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PD15-08 A MORE EXTENSIVE PELVIC LYMPH NODE DISSECTION IS ASSOCIATED WITH IMPROVED SURVIVAL OF PATIENTS WITH NODE POSITIVE PROSTATE CANCER
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such due to a Gleason Score (GS) of 8 to 10. Recent reports suggest substantial heterogeneity of risk within the HrPC cohort. We hypothesized that biopsy GS (bGS) 8 may be diluting the incremental poor risk associated with bGS 9 and specifically with that of primary pattern Gleason 5 when these entities are considered together. Herein, then, we evaluated comparative clinicopathologic outcomes of patients with bGS 8 and 9 disease. METHODS: We reviewed the records of 19844 patients who underwent RP at our institution between 1990-2011 to identify 1177 men with bGS 8-9. Patients were categorized for analysis as: bGS 8 (n¼711, of whom 86.6% were bGS 4+4) vs. 4+5 (n¼347) vs. 5+4 (n¼119). Progression-free (PFS) and cancer-specific survival (CSS) were estimated using the Kaplan-Meier method and compared with the log-rank test. The association of bGS 8, 4+5 and 5+4 with outcome was evaluated with Cox proportional hazards regression models adjusting for N stage, seminal vesicle invasion (SVI), extraprostatic extension (EPE), positive surgical margins (PSM), pT4 stage, preoperative therapy, preoperative PSA, and PSA doubling time. RESULTS: Median postoperative follow-up was 6.1 years (IQR 3.2,11). Median preoperative PSA was similar between groups (bGS 8: 7, 4+5: 6.8, 5+4: 7, p¼0.8). bGS 5+4 and 4+5 were associated with significantly higher rates of adverse clinical and pathologic features than bGS 8, including cT3 disease (24.3% vs. 24.8% vs.14.6%, p<0.0001), radiographic lymphadenopathy (6.7% vs. 4.9% vs. 1.3%, p¼0.0002), SVI (51.7% vs. 43.2% vs. 28.8%, p<0.0001), EPE (71.2% vs. 66.8% vs. 53.9%, p<0.001), PSM (47.9% vs. 42.9% vs. 34.2%, p¼0.004), and N1 disease (19.3% vs. 24.5% vs. 15.7%, p ¼0.003). 10-year PFS was 80%, 68%, and 69% (p<0.0001), while 10-year CSS was 91%, 83%, and 74% (p<0.001) for bGS 8, 4+5 and 5+4 respectively. On multivariate analysis, when compared to bGS 8, bGS 4+5 and 5+4 independently and incrementally predicted increased risk of cancer-specific mortality: bGS 4+5 vs. 8: HR 1.73 (95% CI 1.14, 2.61, p ¼ 0.0099) and bGS 5+4 vs. 8: HR 2.32 (95% CI 1.36,3.94, p¼0.0019). CONCLUSIONS: The presence of bGS 9, specifically bGS 5+4, PC is associated with adverse pathological features and inferior survival versus bGS 8 disease. Higher rates of systemic progression and cancer specific mortality experienced by patients with bGS 9 support the need for substratification within HrPC. Source of Funding: none
PD15-07 ASSESSING THE OPTIMAL EXTENT OF SALVAGE LYMPH NODE DISSECTION IN PATIENTS WITH SINGLE PELVIC NODAL UPTAKE AT [11C]-CHOLINE PET/CT SCAN FROM RECURRING PROSTATE CANCER Maria Passoni*, Andrea Gallina, Ettore Di Trapani, Niccolo Giorgio Gandaglia, Alessandro Larcher, Alessandro Nini, Marco Moschini, Vito Cucchiara, Maria Picchio, Milan, Italy; Rocco Damiano, Catanzaro, Italy; Francesco Cantiello, Milan, Italy; Shahrokh Shariat, Vienna, Austria; Francesco Montorsi, Alberto Briganti, Milan, Italy INTRODUCTION AND OBJECTIVES: Salvage lymph node dissection (sLND) may represent a possible therapeutic approach for patients with limited nodal recurrence and absence of distant metastases. However, there is no consensus about the optimal anatomical extent of sLND. This is mainly based on the heterogenous pathway of nodal metastatic spread and on the low sensitivity of PET/CT for micrometastatic nodal recurrence. The aim of our study was to assess the anatomical extent of sLND in men with single nodal pelvic [11C]-choline uptake in order to correctly plan sLND. METHODS: We retrospectively reviewed data from 70 patients who underwent sLND after a positive PET/CT examination reporting a
Vol. 191, No. 4S, Supplement, Sunday, May 18, 2014
single nodal uptake suggestive of nodal recurrence after radical prostatectomy (RP). Seventeen patients who underwent only retroperitoneal sLND were excluded from analysis. In the remaining population of men who received both pelvic and retroperitoneal sLND, we excluded 22 patients who had tracer uptake in the retroperitoneum, leaving 31 men with tracer uptake only in a single spot in the pelvis eligible for analysis. Frequencies were used as descriptive statistics. Chi-square and independent t test were used for comparisons. RESULTS: Median Time from RP to sLND was 49.7 months (IQR: 31.5- 75.9 months). Overall, the median number of removed LNs at sLND was 26 (IQR 17-37) and the median number of positive LNs was 2 (IQR 1-9). Out of 31 men, 27 had positive LNs (87%). Of these, 14 (45%) had nodal disease only in the pelvis, 1 (3%) only in the retroperitoneum, and 12 (39%) in both locations. Among the 13 men with histologically confirmed retroperitoneal LN metastases, 3 (23%) had uptake in the common iliac nodes, 9 (69%) in the external iliac stations and 1 (8%) had uptake in the external iliac, internal iliac and obturator stations. Men with positive retroperitoneal LNs at sLND had significantly higher rates of positive LNs at radical prostatectomy (50% vs 17%, p¼0.01). There were no other significant differences in clinical and pathological features between the two groups of patients (all p>0.06). CONCLUSIONS: Retroperitoneal LN involvement among patients with [11C]-choline uptake in the pelvis is seen in a common finding, seen in 40% of the patients. Extending the dissection up to the retroperitoneum despite the presence of single positive spot in the pelvis at imaging may have rationale in men with positive pelvic lymph nodes at previous radical prostatectomy. In these patients nodal tumor load may be significantly higher than what detected at [11C]-choline PET/CT scan. Source of Funding: none
PD15-08 A MORE EXTENSIVE PELVIC LYMPH NODE DISSECTION IS ASSOCIATED WITH IMPROVED SURVIVAL OF PATIENTS WITH NODE POSITIVE PROSTATE CANCER Firas Abdollah*, Nazareno Suardi, Alessandro Nini, Marco Moschini, Francesco Mistretta, Emanuele Zaffuto, Vito Cucchiara, Vincenzo Scattoni, Marco Bianchi, Milan, Italy; Vincenzo Mirone, Naples, Italy; Shahrokh F. Shariat, Vienna, Austria; Giorgio Guazzoni, Francesco Montorsi, Alberto Briganti, Milan, Italy INTRODUCTION AND OBJECTIVES: The association between the extent of pelvic lymph node dissection (PLND) and patient survival is currently a controversial topic in prostate cancer. Only a few retrospective reports found an association between the extent of PLND and patient outcome. However, these studies are limited by the lack of standardized anatomical template of nodal dissection. We therefore tested the association between the extent of nodal dissection and patient survival in a single center cohort of node positive patients treated with ePLND. METHODS: The study included 540 consecutive node-positive patients treated with radical prostatectomy (RP) and anatomically defined extended pelvic lymph node dissection (ePLND) at a single European tertiary referral centre between 1992 and 2010. ePLND consisted of removal of obturator, external iliac, hypogastric +/pre-sacral and common iliac lymph nodes. Kaplan-Meier curves assessed time to cancer specific and overall survival. Moreover, univariable and multivariable Cox regression analyses were performed to address predictors of cancer specific and overall mortality. Covariates consisted of patient age and PSA at surgery, pathological Gleason sum, pathological stage, number of positive lymph nodes, number of lymph nodes removed and adjuvant radiation and hormonal therapy. RESULTS: Mean follow-up was 65 months (median: 63). Mean age at surgery was 65.5 yrs (median 66). Mean and median
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PSA at surgery was 26.6 and 11.5 ng/ml, respectively. Pathological stage was pT2, pT3a, pT3b and pT4 in 9.1%, 20%, 64.3% and 6.5% respectively. Pathological Gleason score 8-10 was present in 50.7% of patients. Mean and median number of lymph nodes removed were 21 and 19, respectively. Mean and median number of positive lymph nodes were 3.7 and 2, respectively. Adjuvant radiotherapy and hormonal therapy were given to 39.8 and 84.4%, respectively. The 8 and 10-year cancer specific and overall survival rates were 85 and 80%, and 73.4% and 70% . At multivariable analyses, after adjusting for all confounders, the number of lymph nodes removed was significantly inversely associated with both cancer specific and overall mortality (p¼ 0.02; HR: 0.92 and p¼0.01; 0.93, respectively). The number of positive lymph nodes, pathological Gleason score 8-10 and adjuvant RT were also significantly associated with patient survival (all p0.02). CONCLUSIONS: In node positive patients more extensive PLND is significantly associated with improved cancer specific and overall survival rates. Therefore, in these patients a meticulous PLND is advocated. Source of Funding: none
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86.9% in patients treated with PLND (p¼0.9). At multivariable analysis, PLND status was not a significant predictor of BCR risk (hazard ratio [HR]: 0.69, p¼0.4). In patients treated with PLND, the number of removed nodes was not an independent predictor of BCR risk at univariable (HR: 1.00, p¼0.9) and multivariable analyses (HR: 1.00, p¼0.7). CONCLUSIONS: We report the first validation of the EAU guidelines recommendation on the need for PLND in prostate cancer based on post-operative patient outcome. Neither PLND nor its extent was significantly associated with improved cancer control in men with a LNI risk 5% according to the Briganti nomogram. Therefore, a PLND can be safely omitted in these patients. Source of Funding: None
PD15-10 SIZE AND EXTENSION OF LYMPH NODE METASTASES IN PROSTATE CANCER PATIENTS: IMPLICATIONS FOR RADIOLOGICAL IMAGING BASED ON 6804 LYMPH NODES
PD15-09 PELVIC LYMPH NODE DISSECTION CAN BE SAFELY OMITTED IN MEN WITH A RISK OF NODAL METASTASES £5% BASED ON THE BRIGANTI NOMOGRAM: VALIDATION OF THE EAU GUIDELINS RECCOMENDATIONS FOR NODAL DISSECTION BASED ON PATIENT OUTCOME Firas Abdollah*, Andrea Gallina, Marco Bianchi, Nazareno Suardi, Ettore Di Trapani, Paolo Dell’Oglio, Valerio Di Girolamo, Alessandro Nini, Umberto Capitanio, Milan, Italy; Pierre I. Karakiewicz, Maxine Sun, Montreal, Canada; Shahrokh F. Shariat, Vienna, Austria; Francesco Montorsi, Alberto Briganti, Milan, Italy INTRODUCTION AND OBJECTIVES: The updated EAU guidelines recommendations on the need for pelvic lymph node dissection (PLND) in prostate cancer indicate to omit PLND in all men with a risk of lymph node invasion (LNI) 5% based on the updated Briganti nomogram. Such recommendations have been given based on previous staging studies. However, whether PLND and its extent have no impact on cancer control in these patients with limited LNI risk has not been proven yet. METHODS: This study included 1406 patients treated with radical prostatectomy with or without anatomically extended pelvic lymph node dissection (PLND), between 1999 and 2012. All patients had a lymph node invasion (LNI) predicted probability 5% according to the Briganti nomogram. All had complete clinical and follow-up data. Kaplan-Meier curves assessed the time to BCR, defined as two subsequent prostate-specific antigen values of 0.2 ng/ml or higher. Cox regression tested the relationship between PLND status and biochemical recurrence (BCR) in the overall population. Likewise, Cox regression tested the relationship between the number of removed nodes and BCR in patients treated with PLND. Multivariable analyses were adjusted for all confounders, such as PSA, clinical stage, biopsy Gleason sum and percentage of positive cores . RESULTS: Mean patients age was 65.1 years (median: 66.0, range: 44.0-80.0). Mean and median follow-up times were 46.6 and 39.0 months, respectively. Most patients (87.7%) received PLND. Among these, the mean number of removed nodes was 15.1 (median: 14.0, range: 8-52). Overall, the 5- and 7-years BCR rates were 93.2% and 87.1%, respectively. These rates were respectively 90.6% and 90.6% in patients treated without PLND vs. 93.3% and
Christian Meyer*, Till Eichenauer, Samy Leyh-Bannurah, Thomas Steuber, Georg Salomon, Uwe Michl, Hartwig Huland, Stefan Steurer, Guido Sauter, Hans Heinzer, Markus Graefen, €us, Hamburg, Germany Lars Buda INTRODUCTION AND OBJECTIVES: Vigorous efforts and technical progress have improved radiological lymph node staging in prostate cancer patients. Reliable detection of lymph node metastasis is reported for 8 mm in round nodes and 10 mm in oval nodes with conventional imaging. Even with particle-enhanced imaging techniques, lymph node metastases are detected only down to a diameter of approximately 5 mm. Aim of our study was to assess the size of lymph node metastases (LNM) in prostate cancer patients. METHODS: Between 4/2012 and 9/2013, positive lymph nodes were detected in 317 patients after radical prostatectomy (RP). The size (mm) of LNM was analyzed after pathological work up. In case of multiple LNM, final analyses were restricted to the diameter of the largest metastasis. RESULTS: The analyses of 317 patients resulted in the overall detection of 6804 lymph nodes harboring 799 lymph node metastases. Mean, median (range) PSA was 19.8 ng/ml; 12.24 ng/ml (7.2-21 ng/ml). Mean, median (range) age was 64.9; 65 (61-70) years. Immunochemistry for verification of LNM diagnosis was necessary in 83 (26%) patients. Mean, Median (range) LNM size was 5.94 mm; 3 mm (0.05-47) mm. LNM 10 mm, 8 mm and 5 mm were recorded in 69 (21.7%), 84 (26.5%) and 121 (38.2%) of all patients, respectively. A LNM < 5 mm was found in 196 (61.8%) patients. Micrometastases ( 2 mm) were detected in 119 (37.5%) patients. Interestingly, even in 22/119 (18.5 %) of pT2 tumors, the presence of micrometastases was recorded. In multivariate analysis, addressing the occurrence of LNM 5 mm, Gleason score (O.R. 3.03, CI 2.35-22.08) and PSA (O.R. 1.02, CI 1.001.03) achieved independent predictor status. Conversely, the occurrence of micrometases < 2 mm was only related to high risk Gleason score (O.R. 5.00, CI 2.27-11.01). CONCLUSIONS: Overall, 62% (196/317) of all patients in our cohort harbored LNM smaller than the theoretical threshold of 5 mm. Moreover, even in pT2 tumors micrometastases 2 mm are prevalent in almost 20% of patients. Therefore, standardized surgical pelvic lymph node dissection still remains the best way for staging and potential cure.
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such due to a Gleason Score (GS) of 8 to 10. Recent reports suggest substantial heterogeneity of risk within the HrPC cohort. We hypothesized that biopsy GS (bGS) 8 may be diluting the incremental poor risk associated with bGS 9 and specifically with that of primary pattern Gleason 5 when these entities are considered together. Herein, then, we evaluated comparative clinicopathologic outcomes of patients with bGS 8 and 9 disease. METHODS: We reviewed the records of 19844 patients who underwent RP at our institution between 1990-2011 to identify 1177 men with bGS 8-9. Patients were categorized for analysis as: bGS 8 (n¼711, of whom 86.6% were bGS 4+4) vs. 4+5 (n¼347) vs. 5+4 (n¼119). Progression-free (PFS) and cancer-specific survival (CSS) were estimated using the Kaplan-Meier method and compared with the log-rank test. The association of bGS 8, 4+5 and 5+4 with outcome was evaluated with Cox proportional hazards regression models adjusting for N stage, seminal vesicle invasion (SVI), extraprostatic extension (EPE), positive surgical margins (PSM), pT4 stage, preoperative therapy, preoperative PSA, and PSA doubling time. RESULTS: Median postoperative follow-up was 6.1 years (IQR 3.2,11). Median preoperative PSA was similar between groups (bGS 8: 7, 4+5: 6.8, 5+4: 7, p¼0.8). bGS 5+4 and 4+5 were associated with significantly higher rates of adverse clinical and pathologic features than bGS 8, including cT3 disease (24.3% vs. 24.8% vs.14.6%, p<0.0001), radiographic lymphadenopathy (6.7% vs. 4.9% vs. 1.3%, p¼0.0002), SVI (51.7% vs. 43.2% vs. 28.8%, p<0.0001), EPE (71.2% vs. 66.8% vs. 53.9%, p<0.001), PSM (47.9% vs. 42.9% vs. 34.2%, p¼0.004), and N1 disease (19.3% vs. 24.5% vs. 15.7%, p ¼0.003). 10-year PFS was 80%, 68%, and 69% (p<0.0001), while 10-year CSS was 91%, 83%, and 74% (p<0.001) for bGS 8, 4+5 and 5+4 respectively. On multivariate analysis, when compared to bGS 8, bGS 4+5 and 5+4 independently and incrementally predicted increased risk of cancer-specific mortality: bGS 4+5 vs. 8: HR 1.73 (95% CI 1.14, 2.61, p ¼ 0.0099) and bGS 5+4 vs. 8: HR 2.32 (95% CI 1.36,3.94, p¼0.0019). CONCLUSIONS: The presence of bGS 9, specifically bGS 5+4, PC is associated with adverse pathological features and inferior survival versus bGS 8 disease. Higher rates of systemic progression and cancer specific mortality experienced by patients with bGS 9 support the need for substratification within HrPC. Source of Funding: none
PD15-07 ASSESSING THE OPTIMAL EXTENT OF SALVAGE LYMPH NODE DISSECTION IN PATIENTS WITH SINGLE PELVIC NODAL UPTAKE AT [11C]-CHOLINE PET/CT SCAN FROM RECURRING PROSTATE CANCER Maria Passoni*, Andrea Gallina, Ettore Di Trapani, Niccolo Giorgio Gandaglia, Alessandro Larcher, Alessandro Nini, Marco Moschini, Vito Cucchiara, Maria Picchio, Milan, Italy; Rocco Damiano, Catanzaro, Italy; Francesco Cantiello, Milan, Italy; Shahrokh Shariat, Vienna, Austria; Francesco Montorsi, Alberto Briganti, Milan, Italy INTRODUCTION AND OBJECTIVES: Salvage lymph node dissection (sLND) may represent a possible therapeutic approach for patients with limited nodal recurrence and absence of distant metastases. However, there is no consensus about the optimal anatomical extent of sLND. This is mainly based on the heterogenous pathway of nodal metastatic spread and on the low sensitivity of PET/CT for micrometastatic nodal recurrence. The aim of our study was to assess the anatomical extent of sLND in men with single nodal pelvic [11C]-choline uptake in order to correctly plan sLND. METHODS: We retrospectively reviewed data from 70 patients who underwent sLND after a positive PET/CT examination reporting a
Vol. 191, No. 4S, Supplement, Sunday, May 18, 2014
single nodal uptake suggestive of nodal recurrence after radical prostatectomy (RP). Seventeen patients who underwent only retroperitoneal sLND were excluded from analysis. In the remaining population of men who received both pelvic and retroperitoneal sLND, we excluded 22 patients who had tracer uptake in the retroperitoneum, leaving 31 men with tracer uptake only in a single spot in the pelvis eligible for analysis. Frequencies were used as descriptive statistics. Chi-square and independent t test were used for comparisons. RESULTS: Median Time from RP to sLND was 49.7 months (IQR: 31.5- 75.9 months). Overall, the median number of removed LNs at sLND was 26 (IQR 17-37) and the median number of positive LNs was 2 (IQR 1-9). Out of 31 men, 27 had positive LNs (87%). Of these, 14 (45%) had nodal disease only in the pelvis, 1 (3%) only in the retroperitoneum, and 12 (39%) in both locations. Among the 13 men with histologically confirmed retroperitoneal LN metastases, 3 (23%) had uptake in the common iliac nodes, 9 (69%) in the external iliac stations and 1 (8%) had uptake in the external iliac, internal iliac and obturator stations. Men with positive retroperitoneal LNs at sLND had significantly higher rates of positive LNs at radical prostatectomy (50% vs 17%, p¼0.01). There were no other significant differences in clinical and pathological features between the two groups of patients (all p>0.06). CONCLUSIONS: Retroperitoneal LN involvement among patients with [11C]-choline uptake in the pelvis is seen in a common finding, seen in 40% of the patients. Extending the dissection up to the retroperitoneum despite the presence of single positive spot in the pelvis at imaging may have rationale in men with positive pelvic lymph nodes at previous radical prostatectomy. In these patients nodal tumor load may be significantly higher than what detected at [11C]-choline PET/CT scan. Source of Funding: none
PD15-08 A MORE EXTENSIVE PELVIC LYMPH NODE DISSECTION IS ASSOCIATED WITH IMPROVED SURVIVAL OF PATIENTS WITH NODE POSITIVE PROSTATE CANCER Firas Abdollah*, Nazareno Suardi, Alessandro Nini, Marco Moschini, Francesco Mistretta, Emanuele Zaffuto, Vito Cucchiara, Vincenzo Scattoni, Marco Bianchi, Milan, Italy; Vincenzo Mirone, Naples, Italy; Shahrokh F. Shariat, Vienna, Austria; Giorgio Guazzoni, Francesco Montorsi, Alberto Briganti, Milan, Italy INTRODUCTION AND OBJECTIVES: The association between the extent of pelvic lymph node dissection (PLND) and patient survival is currently a controversial topic in prostate cancer. Only a few retrospective reports found an association between the extent of PLND and patient outcome. However, these studies are limited by the lack of standardized anatomical template of nodal dissection. We therefore tested the association between the extent of nodal dissection and patient survival in a single center cohort of node positive patients treated with ePLND. METHODS: The study included 540 consecutive node-positive patients treated with radical prostatectomy (RP) and anatomically defined extended pelvic lymph node dissection (ePLND) at a single European tertiary referral centre between 1992 and 2010. ePLND consisted of removal of obturator, external iliac, hypogastric +/pre-sacral and common iliac lymph nodes. Kaplan-Meier curves assessed time to cancer specific and overall survival. Moreover, univariable and multivariable Cox regression analyses were performed to address predictors of cancer specific and overall mortality. Covariates consisted of patient age and PSA at surgery, pathological Gleason sum, pathological stage, number of positive lymph nodes, number of lymph nodes removed and adjuvant radiation and hormonal therapy. RESULTS: Mean follow-up was 65 months (median: 63). Mean age at surgery was 65.5 yrs (median 66). Mean and median
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Vol. 191, No. 4S, Supplement, Sunday, May 18, 2014
PSA at surgery was 26.6 and 11.5 ng/ml, respectively. Pathological stage was pT2, pT3a, pT3b and pT4 in 9.1%, 20%, 64.3% and 6.5% respectively. Pathological Gleason score 8-10 was present in 50.7% of patients. Mean and median number of lymph nodes removed were 21 and 19, respectively. Mean and median number of positive lymph nodes were 3.7 and 2, respectively. Adjuvant radiotherapy and hormonal therapy were given to 39.8 and 84.4%, respectively. The 8 and 10-year cancer specific and overall survival rates were 85 and 80%, and 73.4% and 70% . At multivariable analyses, after adjusting for all confounders, the number of lymph nodes removed was significantly inversely associated with both cancer specific and overall mortality (p¼ 0.02; HR: 0.92 and p¼0.01; 0.93, respectively). The number of positive lymph nodes, pathological Gleason score 8-10 and adjuvant RT were also significantly associated with patient survival (all p0.02). CONCLUSIONS: In node positive patients more extensive PLND is significantly associated with improved cancer specific and overall survival rates. Therefore, in these patients a meticulous PLND is advocated. Source of Funding: none
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86.9% in patients treated with PLND (p¼0.9). At multivariable analysis, PLND status was not a significant predictor of BCR risk (hazard ratio [HR]: 0.69, p¼0.4). In patients treated with PLND, the number of removed nodes was not an independent predictor of BCR risk at univariable (HR: 1.00, p¼0.9) and multivariable analyses (HR: 1.00, p¼0.7). CONCLUSIONS: We report the first validation of the EAU guidelines recommendation on the need for PLND in prostate cancer based on post-operative patient outcome. Neither PLND nor its extent was significantly associated with improved cancer control in men with a LNI risk 5% according to the Briganti nomogram. Therefore, a PLND can be safely omitted in these patients. Source of Funding: None
PD15-10 SIZE AND EXTENSION OF LYMPH NODE METASTASES IN PROSTATE CANCER PATIENTS: IMPLICATIONS FOR RADIOLOGICAL IMAGING BASED ON 6804 LYMPH NODES
PD15-09 PELVIC LYMPH NODE DISSECTION CAN BE SAFELY OMITTED IN MEN WITH A RISK OF NODAL METASTASES £5% BASED ON THE BRIGANTI NOMOGRAM: VALIDATION OF THE EAU GUIDELINS RECCOMENDATIONS FOR NODAL DISSECTION BASED ON PATIENT OUTCOME Firas Abdollah*, Andrea Gallina, Marco Bianchi, Nazareno Suardi, Ettore Di Trapani, Paolo Dell’Oglio, Valerio Di Girolamo, Alessandro Nini, Umberto Capitanio, Milan, Italy; Pierre I. Karakiewicz, Maxine Sun, Montreal, Canada; Shahrokh F. Shariat, Vienna, Austria; Francesco Montorsi, Alberto Briganti, Milan, Italy INTRODUCTION AND OBJECTIVES: The updated EAU guidelines recommendations on the need for pelvic lymph node dissection (PLND) in prostate cancer indicate to omit PLND in all men with a risk of lymph node invasion (LNI) 5% based on the updated Briganti nomogram. Such recommendations have been given based on previous staging studies. However, whether PLND and its extent have no impact on cancer control in these patients with limited LNI risk has not been proven yet. METHODS: This study included 1406 patients treated with radical prostatectomy with or without anatomically extended pelvic lymph node dissection (PLND), between 1999 and 2012. All patients had a lymph node invasion (LNI) predicted probability 5% according to the Briganti nomogram. All had complete clinical and follow-up data. Kaplan-Meier curves assessed the time to BCR, defined as two subsequent prostate-specific antigen values of 0.2 ng/ml or higher. Cox regression tested the relationship between PLND status and biochemical recurrence (BCR) in the overall population. Likewise, Cox regression tested the relationship between the number of removed nodes and BCR in patients treated with PLND. Multivariable analyses were adjusted for all confounders, such as PSA, clinical stage, biopsy Gleason sum and percentage of positive cores . RESULTS: Mean patients age was 65.1 years (median: 66.0, range: 44.0-80.0). Mean and median follow-up times were 46.6 and 39.0 months, respectively. Most patients (87.7%) received PLND. Among these, the mean number of removed nodes was 15.1 (median: 14.0, range: 8-52). Overall, the 5- and 7-years BCR rates were 93.2% and 87.1%, respectively. These rates were respectively 90.6% and 90.6% in patients treated without PLND vs. 93.3% and
Christian Meyer*, Till Eichenauer, Samy Leyh-Bannurah, Thomas Steuber, Georg Salomon, Uwe Michl, Hartwig Huland, Stefan Steurer, Guido Sauter, Hans Heinzer, Markus Graefen, €us, Hamburg, Germany Lars Buda INTRODUCTION AND OBJECTIVES: Vigorous efforts and technical progress have improved radiological lymph node staging in prostate cancer patients. Reliable detection of lymph node metastasis is reported for 8 mm in round nodes and 10 mm in oval nodes with conventional imaging. Even with particle-enhanced imaging techniques, lymph node metastases are detected only down to a diameter of approximately 5 mm. Aim of our study was to assess the size of lymph node metastases (LNM) in prostate cancer patients. METHODS: Between 4/2012 and 9/2013, positive lymph nodes were detected in 317 patients after radical prostatectomy (RP). The size (mm) of LNM was analyzed after pathological work up. In case of multiple LNM, final analyses were restricted to the diameter of the largest metastasis. RESULTS: The analyses of 317 patients resulted in the overall detection of 6804 lymph nodes harboring 799 lymph node metastases. Mean, median (range) PSA was 19.8 ng/ml; 12.24 ng/ml (7.2-21 ng/ml). Mean, median (range) age was 64.9; 65 (61-70) years. Immunochemistry for verification of LNM diagnosis was necessary in 83 (26%) patients. Mean, Median (range) LNM size was 5.94 mm; 3 mm (0.05-47) mm. LNM 10 mm, 8 mm and 5 mm were recorded in 69 (21.7%), 84 (26.5%) and 121 (38.2%) of all patients, respectively. A LNM < 5 mm was found in 196 (61.8%) patients. Micrometastases ( 2 mm) were detected in 119 (37.5%) patients. Interestingly, even in 22/119 (18.5 %) of pT2 tumors, the presence of micrometastases was recorded. In multivariate analysis, addressing the occurrence of LNM 5 mm, Gleason score (O.R. 3.03, CI 2.35-22.08) and PSA (O.R. 1.02, CI 1.001.03) achieved independent predictor status. Conversely, the occurrence of micrometases < 2 mm was only related to high risk Gleason score (O.R. 5.00, CI 2.27-11.01). CONCLUSIONS: Overall, 62% (196/317) of all patients in our cohort harbored LNM smaller than the theoretical threshold of 5 mm. Moreover, even in pT2 tumors micrometastases 2 mm are prevalent in almost 20% of patients. Therefore, standardized surgical pelvic lymph node dissection still remains the best way for staging and potential cure.