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Laparoscopic pelvic lymphadenectomy (PLA) in prostate cancer staging and impact on radiotherapy fields
Abstracts
261
AUC and Se for each biopsy approach at different volume thresholds for detection of a significant cancer. Definition of significant cancer
TPM (AUC/Se)
TRUS + Ant Number of (AUC/Se) specimens with a significant cancer
Cancer ≥ 0.2 cc and/or Gleason ≥ 7 Cancer ≥ 0.5 cc and/or Gleason ≥ 7
0.91/97%
0.78/56%
36/96 (=38%)
0.91/96%
0.80/65%
21/96 (=22%)
doi:10.1016/j.bjmsu.2010.09.011 4 Laparoscopic pelvic lymphadenectomy (PLA) in prostate cancer staging and impact on radiotherapy fields C.P. Poullis, S. Agrawal, K. Contractor, S. Mangar, S. Hazell, M. Winkler Charing Cross Hospital, London, United Kingdom Introduction: Staging PLA in high risk prostate cancer may help to determine suitability for radical treatment or whole pelvis radiation. Additionally, long-term androgen deprivation therapy may be avoided. We assess the role and safety of PLA. Methods: Patients with high-risk prostate cancer were selected prospectively. Indications for PLA included a risk of nodal metastases >30% (Roach formula, clinical T3 or radiological N1 disease on MRI). Standard template lymphadenectomy was performed. Results: 36 patients underwent staging PLA. No statistically significant difference in Gleason score, T stage, presenting PSA, or number of nodes resected, was seen for node positive disease. Mean PSA was 44.5 ng/ml. 95% of patients were discharged within 24 h, with no intra-operative complications. The mean number of nodes removed was 14 (SD ± 4). 30% (10/36) experienced early complications which resolved (lymphocoele formation 13%, lymphoedema 8%, scrotal oedema 3%, and obturator nerve paraesthesia 5%). One patient developed a small pulmonary embolus and was anti-coagulated. Node positivity was observed in 30% of patients with PLA compared to 19% detected on MRI. Overall, 70% of cases were node negative and did not undergo whole pelvic radiotherapy, which would have been standard treatment. PLA upstaged MR from N0 to N1 in
36% of cases, and down-staged radiological N1 to N0 disease in 8%. Conclusions: Staging PLA provides valuable prognostic data. It is a well-tolerated diagnostic modality but is associated with morbidity in keeping with published data. It appears more reliable than conventional MRI in stratifying patients suitable for whole pelvis radiotherapy. doi:10.1016/j.bjmsu.2010.09.012 5 Re-classification strategies in men with low risk prostate cancer: TRUS guided biopsy versus template prostate mapping C.M. Moore, W.B. Barzell, P.C. Cathcart, M.M. Melamed, H.A. Ahmed, M. Emberon University College Hospital London, United Kingdom Purpose: Active surveillance (AS) is increasingly recommended to reduce over-treatment in patients with favourable-risk prostate cancer. Suitability for AS is often assessed by re-applying an additional biopsy strategy. We investigate the utility of repeat TRUS biopsy versus template prostate mapping (TPM) in a group of men being considered for AS. Methods and patients: Between 2002 and 2009, 129 men with favourable-risk cancer underwent simultaneous repeat TRUS biopsy together with TPM. Gleason grade and burden were compared between the two biopsy strategies to assess eligibility for AS. Cancer significance was attributed using 4 commonly used definitions. Results: Only 30% of men identified as having low-risk prostate cancer prior to study entry had cancer detected on repeat TRUS biopsy. In contrast, 80% had cancer detected on TPM (p < 0.001). Irrespective of biopsy strategy, eligibility for active surveillance was highly dependent on the definition of clinical significance used; When TPM was used as the re-classification method, 26—80% were eligible for AS in contrast to 79—95% that were deemed eligible after TRUS biopsy. Overall, TRUS biopsy ‘missed’ between 55% and 75% of clinically significant prostate cancers. Agreement between TRUS biopsy and TPM was at best only fair (kappa coefficient 0.12—0.40). Comparison of cancer related outcomes between TPM and TRUS biopsy TRUS biopsy
TPM
Cancer detection
30%
80%
Eligibility for AS Epstein criteria
79%
26%
261
AUC and Se for each biopsy approach at different volume thresholds for detection of a significant cancer. Definition of significant cancer
TPM (AUC/Se)
TRUS + Ant Number of (AUC/Se) specimens with a significant cancer
Cancer ≥ 0.2 cc and/or Gleason ≥ 7 Cancer ≥ 0.5 cc and/or Gleason ≥ 7
0.91/97%
0.78/56%
36/96 (=38%)
0.91/96%
0.80/65%
21/96 (=22%)
doi:10.1016/j.bjmsu.2010.09.011 4 Laparoscopic pelvic lymphadenectomy (PLA) in prostate cancer staging and impact on radiotherapy fields C.P. Poullis, S. Agrawal, K. Contractor, S. Mangar, S. Hazell, M. Winkler Charing Cross Hospital, London, United Kingdom Introduction: Staging PLA in high risk prostate cancer may help to determine suitability for radical treatment or whole pelvis radiation. Additionally, long-term androgen deprivation therapy may be avoided. We assess the role and safety of PLA. Methods: Patients with high-risk prostate cancer were selected prospectively. Indications for PLA included a risk of nodal metastases >30% (Roach formula, clinical T3 or radiological N1 disease on MRI). Standard template lymphadenectomy was performed. Results: 36 patients underwent staging PLA. No statistically significant difference in Gleason score, T stage, presenting PSA, or number of nodes resected, was seen for node positive disease. Mean PSA was 44.5 ng/ml. 95% of patients were discharged within 24 h, with no intra-operative complications. The mean number of nodes removed was 14 (SD ± 4). 30% (10/36) experienced early complications which resolved (lymphocoele formation 13%, lymphoedema 8%, scrotal oedema 3%, and obturator nerve paraesthesia 5%). One patient developed a small pulmonary embolus and was anti-coagulated. Node positivity was observed in 30% of patients with PLA compared to 19% detected on MRI. Overall, 70% of cases were node negative and did not undergo whole pelvic radiotherapy, which would have been standard treatment. PLA upstaged MR from N0 to N1 in
36% of cases, and down-staged radiological N1 to N0 disease in 8%. Conclusions: Staging PLA provides valuable prognostic data. It is a well-tolerated diagnostic modality but is associated with morbidity in keeping with published data. It appears more reliable than conventional MRI in stratifying patients suitable for whole pelvis radiotherapy. doi:10.1016/j.bjmsu.2010.09.012 5 Re-classification strategies in men with low risk prostate cancer: TRUS guided biopsy versus template prostate mapping C.M. Moore, W.B. Barzell, P.C. Cathcart, M.M. Melamed, H.A. Ahmed, M. Emberon University College Hospital London, United Kingdom Purpose: Active surveillance (AS) is increasingly recommended to reduce over-treatment in patients with favourable-risk prostate cancer. Suitability for AS is often assessed by re-applying an additional biopsy strategy. We investigate the utility of repeat TRUS biopsy versus template prostate mapping (TPM) in a group of men being considered for AS. Methods and patients: Between 2002 and 2009, 129 men with favourable-risk cancer underwent simultaneous repeat TRUS biopsy together with TPM. Gleason grade and burden were compared between the two biopsy strategies to assess eligibility for AS. Cancer significance was attributed using 4 commonly used definitions. Results: Only 30% of men identified as having low-risk prostate cancer prior to study entry had cancer detected on repeat TRUS biopsy. In contrast, 80% had cancer detected on TPM (p < 0.001). Irrespective of biopsy strategy, eligibility for active surveillance was highly dependent on the definition of clinical significance used; When TPM was used as the re-classification method, 26—80% were eligible for AS in contrast to 79—95% that were deemed eligible after TRUS biopsy. Overall, TRUS biopsy ‘missed’ between 55% and 75% of clinically significant prostate cancers. Agreement between TRUS biopsy and TPM was at best only fair (kappa coefficient 0.12—0.40). Comparison of cancer related outcomes between TPM and TRUS biopsy TRUS biopsy
TPM
Cancer detection
30%
80%
Eligibility for AS Epstein criteria
79%
26%