Department of Urology, University Hospital Tübingen, Eberhard-Karls University Tübingen, Germany.
Department of Urology, Mayo Clinic, Rochester, MN, USA.
Eur Urol. 2014 Aug;66(2):191-9. doi: 10.1016/j.eururo.2013.05.033. Epub 2013 May 22.
Because pelvic lymph node (LN)-positive prostate cancer (PCa) is generally considered a regionally metastatic disease, surgery needs to be better defined.
To review the impact of radical prostatectomy (RP) and pelvic lymph node dissection (PLND), possibly in conjunction with a multimodal approach using local radiotherapy and/or androgen-deprivation therapy (ADT), in LN-positive PCa.
A systematic Medline search for studies reporting on treatment regimens and outcomes in patients with LN-positive PCa undergoing RP between 1993 and 2012 was performed.
RP can improve progression-free and overall survival in LN-positive PCa, although there is a lack of high-level evidence. Therefore, the former practice of aborting surgery in the presence of positive nodes might no longer be supported by current evidence, especially in those patients with a limited LN tumor burden. Current data demonstrate that the lymphatic spread takes an ascending pathway from the pelvis to the retroperitoneum, in which the internal and the common iliac nodes represent critical landmarks in the metastatic distribution. Sophisticated imaging technologies are still under investigation to improve the prediction of LN-positive PCa. Nonetheless, extended PLND including the common iliac arteries should be offered to intermediate- and high-risk patients to improve nodal staging with a possible benefit in prostate-specific antigen progression-free survival by removing significant metastatic load. Adjuvant ADT has the potential to improve overall survival after RP; the therapeutic role of a trimodal approach with adjuvant local radiotherapy awaits further elucidation. Age is a critical parameter for survival because cancer-specific mortality exceeds overall mortality in younger patients (<60 yr) with high-risk PCa and should be an impetus to treat as thoroughly as possible.
Increasing evidence suggests that RP and extended PLND improve survival in LN-positive PCa. Our understanding of surgery of the primary tumor in LN-positive PCa needs a conceptual change from a palliative option to the first step in a multimodal approach with a significant improvement of long-term survival and cure in selected patients.
由于盆腔淋巴结（LN）阳性前列腺癌（PCa）通常被认为是局部转移性疾病，因此需要更好地定义手术。
回顾根治性前列腺切除术（RP）和盆腔淋巴结清扫术（PLND）的影响，可能结合局部放疗和/或雄激素剥夺治疗（ADT）的多模态方法，在 LN 阳性 PCa 中的作用。
对 1993 年至 2012 年间接受 RP 治疗的 LN 阳性 PCa 患者的治疗方案和结局进行了系统的 Medline 搜索。
RP 可以改善 LN 阳性 PCa 的无进展生存期和总生存期，但缺乏高级别证据。因此，目前的证据不再支持在存在阳性淋巴结时中止手术的前一种做法，尤其是在那些 LN 肿瘤负荷有限的患者中。目前的数据表明，淋巴扩散呈从盆腔到腹膜后向上的途径，其中内部和髂总淋巴结是转移分布的关键标志。复杂的成像技术仍在研究中，以提高对 LN 阳性 PCa 的预测。尽管如此，应向中高危患者提供包括髂总动脉在内的广泛 PLND，以改善淋巴结分期，通过去除大量转移性负荷，可能改善前列腺特异性抗原无进展生存期。辅助 ADT 有可能改善 RP 后的总生存期；辅助局部放疗的三联疗法的治疗作用有待进一步阐明。年龄是生存的关键参数，因为对于高危 PCa 的年轻患者（<60 岁），癌症特异性死亡率超过总死亡率，应该成为尽可能彻底治疗的动力。
越来越多的证据表明 RP 和广泛的 PLND 可改善 LN 阳性 PCa 的生存。我们对 LN 阳性 PCa 中原发性肿瘤手术的理解需要从姑息性选择转变为多模态方法的第一步，这可以显著改善选定患者的长期生存和治愈。
