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CT PROVIDES ACCURATE STAGING OF LYMPH NODE REGIONS PRIOR TO LYMPH NODE DISSECTION IN PATIENTS WITH PROSTATE CANCER
THE JOURNAL OF UROLOGYâ
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PD42-11 68GA-PSMA PET/CT PROVIDES ACCURATE STAGING OF LYMPH NODE REGIONS PRIOR TO LYMPH NODE DISSECTION IN PATIENTS WITH PROSTATE CANCER Annika Herlemann*, Vera Wenter, Alexander Kretschmer, Peter Bartenstein, Christian G. Stief, Christian Gratzke, Wolfgang P. Fendler, Munich, Germany INTRODUCTION AND OBJECTIVES: 68Ga-PSMA-HBED-CC (68Ga-PSMA) PET/CT has received considerable attention as new diagnostic tool for prostate cancer (PCa) staging. We evaluated the accuracy of 68Ga-PSMA PET/CT for nodal staging prior to lymph node dissection (LND) in patients with PCa. METHODS: 34 patients with histologically proven PCa underwent 68Ga-PSMA PET/CT prior to radical prostatectomy with primary lymph node dissection (pLND; n¼20) and PET/CT prior to secondary lymph node dissection (sLND; n¼14). Accuracy (ACC) of PET and CT were analyzed separately for staging of the following 71 lymph node (LN) regions: pelvic left (n¼30), pelvic right (n¼31), presacral (n¼3), and paraaortic (n¼7). Postoperative histopathology was taken as reference standard. RESULTS: Overall 484 LNs were resected from 71 regions. 132 nodes from 37 regions (52%) showed LN metastases on histopathology. Sensitivity, specificity, positive predictive value, negative predictive value for detection of LN metastases were 84, 82, 84, 82% for PET and 65, 76, 75, 67% for CT. PET was more accurate for nodal staging as compared to CT in both, pLND (88 versus 75%) and sLND (77 versus 65%). On a patient basis PET demonstrated a SE of 91%, PPV of 83%, NPV of 80% for detection of LN metastases. SP was lower (67%); the overall ACC for detection of N stage was 82% on a patient basis. CONCLUSIONS: Our study demonstrates high accuracy of 68Ga-PSMA PET/CT for nodal staging in PCa patients both before primary and secondary LND. Source of Funding: None.
PD42-12 EXTRA-PROSTATIC EXTENSION AND SEMINAL VESICLE INVASION ARE EXCEEDINGLY RARE AT RADICAL PROSTATECTOMY FOR GLEASON 6 PROSTATE CANCER USING ISUP MODIFIED SCORING CRITERIA Blake Anderson*, Aria Razmaria, Bonnie Choy, Gregory Zagaja, Arieh Shalhav, Gladell Paner, Scott Eggener, Chicago, IL INTRODUCTION AND OBJECTIVES: Recent studies employing contemporary Gleason grading have demonstrated Gleason score 6 (GS6) prostate cancers lack the ability to metastasize. The goal of this study was to assess the pathologic stage following radical prostatectomy of true GS6 prostate cancers in a large institutional series. METHODS: From 2003 to 2013, 3731 patients underwent robotic radical prostatectomy at a single academic institution. Out of 1106 patients with GS6 identified at surgery, 38 (3.4%) were identified as GS6 with stage pT3a/b on initial pathologic review, 34 with pT3a (extra-prostatic extension; EPE) and 4 with pT3b disease (seminal vesicle invasion; SVI). All cases underwent repeat pathologic evaluation by a single expert genitourinary pathologist (GPP) for Gleason grade, pathological stage, extent of EPE, percent of prostate volume with tumor, percent of Gleason pattern 4 and type of Gleason pattern 4 (e.g. cribriform, fused, ill-formed, glomeruloid, variant patterns). Additionally, all Gleason score 7-9 (GS7-9) pT3b cases from our database, in total 153, were re-reviewed. The 2014 International Society of Urological Pathology (ISUP) modified Gleason grading criteria were applied. RESULTS: Of the 38 GS6 pT3a/b cases, 34 (90%) were upgraded to Gleason 3+4 (32), 4+3 (1) or 4+4 (1). Of the upgraded cases, 8 (24%) had minor (< 5%) components of pattern 4, which under
Vol. 195, No. 4S, Supplement, Monday, May 9, 2016
the 2004 ISUP Gleason grading consensus was not established as a secondary grade. Six (16%) were down-staged to pT2 since only capsular incision was present or tumor invaded capsule but not beyond. After re-review, only 2 cases (0.2% of entire GS6 cohort) with pT3a were observed, both with focal EPE (non-established). Among the reexamined cohort, no cases with pure GS6 and stage pT3b were observed. Ill-formed glands were the most common type of pattern 4 present in 91% of upgraded cases, followed by fused (82%) and cribriform (35%) glands. Ductal (6%) and mucinous (3%) variants were rare reasons for upgrading. Lastly, none of the 153 GS7-9 pT3b cases were downgraded to Gleason 6. CONCLUSIONS: In this large contemporary study, Gleason 6 prostate cancer never had seminal vesicle invasion (0%) and was only rarely (0.2%) associated with extra-prostatic extension. Our data further supports active surveillance as an optimal management strategy for most men with Gleason 6 prostate cancer. Source of Funding: none
Prostate Cancer: Localized: Surgical Therapy VI Podium Monday, May 9, 2016
1:00 PM-3:00 PM
PD43-01 RESULTS OF TWO RANDOMIZED TRIALS FOR THE PREVENTION OF LYMPHOCELES AFTER ROBOTIC PELVIC LYMPH NODE DISSECTION FOR PROSTATE CANCER Sean Henderson, Daniel Gilbert, Janice Rosenthal, Ronney Abaza, Jatin Gupta*, Dublin, OH INTRODUCTION AND OBJECTIVES: Lymphoceles (LC) occur in up to 30-50% of patients after pelvic lymph node dissection (PLND) for prostate cancer. Most are asymptomatic and go undetected as imaging after prostatectomy is infrequent, but serious infections can occur even months later. We performed 2 randomized studies to determine whether LC can be prevented with imaging of all patients to detect even silent LC. One trial involved a hemostatic agent (AristaâAH), and a second trial involved use of advanced electrosurgical bipolar energy (da Vinciâ EndoWristâ One Vessel Sealerâ). METHODS: Patients undergoing robotic prostatectomy with PLND were enrolled into one of two studies with IRB approval. Each patient served as their own internal control with one PLND side randomly chosen for intervention. In study 1, Arista was placed over the field of PLND on one side randomized to treatment only after bilateral PLND was completed. In study 2, PLND was randomly performed in standard fashion using clips and standard instruments while the other side was performed with the Vessel Sealer instead of clips. All patients underwent screening CT scan 3 mos later with radiologists blinded to interventions. A significant LC was defined as a fluid collection 3cm in any plane. RESULTS: No symptomatic lymphoceles occurred in either study. Of 100 patients enrolled in the Arista trial, 88 completed the study. Only 14 screening-detected LCs occurred with all unilateral (16% of patients or 8% of 176 PLND sides). Five occurred on the side where Arista was used vs 9 on untreated sides (5.7% vs 10.2%, p¼0.248). There was no statistically significant difference in LC size (mean 4.6cm) between treated and untreated sides (p¼0.44). Of 120 patients enrolled in the Vessel Sealer trial, 114 completed the study. LCs were identified in 21 patients (18%), one of which was bilateral (9% of 240 sides). Ten occurred on the Vessel Sealer side vs 12 on the standard side (8.8% vs 10.5%, p¼0.41) with no difference in LC size (4.3cm vs 3.6cm, p¼0.35). Operative time was the same for standard PLND vs Vessel Sealer (mean 11.3 vs 11.1min, p¼0.62).
e992
PD42-11 68GA-PSMA PET/CT PROVIDES ACCURATE STAGING OF LYMPH NODE REGIONS PRIOR TO LYMPH NODE DISSECTION IN PATIENTS WITH PROSTATE CANCER Annika Herlemann*, Vera Wenter, Alexander Kretschmer, Peter Bartenstein, Christian G. Stief, Christian Gratzke, Wolfgang P. Fendler, Munich, Germany INTRODUCTION AND OBJECTIVES: 68Ga-PSMA-HBED-CC (68Ga-PSMA) PET/CT has received considerable attention as new diagnostic tool for prostate cancer (PCa) staging. We evaluated the accuracy of 68Ga-PSMA PET/CT for nodal staging prior to lymph node dissection (LND) in patients with PCa. METHODS: 34 patients with histologically proven PCa underwent 68Ga-PSMA PET/CT prior to radical prostatectomy with primary lymph node dissection (pLND; n¼20) and PET/CT prior to secondary lymph node dissection (sLND; n¼14). Accuracy (ACC) of PET and CT were analyzed separately for staging of the following 71 lymph node (LN) regions: pelvic left (n¼30), pelvic right (n¼31), presacral (n¼3), and paraaortic (n¼7). Postoperative histopathology was taken as reference standard. RESULTS: Overall 484 LNs were resected from 71 regions. 132 nodes from 37 regions (52%) showed LN metastases on histopathology. Sensitivity, specificity, positive predictive value, negative predictive value for detection of LN metastases were 84, 82, 84, 82% for PET and 65, 76, 75, 67% for CT. PET was more accurate for nodal staging as compared to CT in both, pLND (88 versus 75%) and sLND (77 versus 65%). On a patient basis PET demonstrated a SE of 91%, PPV of 83%, NPV of 80% for detection of LN metastases. SP was lower (67%); the overall ACC for detection of N stage was 82% on a patient basis. CONCLUSIONS: Our study demonstrates high accuracy of 68Ga-PSMA PET/CT for nodal staging in PCa patients both before primary and secondary LND. Source of Funding: None.
PD42-12 EXTRA-PROSTATIC EXTENSION AND SEMINAL VESICLE INVASION ARE EXCEEDINGLY RARE AT RADICAL PROSTATECTOMY FOR GLEASON 6 PROSTATE CANCER USING ISUP MODIFIED SCORING CRITERIA Blake Anderson*, Aria Razmaria, Bonnie Choy, Gregory Zagaja, Arieh Shalhav, Gladell Paner, Scott Eggener, Chicago, IL INTRODUCTION AND OBJECTIVES: Recent studies employing contemporary Gleason grading have demonstrated Gleason score 6 (GS6) prostate cancers lack the ability to metastasize. The goal of this study was to assess the pathologic stage following radical prostatectomy of true GS6 prostate cancers in a large institutional series. METHODS: From 2003 to 2013, 3731 patients underwent robotic radical prostatectomy at a single academic institution. Out of 1106 patients with GS6 identified at surgery, 38 (3.4%) were identified as GS6 with stage pT3a/b on initial pathologic review, 34 with pT3a (extra-prostatic extension; EPE) and 4 with pT3b disease (seminal vesicle invasion; SVI). All cases underwent repeat pathologic evaluation by a single expert genitourinary pathologist (GPP) for Gleason grade, pathological stage, extent of EPE, percent of prostate volume with tumor, percent of Gleason pattern 4 and type of Gleason pattern 4 (e.g. cribriform, fused, ill-formed, glomeruloid, variant patterns). Additionally, all Gleason score 7-9 (GS7-9) pT3b cases from our database, in total 153, were re-reviewed. The 2014 International Society of Urological Pathology (ISUP) modified Gleason grading criteria were applied. RESULTS: Of the 38 GS6 pT3a/b cases, 34 (90%) were upgraded to Gleason 3+4 (32), 4+3 (1) or 4+4 (1). Of the upgraded cases, 8 (24%) had minor (< 5%) components of pattern 4, which under
Vol. 195, No. 4S, Supplement, Monday, May 9, 2016
the 2004 ISUP Gleason grading consensus was not established as a secondary grade. Six (16%) were down-staged to pT2 since only capsular incision was present or tumor invaded capsule but not beyond. After re-review, only 2 cases (0.2% of entire GS6 cohort) with pT3a were observed, both with focal EPE (non-established). Among the reexamined cohort, no cases with pure GS6 and stage pT3b were observed. Ill-formed glands were the most common type of pattern 4 present in 91% of upgraded cases, followed by fused (82%) and cribriform (35%) glands. Ductal (6%) and mucinous (3%) variants were rare reasons for upgrading. Lastly, none of the 153 GS7-9 pT3b cases were downgraded to Gleason 6. CONCLUSIONS: In this large contemporary study, Gleason 6 prostate cancer never had seminal vesicle invasion (0%) and was only rarely (0.2%) associated with extra-prostatic extension. Our data further supports active surveillance as an optimal management strategy for most men with Gleason 6 prostate cancer. Source of Funding: none
Prostate Cancer: Localized: Surgical Therapy VI Podium Monday, May 9, 2016
1:00 PM-3:00 PM
PD43-01 RESULTS OF TWO RANDOMIZED TRIALS FOR THE PREVENTION OF LYMPHOCELES AFTER ROBOTIC PELVIC LYMPH NODE DISSECTION FOR PROSTATE CANCER Sean Henderson, Daniel Gilbert, Janice Rosenthal, Ronney Abaza, Jatin Gupta*, Dublin, OH INTRODUCTION AND OBJECTIVES: Lymphoceles (LC) occur in up to 30-50% of patients after pelvic lymph node dissection (PLND) for prostate cancer. Most are asymptomatic and go undetected as imaging after prostatectomy is infrequent, but serious infections can occur even months later. We performed 2 randomized studies to determine whether LC can be prevented with imaging of all patients to detect even silent LC. One trial involved a hemostatic agent (AristaâAH), and a second trial involved use of advanced electrosurgical bipolar energy (da Vinciâ EndoWristâ One Vessel Sealerâ). METHODS: Patients undergoing robotic prostatectomy with PLND were enrolled into one of two studies with IRB approval. Each patient served as their own internal control with one PLND side randomly chosen for intervention. In study 1, Arista was placed over the field of PLND on one side randomized to treatment only after bilateral PLND was completed. In study 2, PLND was randomly performed in standard fashion using clips and standard instruments while the other side was performed with the Vessel Sealer instead of clips. All patients underwent screening CT scan 3 mos later with radiologists blinded to interventions. A significant LC was defined as a fluid collection 3cm in any plane. RESULTS: No symptomatic lymphoceles occurred in either study. Of 100 patients enrolled in the Arista trial, 88 completed the study. Only 14 screening-detected LCs occurred with all unilateral (16% of patients or 8% of 176 PLND sides). Five occurred on the side where Arista was used vs 9 on untreated sides (5.7% vs 10.2%, p¼0.248). There was no statistically significant difference in LC size (mean 4.6cm) between treated and untreated sides (p¼0.44). Of 120 patients enrolled in the Vessel Sealer trial, 114 completed the study. LCs were identified in 21 patients (18%), one of which was bilateral (9% of 240 sides). Ten occurred on the Vessel Sealer side vs 12 on the standard side (8.8% vs 10.5%, p¼0.41) with no difference in LC size (4.3cm vs 3.6cm, p¼0.35). Operative time was the same for standard PLND vs Vessel Sealer (mean 11.3 vs 11.1min, p¼0.62).