Unit of Urology, Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
Department of Urology, Mayo Clinic, Rochester, MN, USA.
Eur Urol. 2019 May;75(5):817-825. doi: 10.1016/j.eururo.2018.10.042. Epub 2018 Nov 5.
A role for local therapies including radical prostatectomy (RP) in prostate cancer (PCa) patients with clinical lymphadenopathies has been proposed. However, no data are available to identify men who would benefit from RP in this setting.
To identify predictors of clinical recurrence (CR) in surgically managed PCa patients with clinical lymphadenopathies.
DESIGN, SETTING, AND PARTICIPANTS: We identified 162 patients with lymphadenopathies treated with RP and lymph node dissection at three referral centers.
CR was defined as the onset of metastases detected by conventional imaging. Kaplan-Maier analyses assessed time to CR after stratifying patients according to the site of lymphadenopathies and nodal burden. Regression tree analysis stratified patients into risk groups on the basis of their preoperative characteristics.
Overall, 80% of patients had lymphadenopathies in the pelvis alone and 20% in the retroperitoneum±pelvis. The median size of positive nodes was 13mm. A total of 84 patients (52%) received neoadjuvant androgen deprivation therapy and 127 (78%) had pathological lymph node invasion. The median follow-up for survivors was 64 mo. The 8-yr CR-free and CSM-free survival rates were 59% and 80%, respectively. Biopsy grade group and preoperative nodal burden should identify patients more likely to experience CR. While <10% of men with biopsy grade group 1-3 and two or fewer clinical lymphadenopathies developed CR, up to 60% of patients with biopsy grade group 4-5 and retroperitoneal node involvement ultimately experienced CR at 8 yr after RP. The discrimination of the regression tree was 76% according to the area under the receiver operating characteristic curve. Our study is limited by potential unmeasured confounders and the relatively small sample size.
Surgery in a multimodal setting might play a role in PCa patients with biopsy grade group 1-3 and/or enlarged nodes in the pelvis. Conversely, grade group 4-5 PCa and lymphadenopathies in the retroperitoneum are associated with worse oncologic outcomes.
Approximately half of prostate cancer patients with clinical lymphadenopathies treated with radical prostatectomy are free from metastases at 8-yr follow-up. Radical prostatectomy with or without systemic therapies might play a role in selected patients with biopsy grade group 1-3 disease and/or enlarged nodes in the pelvis. Conversely, a higher grade group and the presence of lymphadenopathies in the retroperitoneum should identify candidates for systemic therapies upfront.
已经提出了包括根治性前列腺切除术（RP）在内的局部治疗在有临床淋巴结病的前列腺癌（PCa）患者中的作用。然而，目前尚无数据可用于确定在此情况下从 RP 中受益的男性。
确定接受 RP 和淋巴结清扫术治疗的有临床淋巴结病的 PCa 患者中临床复发（CR）的预测因素。
设计、地点和参与者：我们在三个转诊中心确定了 162 名接受 RP 和淋巴结清扫术治疗的有淋巴结病的患者。
CR 定义为通过常规影像学检测到转移的开始。Kaplan-Meier 分析根据淋巴结病的部位和淋巴结受累程度对患者进行分层，以评估 CR 后的时间。基于术前特征，回归树分析将患者分层为风险组。
总体而言，80%的患者盆腔单独有淋巴结病，20%的患者腹膜后和/或盆腔有淋巴结病。阳性淋巴结的中位大小为 13mm。共有 84 名患者（52%）接受了新辅助雄激素剥夺治疗，127 名患者（78%）有淋巴结侵犯。幸存者的中位随访时间为 64 个月。8 年的无 CR 和 CSM 生存率分别为 59%和 80%。活检分级组和术前淋巴结受累程度应能确定更有可能发生 CR 的患者。尽管活检分级组 1-3 和只有 2 个临床淋巴结病的男性中，<10%发生 CR，但在接受 RP 治疗 8 年后，多达 60%的活检分级组 4-5 和腹膜后淋巴结受累的患者最终发生 CR。根据接收者操作特征曲线下的面积，回归树的判别率为 76%。我们的研究受到潜在未测量混杂因素和相对较小的样本量的限制。
在接受 RP 治疗的活检分级组 1-3 和/或盆腔淋巴结肿大的 PCa 患者中，多模式治疗可能发挥作用。相反，分级组 4-5 的 PCa 和腹膜后淋巴结病与较差的肿瘤学结果相关。
接受根治性前列腺切除术治疗的有临床淋巴结病的前列腺癌患者中，约有一半在 8 年随访时无转移。对于活检分级组 1-3 疾病和/或盆腔淋巴结肿大的患者，RP 联合或不联合系统治疗可能发挥作用。相反，分级组较高和腹膜后淋巴结病应确定患者是否需要早期采用系统治疗。
