Salvage Pelvic Lymph Node Dissection in Recurrent Prostate Cancer: Surgical and Early Oncological Outcome

[SuppWife]

While googling possible treatment of retroperitoneal lymph nodes I found this and thought it was interesting. I know this is not my husband's situation but others might be interested who haven't started ADT and who have slower moving PSA.

Is surgery for RPLNs ever a good idea for recurrent prostate cancer?

Any learned members have opinions or thoughts?

ncbi.nlm.nih.gov/pmc/articl...

Abstract

Methodology. Seventeen patients with prostate-specific antigen (PSA) rise following local treatment for prostate cancer with curative intent underwent open or minimally invasive salvage pelvic lymph node dissection (SLND) for oligometastatic disease (<4 synchronous metastases) or as staging prior to salvage radiotherapy. Biochemical recurrence after complete biochemical response (cBR) was defined as 2 consecutive PSA increases >0,2 ng/mL; and after incomplete biochemical response as 2 consecutive PSA rises. Newly found metastasis on imaging defined clinical progression (CP). Palliative androgen deprivation therapy (ADT) was initiated if >3 metastases were detected or if patients became symptomatic. Kaplan-Meier statistics were applied. Results. Clavien-Dindo grade 1, 2, 3a, and 3b complications were seen in 6, 1, 1, and 2 patients, respectively. Median follow-up time was 22 months. Among 13 patients treated for oligometastatic disease, 8 (67%) had a PSA decline, with 3 patients showing cBR. Median PSA progression-free survival (FS) was 4.1 months and median CP-FS 7 months. Three patients started ADT, resulting in a 2-year ADT-FS rate of 79.5%. Conclusion. SLND is feasible, but postoperative complication rate seems higher than that for primary LND. Biochemical and clinical response duration is limited, but as part of an oligometastatic treatment regime it can defer palliative ADT.

5. Conclusions

This series presents surgical and early oncological results after SLND without the effect of any adjuvant therapies, be it ADT or radiation therapy. SLND for oligometastatic PC recurrence seems feasible, both open and minimally invasive, but postoperative complication rate is rather high as compared to primary PLND series. Although only a limited number of patients had a durable biochemical response, as part of an oligometastatic treatment regime it can defer palliative ADT. Larger, prospective trials are needed for further clarification of these results.

[Tall_Allen]

IMO - always a bad idea unless one can't have radiation. High rates of lymphocele and lymphedema (note high complication rate), and rarely curative (note low rate of CR even in 22 mo. follow-up). There should have been 2 years of ADT at least.

[Explorer08 in reply to Tall_Allen]

Tall_Allen, my urologic oncologist told me the exact same thing. Lymphedema, in particular, would most likely result, she noted.

[Justfor_]

There is an experimental PSMA guided salvage lymphnodeectomy.

A radiation detector is attached to one of the robotic arms of a usual daVinci robotic system guiding the surgeon to places of high PSMA concentration. Injection into the patient of the PSMA radio ligand is effected right before the start of the operation. Small numbers of procedures thus far though.

[GP24]

I prefer radiation of the mets with SBRT. Regarding lymph node dissection here is a later study with 189 patients. pubmed.ncbi.nlm.nih.gov/326...

They conclude:"In contrast with prior evidence, we found that the majority of these men recurred after sLND and eventually died from PCa. A significant survival benefit associated with the administration of androgen deprivation therapy after sLND suggests that sLND should be considered part of a multimodal approach rather than an exclusive treatment strategy. "

The PSMA guided salvage lymphadenectomy Justfor_ mentioned is standard of care in Hamburg and Munich. Otherwise chances are high that affected lymph nodes remain after the lymph node dissection. The surgeon usually cannot see if they are affected or not during surgery.

[btca]

Inspired by your post I found this; europeanurology.com/article... ; Sounds like there has been some studies with more undesirable side effects than benefits. More study needed.