JU INSIGHT Unilateral Pelvic Lymph Node Dissection in Prostate Cancer Diagnosed in Era of MRI-targeted Biopsy

By: Alberto Martini, MD, La Croix du Sud Hospital, Toulouse, France, Lieke Wever, MD, St Antonius Ziekenhuis, Nieuwegein, The Netherlands, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands, Timo F. W. Soeterik, MD, St Antonius Ziekenhuis, Nieuwegein, The Netherlands, Arnas Rakauskas, MD, Lausanne University Hospital and University of Lausanne, Switzerland, Christian Daniel Fankhauser, MD, University Hospital Zurich, University of Zurich, Switzerland, Josias Bastian Grogg, University Hospital Zurich, University of Zurich, Switzerland, Enrico Checcucci, MD, MSc, San Luigi Hospital, Turin, Italy, Daniele Amparore, MD, San Luigi Hospital, Turin, Italy, Luciano Haiquel, MD, Institut Mutualiste Montsouris, Paris, France, Lara Rodriguez-Sanchez, MD, Institut Mutualiste Montsouris, Paris, France, Guillaume Ploussard, MD, PhD, La Croix du Sud Hospital, Toulouse, France, Peng Qiang, Kantonsspital Winterthur, Switzerland, Andres Affentranger, Kantonsspital Winterthur, Switzerland, Alessandro Marquis, MD, San Giovanni Battista Hospital, University of Turin, Italy, Giancarlo Marra, MD, San Giovanni Battista Hospital, University of Turin, Italy, Otto Ettala, PhD, Turku University, Finland, Fabio Zattoni, MD, PhD, Academical Medical Centre Hospital, Udine, Italy, University of Padua, Italy, Ugo Giovanni Falagario, MD, University of Foggia, Italy, Mario De Angelis, IRCCS San Raffaele Hospital, Milan, Italy, Claudia Kesch, MD, University Hospital Essen, Germany, German Cancer Consortium (DKTK)-University Hospital Essen, Germany, Maria Apfelbeck, MD, LMU, Munich, Germany, Tarek Al-Hammouri, University College London and University College London Hospitals NHS Foundation Trust, United Kingdom, Alexander Kretschmer, MD, LMU, Munich, Germany, Veeru Kasivisvanathan, PhD, University College London and University College London Hospitals NHS Foundation Trust, United Kingdom, Felix Preisser, MD, University Hospital Frankfurt, Germany, Emilie Lefebvre, CHU Lille, France, Jonathan Olivier, MD, CHU Lille, France, Jan Philipp Radtke, MD, University Hospital Essen, Germany, German Cancer Consortium (DKTK)-University Hospital Essen, Germany, Alberto Briganti, MD, PhD, IRCCS San Raffaele Hospital, Milan, Italy, Francesco Montorsi, MD, PhD, IRCCS San Raffaele Hospital, Milan, Italy, Giuseppe Carrieri, MD, University of Foggia, Italy, Fabrizio Dal Moro, MD, Academical Medical Centre Hospital, Udine, Italy, University of Padua, Italy, Peter Boström, MD, Turku University, Finland, Ivan Jambor, MD, Turku University, Finland, Paolo Gontero, MD, San Giovanni Battista Hospital, University of Turin, Italy, Peter K. Chiu, PhD, The Chinese University of Hong Kong, China, Hubert John, MD, Kantonsspital Winterthur, Switzerland, Petr Macek, MD, Institut Mutualiste Montsouris, Paris, France, Francesco Porpiglia, MD, San Luigi Hospital, Turin, Italy, Thomas Hermanns, MD, University Hospital Zurich, University of Zurich, Switzerland, Roderick C.N. van den Bergh, MD, St Antonius Ziekenhuis, Nieuwegein, The Netherlands, Jean-Paul A. van Basten, MD, St Antonius Ziekenhuis, Nieuwegein, The Netherlands, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands, Giorgio Gandaglia, MD, PhD, IRCCS San Raffaele Hospital, Milan, Italy, Massimo Valerio, MD, PhD, Geneva University Hospital, University of Geneva, Switzerland | Posted on: 20 Jul 2023

On behalf of the Young Academic Urologists Working Group on Prostate Cancer of the European Association of Urology

Martini A, Wever L, Soeterik TFW, et al. Unilateral pelvic lymph node dissection in prostate cancer patients diagnosed in the era of magnetic resonance imaging–targeted biopsy: a study that challenges the dogma. J Urol. 2023;210(1):117-127.

Study Need and Importance

The currently available clinical models for lymph node invasion (LNI) prediction are hampered by a relatively low specificity, the removed lymph nodes being negative up to 70% of the time. Up to 2016, prostate cancer (PCa) clinical staging was based mostly on digital rectal examination and prostatic biopsy according to prespecified templates, also referred to as “random” biopsy. Since then, the diagnostic pathway for prostate cancer has changed and currently consists in MRI first with subsequent targeted biopsy of the suspicious areas of the prostate along with random sampling of the gland. This represents a major step forward in managing PCa; the use of preoperative MRI provides surgeons with seminal staging information. To our knowledge, this is the first study to assess the feasibility of unilateral extended pelvic lymph node dissection (ePLND) in the era of modern PCa imaging.

What We Found

LNI contralateral to the prostatic lobe with worse tumor characteristics is rare and depends on the presence of cancer contralateral to the dominant side, its grade, and extent. Our findings provide the grounds for evaluating unilateral ePLND in future studies.

Limitations

The multi-institutional nature of our data might harbor a certain degree of unaccounted heterogeneity, especially concerning MRI acquisition, reporting, and biopsy together with the lack of external validation.

Interpretation for Patient Care

In the era of modern PCa imaging, ePLND can be omitted contralateral to the prostatic lobe with the worse tumor burden in selected patients, especially in the absence of high-risk clinical features. We propose a model for the prediction of LNI contralateral to the dominant prostate lobe that can help avoid contralateral ePLND in almost one-third of cases. Potential benefits of our model in clinical practice could be shorter operative time and lower risk of complications and costs (see Figure).

Figure. Distribution of contralateral lymph node metastases according to International Society of Urological Pathology (ISUP) grade on the dominant and contralateral sides in the absence of high-risk clinical features (prostate-specific antigen ≥20 ng/mL and/or extraprostatic extension or seminal vesicle invasion on multiparametric magnetic resonance imaging and/or grade group ≥4). LNI indicates lymph node invasion; neg, negative.