Korean J Urol.  2011 Jul;52(7):437-445.

Role of Pelvic Lymph Node Dissection in Prostate Cancer Treatment

• Joung JY
• Cho IC
• Lee KH

Abstract

Pelvic lymph node dissection (PLND) is the most accurate and reliable staging procedure for detecting lymph node invasion (LNI) in prostate cancer. Recently, [11C]-choline positron emission tomography imaging and magnetic resonance imaging with lymphotropic superpara-magnetic nanoparticles have shown potential for detecting LNI but are still under investigation. The risk of LNI in low-risk groups could be underestimated by use of the current nomograms, which rely on data collected from patients who underwent only limited PLND. Extended PLND (ePLND) shows higher lymph node yield, which leads to the removal of more positive nodes and fewer missed positive nodes. It may be possible to refrain from performing PLND on low-risk patients with a prostate-specific antigen value <10 ng/ml and a biopsy Gleason score < or =6, but the risk of biopsy-related understaging should be kept in mind. Theoretically, meticulous ePLND may also impact prostate cancer survival by clearing low-volume diseases and occult micrometastasis even in pN0. The therapeutic role of PLND in prostate cancer patients is still an open question, especially in individuals with low-risk disease. Patients with intermediate- to high-risk disease are more likely to benefit from ePLND.

Keyword

Lymph node dissections; Prostate cancer; Prostatectomy

MeSH Terms

Biopsy
Humans
Lymph Node Excision
Lymph Nodes
Magnetic Resonance Imaging
Nanoparticles
Neoplasm Grading
Neoplasm Micrometastasis
Nomograms
Positron-Emission Tomography
Prostate
Prostate-Specific Antigen
Prostatectomy
Prostatic Neoplasms
Prostate-Specific Antigen

Figure

• 

  FIG. 1 Pelvic lymph node dissection field including the (1) external iliac node, (2) obturator node, and (3) internal iliac node. Reproduced with permission [32].

Reference

1. Walsh PC, Partin AW, Epstein JI. Cancer control and quality of life following anatomical radical retropubic prostatectomy: results at 10 years. J Urol. 1994. 152:1831–1836.

2. Catalona WJ, Smith DS. Cancer recurrence and survival rates after anatomic radical retropubic prostatectomy for prostate cancer: intermediate-term results. J Urol. 1998. 160:2428–2434.

3. Gervasi LA, Mata J, Easley JD, Wilbanks JH, Seale-Hawkins C, Carlton CE Jr, et al. Prognostic significance of lymph nodal metastases in prostate cancer. J Urol. 1989. 142:332–336.

4. Hull GW, Rabbani F, Abbas F, Wheeler TM, Kattan MW, Scardino PT. Cancer control with radical prostatectomy alone in 1,000 consecutive patients. J Urol. 2002. 167:528–534.

5. Fowler JE Jr, Whitmore WF Jr. The incidence and extent of pelvic lymph node metastases in apparently localized prostatic cancer. Cancer. 1981. 47:2941–2945.

6. Zincke H. Extended experience with surgical treatment of stage D1 adenocarcinoma of prostate. Significant influences of immediate adjuvant hormonal treatment (orchiectomy) on outcome. Urology. 1989. 33:5 Suppl. 27–36.

7. Petros JA, Catalona WJ. Lower incidence of unsuspected lymph node metastases in 521 consecutive patients with clinically localized prostate cancer. J Urol. 1992. 147:1574–1575.

8. Han M, Partin AW, Pound CR, Epstein JI, Walsh PC. Long-term biochemical disease-free and cancer-specific survival following anatomic radical retropubic prostatectomy. The 15-year Johns Hopkins experience. Urol Clin North Am. 2001. 28:555–565.

9. Messing EM, Manola J, Yao J, Kiernan M, Crawford D, Wilding G, et al. Immediate versus deferred androgen deprivation treatment in patients with node-positive prostate cancer after radical prostatectomy and pelvic lymphadenectomy. Lancet Oncol. 2006. 7:472–479.

10. Partin AW, Kattan MW, Subong EN, Walsh PC, Wojno KJ, Oesterling JE, et al. Combination of prostate-specific antigen, clinical stage, and Gleason score to predict pathological stage of localized prostate cancer. A multi-institutional update. JAMA. 1997. 277:1445–1451.

11. Kattan MW, Stapleton AM, Wheeler TM, Scardino PT. Evaluation of a nomogram used to predict the pathologic stage of clinically localized prostate carcinoma. Cancer. 1997. 79:528–537.

12. Makarov DV, Trock BJ, Humphreys EB, Mangold LA, Walsh PC, Epstein JI, et al. Updated nomogram to predict pathologic stage of prostate cancer given prostate-specific antigen level, clinical stage, and biopsy Gleason score (Partin tables) based on cases from 2000 to 2005. Urology. 2007. 69:1095–1101.

13. Briganti A, Karakiewicz PI, Chun FK, Gallina A, Salonia A, Zanni G, et al. Percentage of positive biopsy cores can improve the ability to predict lymph node invasion in patients undergoing radical prostatectomy and extended pelvic lymph node dissection. Eur Urol. 2007. 51:1573–1581.

14. Bluestein DL, Bostwick DG, Bergstralh EJ, Oesterling JE. Eliminating the need for bilateral pelvic lymphadenectomy in select patients with prostate cancer. J Urol. 1994. 151:1315–1320.

15. Conrad S, Graefen M, Pichlmeier U, Henke RP, Hammerer PG, Huland H. Systematic sextant biopsies improve preoperative prediction of pelvic lymph node metastases in patients with clinically localized prostatic carcinoma. J Urol. 1998. 159:2023–2029.

16. Burkhard FC, Schumacher MC, Studer UE. An extended pelvic lymph-node dissection should be performed in most patients if radical prostatectomy is truly indicated. Nat Clin Pract Urol. 2006. 3:454–455.

17. de Jong IJ, Pruim J, Elsinga PH, Vaalburg W, Mensink HJ. Preoperative staging of pelvic lymph nodes in prostate cancer by 11C-choline PET. J Nucl Med. 2003. 44:331–335.

18. Harisinghani MG, Barentsz J, Hahn PF, Deserno WM, Tabatabaei S, van de Kaa CH, et al. Noninvasive detection of clinically occult lymph-node metastases in prostate cancer. N Engl J Med. 2003. 348:2491–2499.

19. Sartor O, McLeod D. Indium-111-capromab pendetide scans: an important test relevant to clinical decision making. Urology. 2001. 57:399–401.

20. Manyak MJ, Hinkle GH, Olsen JO, Chiaccherini RP, Partin AW, Piantadosi S, et al. Immunoscintigraphy with indium-111-capromab pendetide: evaluation before definitive therapy in patients with prostate cancer. Urology. 1999. 54:1058–1063.

21. Ponsky LE, Cherullo EE, Starkey R, Nelson D, Neumann D, Zippe CD. Evaluation of preoperative ProstaScint scans in the prediction of nodal disease. Prostate Cancer Prostatic Dis. 2002. 5:132–135.

22. Wawroschek F, Vogt H, Weckermann D, Wagner T, Harzmann R. The sentinel lymph node concept in prostate cancer - first results of gamma probe-guided sentinel lymph node identification. Eur Urol. 1999. 36:595–600.

23. Wawroschek F, Vogt H, Weckermann D, Wagner T, Hamm M, Harzmann R. Radioisotope guided pelvic lymph node dissection for prostate cancer. J Urol. 2001. 166:1715–1719.

24. Raghavaiah NV, Jordan WP Jr. Prostatic lymphography. J Urol. 1979. 121:178–181.

25. Whitmore WF 3rd, Blute RD Jr, Kaplan WD, Gittes RF. Radiocolloid scintigraphic mapping of the lymphatic drainage of the prostate. J Urol. 1980. 124:62–67.

26. Gil-Vernet JM. Prostate cancer: anatomical and surgical considerations. Br J Urol. 1996. 78:161–168.

27. Cellini N, Luzi S, Mantini G, Mattiucci GC, Morganti AG, Digesu C, et al. Lymphatic drainage and CTV in carcinoma of the prostate. Rays. 2003. 28:337–341.

28. Heidenreich A, Ohlmann CH, Polyakov S. Anatomical extent of pelvic lymphadenectomy in patients undergoing radical prostatectomy. Eur Urol. 2007. 52:29–37.

29. Dhar NB, Burkhard FC, Studer UE. Role of lymphadenectomy in clinically organ-confined prostate cancer. World J Urol. 2007. 25:39–44.

30. Clark T, Parekh DJ, Cookson MS, Chang SS, Smith ER Jr, Wells N, et al. Randomized prospective evaluation of extended versus limited lymph node dissection in patients with clinically localized prostate cancer. J Urol. 2003. 169:145–147.

31. Heidenreich A, Varga Z, Von Knobloch R. Extended pelvic lymphadenectomy in patients undergoing radical prostatectomy: high incidence of lymph node metastasis. J Urol. 2002. 167:1681–1686.

32. Bader P, Burkhard FC, Markwalder R, Studer UE. Disease progression and survival of patients with positive lymph nodes after radical prostatectomy. Is there a chance of cure? J Urol. 2003. 169:849–854.

33. Weingärtner K, Ramaswamy A, Bittinger A, Gerharz EW, Vöge D, Riedmiller H. Anatomical basis for pelvic lymphadenectomy in prostate cancer: results of an autopsy study and implications for the clinic. J Urol. 1996. 156:1969–1971.

34. Bader P, Burkhard FC, Markwalder R, Studer UE. Is a limited lymph node dissection an adequate staging procedure for prostate cancer? J Urol. 2002. 168:514–518.

35. Mattei A, Fuechsel FG, Bhatta Dhar N, Warncke SH, Thalmann GN, Krause T, et al. The template of the primary lymphatic landing sites of the prostate should be revisited: results of a multimodality mapping study. Eur Urol. 2008. 53:118–125.

36. Bochner BH, Herr HW, Reuter VE. Impact of separate versus en bloc pelvic lymph node dissection on the number of lymph nodes retrieved in cystectomy specimens. J Urol. 2001. 166:2295–2296.

37. Stein JP, Penson DF, Cai J, Miranda G, Skinner EC, Dunn MA, et al. Radical cystectomy with extended lymphadenectomy: evaluating separate package versus en bloc submission for node positive bladder cancer. J Urol. 2007. 177:876–881.

38. Bochner BH, Cho D, Herr HW, Donat M, Kattan MW, Dalbagni G. Prospectively packaged lymph node dissections with radical cystectomy: evaluation of node count variability and node mapping. J Urol. 2004. 172:1286–1290.

39. Kim SC, Jeong I, Song C, Hong JH, Kim CS, Ahn H. Biochemical recurrence-free and cancer-specific survival after radical prostatectomy at a single institution. Korean J Urol. 2010. 51:836–842.

40. Ham WS, Park SY, Rha KH, Choi YD. Outcomes of robotic prostatectomy for treating clinically advanced prostate cancer. Korean J Urol. 2008. 49:325–329.

41. Briganti A, Chun FK, Salonia A, Suardi N, Gallina A, Da Pozzo LF, et al. Complications and other surgical outcomes associated with extended pelvic lymphadenectomy in men with localized prostate cancer. Eur Urol. 2006. 50:1006–1013.

42. Cagiannos I, Karakiewicz P, Eastham JA, Ohori M, Rabbani F, Gerigk C, et al. A preoperative nomogram identifying decreased risk of positive pelvic lymph nodes in patients with prostate cancer. J Urol. 2003. 170:1798–1803.

43. Bishoff JT, Reyes A, Thompson IM, Harris MJ, St Clair SR, Gomella L, et al. Pelvic lymphadenectomy can be omitted in selected patients with carcinoma of the prostate: development of a system of patient selection. Urology. 1995. 45:270–274.

44. Narayan P, Fournier G, Gajendran V, Leidich R, Lo R, Wolf JS Jr, et al. Utility of preoperative serum prostate-specific antigen concentration and biopsy Gleason score in predicting risk of pelvic lymph node metastases in prostate cancer. Urology. 1994. 44:519–524.

45. Roach M 3rd, Marquez C, Yuo HS, Narayan P, Coleman L, Nseyo UO, et al. Predicting the risk of lymph node involvement using the pre-treatment prostate specific antigen and Gleason score in men with clinically localized prostate cancer. Int J Radiat Oncol Biol Phys. 1994. 28:33–37.

46. Crawford ED, Batuello JT, Snow P, Gamito EJ, McLeod DG, Partin AW, et al. The use of artificial intelligence technology to predict lymph node spread in men with clinically localized prostate carcinoma. Cancer. 2000. 88:2105–2109.

47. Batuello JT, Gamito EJ, Crawford ED, Han M, Partin AW, McLeod DG, et al. Artificial neural network model for the assessment of lymph node spread in patients with clinically localized prostate cancer. Urology. 2001. 57:481–485.

48. Han M, Snow PB, Brandt JM, Partin AW. Evaluation of artificial neural networks for the prediction of pathologic stage in prostate carcinoma. Cancer. 2001. 91:8 Suppl. 1661–1666.

49. Poulakis V, Witzsch U, De Vries R, Emmerlich V, Meves M, Altmannsberger HM, et al. Preoperative neural network using combined magnetic resonance imaging variables, prostate specific antigen and Gleason score to predict prostate cancer stage. J Urol. 2004. 172:1306–1310.

50. Karam JA, Svatek RS, Karakiewicz PI, Gallina A, Roehrborn CG, Slawin KM, et al. Use of preoperative plasma endoglin for prediction of lymph node metastasis in patients with clinically localized prostate cancer. Clin Cancer Res. 2008. 14:1418–1422.

51. Wang L, Hricak H, Kattan MW, Schwartz LH, Eberhardt SC, Chen HN, et al. Combined endorectal and phased-array MRI in the prediction of pelvic lymph node metastasis in prostate cancer. AJR Am J Roentgenol. 2006. 186:743–748.

52. Partin AW, Mangold LA, Lamm DM, Walsh PC, Epstein JI, Pearson JD. Contemporary update of prostate cancer staging nomograms (Partin Tables) for the new millennium. Urology. 2001. 58:843–848.

53. Briganti A, Chun FK, Salonia A, Zanni G, Scattoni V, Valiquette L, et al. Validation of a nomogram predicting the probability of lymph node invasion among patients undergoing radical prostatectomy and an extended pelvic lymphadenectomy. Eur Urol. 2006. 49:1019–1026.

54. Conrad S, Graefen M, Pichlmeier U, Henke RP, Erbersdobler A, Hammerer PG, et al. Prospective validation of an algorithm with systematic sextant biopsy to predict pelvic lymph node metastasis in patients with clinically localized prostatic carcinoma. J Urol. 2002. 167:521–525.

55. Briganti A, Chun FK, Salonia A, Gallina A, Farina E, Da Pozzo LF, et al. Validation of a nomogram predicting the probability of lymph node invasion based on the extent of pelvic lymphadenectomy in patients with clinically localized prostate cancer. BJU Int. 2006. 98:788–793.

56. Wawroschek F, Vogt H, Wengenmair H, Weckermann D, Hamm M, Keil M, et al. Prostate lymphoscintigraphy and radio-guided surgery for sentinel lymph node identification in prostate cancer. Technique and results of the first 350 cases. Urol Int. 2003. 70:303–310.

57. Song C, Kang T, Lee MS, Ro JY, Lee SE, Lee E, et al. Clinico-pathological characteristics of prostate cancer in Korean men and nomograms for the prediction of the pathological stage of the clinically localized prostate cancer: a multi-institutional update. Korean J Urol. 2007. 48:125–130.

58. D'Amico AV, Whittington R, Malkowicz SB, Schultz D, Blank K, Broderick GA, et al. Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer. JAMA. 1998. 280:969–974.

59. Schumacher MC, Burkhard FC, Thalmann GN, Fleischmann A, Studer UE. Is pelvic lymph node dissection necessary in patients with a serum PSA <10ng/ml undergoing radical prostatectomy for prostate cancer? Eur Urol. 2006. 50:272–279.

60. Bhatta-Dhar N, Reuther AM, Zippe C, Klein EA. No difference in six-year biochemical failure rates with or without pelvic lymph node dissection during radical prostatectomy in low-risk patients with localized prostate cancer. Urology. 2004. 63:528–531.

61. Grossfeld GD, Chang JJ, Broering JM, Li YP, Lubeck DP, Flanders SC, et al. Under staging and under grading in a contemporary series of patients undergoing radical prostatectomy: results from the Cancer of the Prostate Strategic Urologic Research Endeavor database. J Urol. 2001. 165:851–856.

62. Golimbu M, Provet J, Al-Askari S, Morales P. Radical prostatectomy for stage D1 prostate cancer. Prognostic variables and results of treatment. Urology. 1987. 30:427–435.

63. Catalona WJ, Miller DR, Kavoussi LR. Intermediate-term survival results in clinically understaged prostate cancer patients following radical prostatectomy. J Urol. 1988. 140:540–543.

64. Pound CR, Partin AW, Eisenberger MA, Chan DW, Pearson JD, Walsh PC. Natural history of progression after PSA elevation following radical prostatectomy. JAMA. 1999. 281:1591–1597.

65. Pagliarulo V, Hawes D, Brands FH, Groshen S, Cai J, Stein JP, et al. Detection of occult lymph node metastases in locally advanced node-negative prostate cancer. J Clin Oncol. 2006. 24:2735–2742.

66. Ferrari AC, Stone NN, Kurek R, Mulligan E, McGregor R, Stock R, et al. Molecular load of pathologically occult metastases in pelvic lymph nodes is an independent prognostic marker of biochemical failure after localized prostate cancer treatment. J Clin Oncol. 2006. 24:3081–3088.

67. Terakawa T, Miyake H, Kurahashi T, Furukawa J, Takenaka A, Fujisawa M. Improved sensitivity for detecting micrometastases in pelvic lymph nodes by real-time reverse transcriptase polymerase chain reaction (RT-PCR) compared with conventional RT-PCR in patients with clinically localized prostate cancer undergoing radical prostatectomy. BJU Int. 2009. 103:1074–1078.

68. Daneshmand S, Quek ML, Stein JP, Lieskovsky G, Cai J, Pinski J, et al. Prognosis of patients with lymph node positive prostate cancer following radical prostatectomy: long-term results. J Urol. 2004. 172:2252–2255.

69. Allaf ME, Palapattu GS, Trock BJ, Carter HB, Walsh PC. Anatomical extent of lymph node dissection: impact on men with clinically localized prostate cancer. J Urol. 2004. 172:1840–1844.

70. Joslyn SA, Konety BR. Impact of extent of lymphadenectomy on survival after radical prostatectomy for prostate cancer. Urology. 2006. 68:121–125.

71. Boorjian SA, Thompson RH, Siddiqui S, Bagniewski S, Bergstralh EJ, Karnes RJ, et al. Long-term outcome after radical prostatectomy for patients with lymph node positive prostate cancer in the prostate specific antigen era. J Urol. 2007. 178:864–870.

72. Palapattu GS, Allaf ME, Trock BJ, Epstein JI, Walsh PC. Prostate specific antigen progression in men with lymph node metastases following radical prostatectomy: results of long-term followup. J Urol. 2004. 172:1860–1864.

73. Masterson TA, Bianco FJ Jr, Vickers AJ, DiBlasio CJ, Fearn PA, Rabbani F, et al. The association between total and positive lymph node counts, and disease progression in clinically localized prostate cancer. J Urol. 2006. 175:1320–1324.

74. DiMarco DS, Zincke H, Sebo TJ, Slezak J, Bergstralh EJ, Blute ML. The extent of lymphadenectomy for pTXNO prostate cancer does not affect prostate cancer outcome in the prostate specific antigen era. J Urol. 2005. 173:1121–1125.

75. Murphy AM, Berkman DS, Desai M, Benson MC, McKiernan JM, Badani KK. The number of negative pelvic lymph nodes removed does not affect the risk of biochemical failure after radical prostatectomy. BJU Int. 2010. 105:176–179.

76. Weight CJ, Reuther AM, Gunn PW, Zippe CR, Dhar NB, Klein EA. Limited pelvic lymph node dissection does not improve biochemical relapse-free survival at 10 years after radical prostatectomy in patients with low-risk prostate cancer. Urology. 2008. 71:141–145.

77. Berglund RK, Sadetsky N, DuChane J, Carroll PR, Klein EA. Limited pelvic lymph node dissection at the time of radical prostatectomy does not affect 5-year failure rates for low, intermediate and high risk prostate cancer: results from CaPSURE. J Urol. 2007. 177:526–529.

78. Heidenreich A, Aus G, Bolla M, Joniau S, Matveev VB, Schmid HP, et al. EAU guidelines on prostate cancer. Eur Urol. 2008. 53:68–80.

79. Kröpfl D, Krause R, Hartung R, Pfeiffer R, Behrendt H. Subcutaneous heparin injection in the upper arm as a method of avoiding lymphoceles after lymphadenectomies in the lower part of the body. Urol Int. 1987. 42:416–423.