Changing Patterns Of Pelvic Lymphadenectomy For Prostate Cancer: Results From CaPSURE

UroToday.com - Surgical staging of pelvic lymph nodes for prostate cancer (CaP) is in continuing evolution, reports Dr. Kawakami and CaPSURE colleagues in the October 2006 issue of the Journal of Urology. Historically, pelvic lymphadenectomy (PLND) was performed for diagnostic staging prior to definitive therapy. Present data suggests that an extended PLND may offer therapeutic benefit. In the past decade, use of risk stratification and nomograms have tailored the use of PLND to those patients more likely to have metastasis.

The authors hypothesized that the use of PLND would be less over time in lower risk CaP patients. To do the study, they used CaPSURE, an observational CaP registry from 40 US urology practices. CaPSURE has no treatment protocols or algorithms, and therefore reflects usual urology practice patterns. CaPSURE includes comprehensive clinical, demographic and treatment data. CaP patients were stratified into the D'Amico risk criteria; low, intermediate and high. Trends of PLND utilization with time were analyzed in 3-year intervals.

Data was available on 4,303 men who underwent radical prostatectomy. PLND was performed in 3,666 of these 4,303 men (85%). The mean number of nodes reported pathologically was 5.7. Positive lymph nodes were found in 2.6% of the 3,666 men. Significant predictors of PLND were PSA, Gleason score and clinical stage. PLND was heavily utilized in higher risk patients; 92% of those with a PSA >10ng/ml, 98% of those with a Gleason score 8-10, and 93% of those with stage T3 disease. Fewer patients with low or intermediate risk CaP underwent PLND, while almost all high-risk patients had PLND. Positive lymph nodes were identified in 0.87%, 2.0% and 7.1% of low, intermediate and high risk patients. The number of nodes identified was predicted by the year of surgery, surgery site and patient risk category. The mean number of nodes removed decreased from 8.6 in 1989 to 5.3 in the time span 2001-2005. More nodes were removed in the high (6.7) vs. low risk (5.3) group.

These data demonstrate that the rate of PLND had decreased by 20% for low risk and 13% for intermediate risk CaP. It has remained stable for high risk disease. However, with the low detection rate of positive lymph nodes in intermediate risk men and a PLND complication rate of 4-6%, it can be argued that intermediate risk patients do not need PLND.

Kawakami J, Meng MV, Sadetsky N, Latini DM, Duchane J, Carroll PR; CaPSURE Investigators

J Urol. 2006 Oct;176(4 Pt 1):1382-6
Review By UroToday.com Contributing Editor Christopher P. Evans, M.D

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