Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy.
Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy.
Eur Urol. 2020 Dec;78(6):779-782. doi: 10.1016/j.eururo.2020.06.047. Epub 2020 Jul 2.
The best surgical template for salvage pelvic lymph node dissection (sLND) in patients with nodal recurrence from prostate cancer (PCa) after radical prostatectomy (RP) is currently unknown. We analyzed data of 189 patients with a unilateral positive positron emission tomography (PET) scan of the pelvic lymph node areas, who were treated with bilateral pelvic sLND after RP at 11 high-volume centers. The primary endpoint was missed contralateral disease at final pathology, defined as lymph node positive for PCa in the side opposite to the positive spot(s) at the PET scan. Overall, 93 (49%) and 96 (51%) patients received a C-choline and a Ga prostate-specific membrane antigen (PSMA) PET scan, respectively, and 171 (90%) and 18 (10%) men had one and two positive spots, respectively. The rate of missed contralateral PCa was 18% (34/189), with the rates being 17% (29/171) and 28% (5/18) in men with one and two positive spots, respectively. While the rate of contralateral disease did not differ between Ga-PSMA and C-choline (29% and 27%, respectively) among men with two positive spots, the rate of contralateral PCa was only 6% with Ga-PSMA versus 28% with C-choline in patients with a single positive spot. This finding was confirmed at multivariable logistic regression analysis predicting missed disease at final pathology after accounting for confounders (odds ratio: 0.24; p = 0.001). However, in men with a single positive spot at Ga-PSMA PET/computed tomography, the rate of single confirmed lymph node metastasis at final pathology was only 33%, suggesting the need for extended template even if unilateral dissection is performed. Awaiting confirmatory studies, patients diagnosed with a single positive spot at the Ga-PSMA PET scan might be considered for unilateral extended pelvic sLND. PATIENT SUMMARY: We assessed the risk of missing contralateral disease in patients with a positron emission tomography (PET) scan suggestive of unilateral nodal recurrence from prostate cancer (PCa) after radical prostatectomy and who were treated with bilateral salvage lymph node dissection (sLND). Variability exists according to the number of positive spots and PET tracer, with the lowest rate of missed PCa in men diagnosed with a single positive spot at a Ga prostate-specific membrane antigen PET scan (6%). If replicated, our data suggest that these patients might be considered for unilateral extended pelvic sLND.
目前，对于根治性前列腺切除术后前列腺癌（PCa）淋巴结复发患者，挽救性盆腔淋巴结清扫术（sLND）的最佳手术模板尚不清楚。我们分析了 189 名患者的数据，这些患者在 11 个大容量中心接受了根治性前列腺切除术后，对盆腔淋巴结区域进行了单侧正电子发射断层扫描（PET）扫描，发现阳性结果后，均接受了双侧盆腔 sLND 治疗。主要终点是最终病理学上错过对侧疾病，定义为在 PET 扫描阳性部位对侧的淋巴结有 PCa 阳性。总体而言，93 名（49%）和 96 名（51%）患者分别接受了 C-胆碱和 Ga 前列腺特异性膜抗原（PSMA）PET 扫描，171 名（90%）和 18 名（10%）男性分别有一个和两个阳性点。对侧 PCa 漏诊率为 18%（34/189），有一个和两个阳性点的男性分别为 17%（29/171）和 28%（5/18）。虽然在有两个阳性点的男性中，Ga-PSMA 和 C-胆碱的对侧疾病发生率没有差异（分别为 29%和 27%），但在有单个阳性点的患者中，Ga-PSMA 的对侧 PCa 发生率仅为 6%，而 C-胆碱的对侧 PCa 发生率为 28%。在多变量逻辑回归分析中，考虑到混杂因素后，这一发现可以预测最终病理学上的漏诊疾病（优势比：0.24；p=0.001）。然而，在 Ga-PSMA PET/计算机断层扫描中仅有一个阳性点的男性中，最终病理学上仅有 33%的患者单发性确认的淋巴结转移，这表明即使进行单侧清扫，也需要扩展模板。在等待确认性研究的同时，在 Ga-PSMA PET 扫描中诊断出单个阳性点的患者，可考虑行单侧扩展盆腔 sLND。患者总结：我们评估了在根治性前列腺切除术后，前列腺癌（PCa）淋巴结复发患者进行正电子发射断层扫描（PET）扫描提示单侧淋巴结复发后，行双侧挽救性淋巴结清扫术（sLND）时，对侧疾病漏诊的风险。根据阳性点的数量和 PET 示踪剂的不同，漏诊 PCa 的风险也存在差异，在 Ga 前列腺特异性膜抗原 PET 扫描中诊断出单个阳性点的男性中，漏诊率最低（6%）。如果得到证实，我们的数据表明，这些患者可能需要考虑单侧扩展盆腔 sLND。
