Hello group and as the year start i wish to all peace and love around you.
After my targeted biopsy at G 4+5 and G 4+3 all on one side, with no peri-neural invasion, no seminal invasion and a 17 PSA at the same level for one year... i have been prescribed a PR + ePLND (extended lymphadenectomy) to occur in February. The oncologist and I have discussed the max PR option but he felt (and me also) that it would be best to conserve "options" for the future. This Dr is experienced, he his a researcher on prostate cancer and oncologist-surgeon. He said ihe can spare nerves on the left side but it would not be prudent on the right side (where the G9 and G7 are).
But he also said you need ePLND. The definition speak itself:
The presence of nodal metastases (LN+) remains an adverse prognostic factor in patients treated for prostate cancer (PCa), and, in intermediate and high-risk patients (pts), current European Association of Urology (EAU) PCa guidelines recommend performing extended pelvic lymph node dissection (ePLND) in case of an estimated risk for LN+ >5%
Front. Surg., 07 September 2018| doi.org/10.3389/fsurg.2018....
Using the 2016 Partin table it yield a probability of 24 % of lymph node involvement:
Another more recent (2018) nomogram based on mpMRI yield a probability of 15 %:
evidencio.com/models/show/1555 result shown in the image
So the risk seems to be between 15 and 24 %.
ePLND is recommended as "best practice" for high risk patient as he said. But after reading many of the posts of fellows here and also most of the recent litterature i arrive at a different conclusion. Supporting articles:
The question is the following: Is ePLND more a staging technique than a therapeutic approach ? All the arguments are found on retrospective studies and limited number of patients. 25 % of chance of having node involvement means also 75 % of chance of not having node involvement. My understanding is that if they found after the RARP:
-Postive margin upon dissection of the prostate or seminal vesicles
-Increasing PSA 3 or 6 months after surgery
Then i will need anyway either hormonal or radiation as adjuvant. Maybe i could let the surgeon remove some nodes (limited lymphadenectomy) but not the extended which lead to much more probability of morbidity.
Is it possible that in a near future... a random study would invalidate all the conclusion of the current retrospective studies and claim that there are not so much difference in survival or incidence of biological recurence between having a PLND or not ?