 patients with LNI treated with RP and extended PLND between January 1990 and July 2008 at a single tertiary referral center. All patients underwent an anatomically defined extended PLND (including removal of obturator, external iliac and hypogastric nodes ⫹/⫺ common iliac nodes). Patients were divided according to the number of nodes removed: ⬍15 (n⫽ 244, 35.4%; group 1) and ⱖ15 nodes (n⫽445, 64.6%; group 2). KaplanMeier curves assessed cancer specific survival (CSS) rates. Univariable and multivariable models tested the association between predictors and CSS in both groups. Predictors included age at surgery, pre-operative PSA, pathological stage, pathological Gleason score, lymph node density, and adjuvant radiotherapy. RESULTS: Mean age was 65.6 years (median: 65.9; range: 44 – 83). Mean PSA was 34.1 ng/ml (median 12.5; range 0.6 –350 ng/ml). The mean number of lymph nodes removed was 19 (median: 17; range:4 – 63) while the mean number of positive lymph nodes was 3.5 (median: 2; range:1–59). The actuarial OS and CSS rate at 5,8 and 10 years was 83 and 88, 74 and 80, 71 and 77%, respectively. Overall, LND represented an univariate and multivariate significant predictor of CSS (p⫽0.001). However, when the same analyses were repeated in each group (namely, ⬍15 vs ⱖ15 nodes), LND was significantly associated with CSS only in patient with more extensive nodal dissections (group 1 vs group 2: p⫽0.7 vs p⬍0.001, respectively) even after accounting for all the mentioned predictors. CONCLUSIONS: Our study represents the first analysis reporting a significant correlation between LND and the extent of PLND in node positive prostate cancer. Lymph node density does represent a multivariate significant predictor of CSS only in patients with more extensive PLND, probably due to a more accurate nodal staging. These results seem to support the need for more extensive PLND in patients with positive lymph nodes. Source of Funding: None
294 IN HIGH-RISK PROSTATE CANCER, 3 OR MORE POSITIVE NODES AT RADICAL PROSTATECTOMY REPRESENT AN INDEPENDENT PREDICTOR OF WORSE CSS, WHILE 1 OR 2 POSITIVE NODES DO NOT INFLUENCE CSS Steven Joniau, Anthony Van Baelen*, Leuven, Belgium; Paolo Gontero, Turin, Italy; Alberto Briganti, Milan, Italy; Giansilvio Marchioro, Novara, Italy; Umberto Capitanio, Milan, Italy; Pia Bader, Karlsruhe, Germany; Bertrand Tombal, Brussels, Belgium; Klara Bury, Leuven, Belgium; Bruno Frea, Novara, Italy; Alessandro Tizzani, Turin, Italy; Hubertus Riedmiller, Wu¨rzburg, Germany; Hein Van Poppel, Leuven, Belgium; Martin Spahn, Wu¨rzburg, Germany INTRODUCTION AND OBJECTIVES: The finding of nodal metastases (N⫹) at the time of radical prostatectomy (RP) and pelvic
THE JOURNAL OF UROLOGY姞
CONCLUSIONS: In high-risk prostate cancer patients, neither cut-off of removed lymph nodes is a significant predictor of CSS, while a cut-off of at least 21 removed nodes predicts a significantly improved OS. Source of Funding: None
e119
293 LYMPH NODE DENSITY PREDICTS SURVIVAL OF PATIENTS WITH NODAL METASTASES AND PROSTATE CANCER ONLY IN PRESENCE OF MORE EXTENSIVE NODAL DISSECTION. IMPORTANCE OF ACCURATE STAGING Alberto Briganti*, Andrea Gallina, Nazareno Suardi, Umberto Capitanio, Manuela Tutolo, Marco Bianchi, Dario Di Trapani, Ettore Di Trapani, Luigi Filippo Da Pozzo, Renzo Colombo, Patrizio Rigatti, Francesco Montorsi, Milan, Italy
292 RADIO-GUIDED SENTINEL LYMPH NODE DISSECTION IN OVER 1,200 CASES WITH PROSTATE CANCER: RATE OF LYMPH NODE POSITIVE PATIENTS DEPENDING ON PREOPERATIVE PROGNOSTIC FACTORS Alexander Winter*, Rolf-Peter Henke, Friedhelm Wawroschek, Oldenburg, Germany INTRODUCTION AND OBJECTIVES: The pelvic lymphadenectomy (PLND) is currently the most reliable staging method for the detection of lymph node (LN) metastases in clinically localized prostate cancer. Any limitation of the dissection area decreased the sensitivity of detection of metastases. Therefore the European (EAU) guidelines recommend an extended or sentinel-guided PLND (SLND) at least for patients with intermediate or high risk disease. Based on this we analyzed the rate of LN positive (LN⫹) patients detected by SLND depending on preoperative prognostic factors and opposed them to nomogram data and the EAU guidelines. METHODS: We included 1,233 patients who had received a SLND and a radical retropubic prostatectomy (01/2005 – 12/2009). The average number of removed LN was determined. The rate of LN⫹ patients was analysed total, for low risk (PSA ⬍10, Gleason-Score (G.-S.) ⬍6 / ⱕT2a), intermediate risk (PSA 10 ⬍20 and/or G.-S. 7 and/or T2b) and high risk (PSA ⬎20 and/or G.-S. 8 –10 and/or ⱖT2c) prostate cancer. The results were compared with the partin tables and the recommendations of the EAU guidelines (no PLND: PSA ⬍20 / G.-S. ⬍6 / ⱕT2). RESULTS: An average of 10 LN was removed. 17.4% of the patients had LN metastases. The rate of LN⫹ patients were distributed as follows: low risk (n⫽436) 3.2%, intermediate risk (n⫽446) 14.8% and high risk prostate cancer (n⫽351) 38.2%. According to the partin tables one would have expected much less LN⫹ patients particularly in the low and high risk situation (Table 1). According to the EAU guideline 6.1% LN⫹ patients would not have been detected. In the cT2 tumors of this collective even 12.1% patients with LN metastases would not have been found. CONCLUSIONS: Because of their high sensitivity the SLND is regarded as optional to the extended PLND in the EAU guidelines. In our collective in all risk situations more LN⫹ patients were detected by SLND than expected according to the partin tables. In view of 12.1% LN⫹ patients in cT2 tumors which are not provide for a PLND in the EAU guidelines we consider the SLND even in such cases. The SLND offers a relative low expenditure and a minimal morbidity, without having to expect a significantly reduced detection of metastases. Rate of LN⫹ patients depending of preoperative prognostic factors Preoperative parameters Partin tables SLND PSA 6.1–10 / G.-S. ⬍⫽6 / T2a 0% 11% PSA ⬎10 / G.-S. 7 / T2b
29%
31%
PSA ⬎10 / G.-S. 8–10 / T2c
26%
75%
Source of Funding: None
INTRODUCTION AND OBJECTIVES: Lymph node density (LND) has previously been shown to be a significant predictor of survival in patients with prostate cancer and lymph node invasion (LNI) treated with radical prostatectomy (RP) and pelvic lymph node dissection (PLND). However, such association might be strongly related to the extent of PLND, since less extensive dissection are associated with high rates of non-detected nodal metastases. We hypothesized that LND may be influenced by the extent of PLND and it might not predict survival in patients with more limited PLND due to a less accurate nodal staging. METHODS: The study included 689 patients with LNI treated with RP and extended PLND between January 1990 and July 2008 at a single tertiary referral center. All patients underwent an anatomically defined extended PLND (including removal of obturator, external iliac and hypogastric nodes ⫹/⫺ common iliac nodes). Patients were divided according to the number of nodes removed: ⬍15 (n⫽ 244, 35.4%; group 1) and ⱖ15 nodes (n⫽445, 64.6%; group 2). KaplanMeier curves assessed cancer specific survival (CSS) rates. Univariable and multivariable models tested the association between predictors and CSS in both groups. Predictors included age at surgery, pre-operative PSA, pathological stage, pathological Gleason score, lymph node density, and adjuvant radiotherapy. RESULTS: Mean age was 65.6 years (median: 65.9; range: 44 – 83). Mean PSA was 34.1 ng/ml (median 12.5; range 0.6 –350 ng/ml). The mean number of lymph nodes removed was 19 (median: 17; range:4 – 63) while the mean number of positive lymph nodes was 3.5 (median: 2; range:1–59). The actuarial OS and CSS rate at 5,8 and 10 years was 83 and 88, 74 and 80, 71 and 77%, respectively. Overall, LND represented an univariate and multivariate significant predictor of CSS (p⫽0.001). However, when the same analyses were repeated in each group (namely, ⬍15 vs ⱖ15 nodes), LND was significantly associated with CSS only in patient with more extensive nodal dissections (group 1 vs group 2: p⫽0.7 vs p⬍0.001, respectively) even after accounting for all the mentioned predictors. CONCLUSIONS: Our study represents the first analysis reporting a significant correlation between LND and the extent of PLND in node positive prostate cancer. Lymph node density does represent a multivariate significant predictor of CSS only in patients with more extensive PLND, probably due to a more accurate nodal staging. These results seem to support the need for more extensive PLND in patients with positive lymph nodes. Source of Funding: None
294 IN HIGH-RISK PROSTATE CANCER, 3 OR MORE POSITIVE NODES AT RADICAL PROSTATECTOMY REPRESENT AN INDEPENDENT PREDICTOR OF WORSE CSS, WHILE 1 OR 2 POSITIVE NODES DO NOT INFLUENCE CSS Steven Joniau, Anthony Van Baelen*, Leuven, Belgium; Paolo Gontero, Turin, Italy; Alberto Briganti, Milan, Italy; Giansilvio Marchioro, Novara, Italy; Umberto Capitanio, Milan, Italy; Pia Bader, Karlsruhe, Germany; Bertrand Tombal, Brussels, Belgium; Klara Bury, Leuven, Belgium; Bruno Frea, Novara, Italy; Alessandro Tizzani, Turin, Italy; Hubertus Riedmiller, Wu¨rzburg, Germany; Hein Van Poppel, Leuven, Belgium; Martin Spahn, Wu¨rzburg, Germany INTRODUCTION AND OBJECTIVES: The finding of nodal metastases (N⫹) at the time of radical prostatectomy (RP) and pelvic