04 Treatment modalities in PCa Flashcards
Pelvic lymph node dissection during radical prostatectomy
A systematic review has demonstrated that performing PLND during RP failed to improve oncological outcomes, including survival (Fossati, N., et al. Eur Urol, 2017)
Moreover, two RCTs have failed to show a benefit of an extended approach vs. a limited PLND on early oncologic outcomes.
Lestingi, J.F.P., et al. Eur Urol, 2021
Touijer, K.A., et al. Eur Urol Oncol, 2021
Extended PLND
includes removal of external iliac, obturator and internal iliac LNs.
Normograms for estimating risk of patients harbouring positive LNs
Partin and MSKCC nomograms. However, these nomograms were developed in the pre-MRI setting.
+Partin and MSKCC tools in predicting positive lymph nodes in prostate cancer: a systematic review and meta-analysis.
An updated nomogram has been externally validated in men diagnosed based on MRI followed by MRItargeted biopsy.
Development and Internal Validation of a Novel Model to Identify the
Candidates for Extended Pelvic Lymph Node Dissection in Prostate Cancer
Role of PSMA-PET in omitting PLND
A 2021 systematic review and meta-analysis of 27 studies showed that PSMA PET had a significantly higher sensitivity (93% vs. 54%, p = 0.008) and NPV (96% vs. 83%, p = 0.044) for LN positivity in intermediate-risk vs. high-risk groups (Stabile, A., et al. Eur Urol Oncol, 2022). This suggests that, given a lack of survival benefit of PLND, it might be safely omitted in intermediate-risk patients whose staging PSMA PET is negative. However, only 1 of the 27 studies with only 42 patients had focused on intermediate-risk cancer, indicating a need for further data in this risk group. The authors conclude that PLND should still be performed in high-risk patients with negative PSMA PET, however
this should also be balanced against the risk of morbidity of PLND. For patients with positive pelvic LNs on PSMA PET only, evidence is currently unavailable on the best treatment strategy
