Elsevier

European Urology

Volume 57, Issue 5, May 2010, Pages 754-761
European Urology

Platinum Priority – Prostate Cancer
Editorial by Urs E. Studer, Laurence Collette and Richard Sylvester on pp. 762–763 of this issue
Survival Benefit of Radical Prostatectomy in Lymph Node–Positive Patients with Prostate Cancer

https://doi.org/10.1016/j.eururo.2009.12.034Get rights and content

Abstract

Background

Positive lymph node (LN) status is considered a systemic disease state. In prostate cancer, LN-positive diagnosis during pelvic LN dissection (PLND) potentially leads to the abandonment of radical prostatectomy (RP).

Objective

To compare the overall survival (OS) and relative survival (RS; as an estimate for cancer-specific survival) in LN-positive patients with or without RP.

Design, setting, and participants

Between 1988 and 2007, a total of 35 629 men with prostate cancer were identified at the Munich Cancer Registry; of those, 1413 patients had positive LNs.

Intervention

Of these 1413 LN-positive patients, prostatectomy was abandoned in 456 LN-positive patients, whereas 957 underwent RP despite the LN-positive finding.

Measurements

Crucial analyses are based on 938 LN-positive patients (688 with RP and 250 without RP) with complete data regarding age, grade, and prostate-specific antigen (PSA). OS (Kaplan-Meier estimates) and RS are presented, and Cox regression analysis was used to show the influence of predictors such as clinical stage, age at surgery, number of positive LNs, PSA level, grade, and extent of surgery.

Results

Median follow-up was 5.6 yr. OS of patients at 5 yr and 10 yr was 84% and 64%, respectively, with RP and was 60% and 28%, respectively, with aborted RP. The RS of patients at 5 yr and 10 yr was 95% and 86%, respectively, with RP and was 70% and 40%, respectively, with abandoned surgery. There was an imbalance, however, in the number of positive LNs: 17.2% with RP had four or more positive nodes versus 28% in the patient group without RP. In the multivariate model, RP was a strong independent predictor of survival (hazard ratio: 2.04 [95% confidence interval, 1.59–2.63; p < 0.0001]).

Conclusion

LN-positive patients with complete RP had improved survival compared to patients with abandoned RP. These results suggest that RP may have a survival benefit and the abandonment of RP in node-positive cases may not be justified.

Introduction

Radical prostatectomy (RP) is commonly accepted as standard therapy for early stage prostate cancer [1], [2], [3], [4]. Although multiple investigations have demonstrated that RP is also a valid option for patients with locally advanced disease [5], [6], RP is often abandoned in cases with positive lymph nodes (LNs). Prostate cancer patients who are LN positive are considered to have a systemic disease with poor prognosis and are often treated with hormonal therapy [7] and/or radiotherapy (RT).

Interestingly, few studies have shown reasonable cancer-specific survival (CSS) of patients with histologically diagnosed pelvic LN metastases who received RP [8], [9], [10], [11], [12]. Furthermore, not all patients with nodal disease are at the same risk of cancer-specific death. Patients with minimal nodal disease have improved survival and may benefit from RP [10], [11].

Today, most surgeons do not routinely perform frozen section analysis of pelvic LNs or abandon RP in the case of an LN-positive finding. The comparison of CSS in LN-positive patients who receive complete RP versus abandoned RP is often compromised by small populations and short follow-up. In this study, we analyzed overall survival (OS) and relative survival (RS) in LN-positive patients with or without RP.

Section snippets

Data collection

The Munich Cancer Registry (MCR) was established in 1978. Initially, the MCR cooperated with the two university hospitals in Munich, Germany, and since 1988, collaborations have extended to all city hospitals and the district of Munich, a region of about 2.3 million inhabitants. The MCR was enlarged to 3.8 million people in 2002 and to 4.5 million in 2007. With an incidence rate of 80 per 100 000 people (world standard), the MCR observes a high population-based incidence of prostate cancer

Results

OS and RS rates for this population-based sample (n = 27 956) are presented in Fig. 1. The 5-yr OS was 76.7% (RS was 93.3%) and 10-yr OS was 55.2% (RS was 84.9%) in this cohort. Fig. 2 shows OS and RS for patients with PLND and complete prostatectomy, according to the number of positive LNs, and demonstrates the prognostic value of LN status.

Table 1 lists the clinical and pathologic characteristics for 1413 patients that composed the current study cohort. The median age was 65.4 yr. Patients with

Discussion

Recent studies have demonstrated that RP is a valid option for patients with locally advanced disease [1], [5], [6]. RP was rarely performed before the 1980s and revolutionized the early 1980s when it was introduced as the accepted form of surgical treatment for localized prostate cancer [13], [14], [15]. When RP was first performed, surgery was commonly abandoned if suspicious pelvic LNs were detected during PLND; the patient was then considered to have systemic disease. This strategy was

Conclusions

Our long-term investigation of node-positive prostate cancer patients treated with PLND and completed or abandoned RP shows significantly improved survival in patients with completed RP. These results suggest that intraoperative frozen section analysis with abandonment of RP may not be justified.

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1

Jutta Engel and Patrick J. Bastian contributed equally to this paper.

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