Prostate CancerDecreasing Rate and Extent of Lymph Node Staging in Patients Undergoing Radical Prostatectomy May Undermine the Rate of Diagnosis of Lymph Node Metastases in Prostate Cancer
Introduction
Most prostate cancer patients present with clinically localized disease and are treated with radical prostatectomy (RP) [1], [2]. At surgery, pelvic lymph node dissection (PLND) represents the most accurate staging procedure for the presence of lymph node (LN) metastases [3], [4].
Over the past two decades, an ongoing debate has focused on the extent of PLND that should ideally be performed to more accurately assign LN stage [3]. The opinions range from omitting the PLND [5], [6] to performing an extended PLND that encompasses virtually all pelvic LNs [7], [8]. To date, only institutional studies of limited sample size have examined the relationship between the extent of PLND and its ability to detect the presence of LN metastases [7], [8], [9], [10], [11], [12], [13], [14], [15]. Therefore the existing data regarding the indications, rationale, and extent of PLND originate from relatively small studies. Based on the paucity of data, we decided to examine the rate of PLND and the variation in LN count (LNC) at PLND over the past two decades within the Surveillance Epidemiology and End Results (SEER) database. We also examined the relationship between LNC and the likelihood of finding LN metastases.
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Patient population
Patients treated with RP for histologically confirmed nonmetastatic adenocarcinoma of the prostate between 1988 and 2006 were identified using the 17 SEER [16] database (International Classification of Disease for Oncology [61.9]; histologic code: 8140). All patients were between 34 and 94 yr of age. Patients with missing stage and/or grade were excluded. We also excluded individuals with undifferentiated disease because this histology may be confounded with small cell histology. These
Results
A total of 130 080 patients treated with RP were evaluated (Table 1). PLND was omitted (pNx) in 25.9% of patients. The rate of pNx was 29% in pT2 patients versus 14.5% and 16.7% in pT3 and pT4 patients, respectively (p < 0.001). Similarly, the rate of pNx was 27.0%, 27.2%, and 22.9% in patients with Gleason scores 2–4, 5–7, and 8–10, respectively (p < 0.001). The rate of pNx increased in the most contemporary year of the surgery category (30.1% in 2000–2006 vs 20.8% in 1988–1993; p < 0.001). The rate
Discussion
The objective of our analysis was threefold. First, we examined the rate of PLND and found that 26% of individuals did not undergo a PLND at RP. The probability of undergoing a PLND decreased over time. In the most contemporary year (2006), 30% of patients were pNx. Moreover, important interregistry differences in pNx stage were recorded: 14–50%. Patients with more favorable stage (pT2) and grade (Gleason score 2–4) were most frequently left without PLND. Nonetheless, 21.1%, 14.5%, 16.7%, and
Conclusions
Our study showed a clear trend with fewer PLNDs performed over time at RP, even in patients with unfavorable preoperative clinical and/or pathologic characteristics. Additionally, when PLND is performed, LNC is frequently insufficient, which undermines the ability of PLND to detect pN1 stage. As a direct result, fewer patients are diagnosed with LN metastases. Our findings cannot be attributed exclusively to stage migration. The impact of this phenomenon on cancer control outcomes still needs
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Both authors contributed equally to the manuscript.