RADICAL PROSTATECTOMY IMPROVES SURVIVAL IN N+ DISEASE
NEW YORK (Reuters Health) Jun 07 - For prostate cancer patients with positive lymph nodes, radical prostatectomy, far from being futile, actually improves outcomes, a literature review suggests.
Aborting the surgery when nodes are positive "is no longer supported by current evidence, especially in patients with a limited lymph node tumor burden," conclude the authors of the report in European Urology, published online May 23.
Dr. Georgios Gakis, at Eberhard-Karls University Tubingen, Germany, and an international team say they undertook their study because emerging data have suggested that radical prostatectomy can have a benefit in this setting, and furthermore, that extended pelvic lymphadenectomy in lymph-node-positive prostate cancer may also be beneficial, based on experience with muscle-invasive bladder cancer.
They initially identified 857 relevant records, ultimately citing 69 studies in their paper. They point out that most studies were retrospective and therefore subject to selection bias, and that generally the level of evidence was not high.
Nonetheless, they concluded that radical prostatectomy does improve survival in lymph node (LN)-positive prostate cancer. In one study, for example, 10-year survival was 64% in patients who were treated with radical prostatectomy compared to 28% among those in whom the procedure was aborted - albeit that the groups were imbalanced in terms of the number of positive lymph nodes.
The team also concluded that evidence supports extended lymph node dissection in some patients with LN-positive prostate cancer. A recent prospective study found no difference in five-year progression-free survival for low-risk patients between those who underwent standard or extended pelvic LN dissection (90.1% vs 91.3%), whereas there was a significant difference for intermediate-risk patients (73.1% vs 85.7%; p=0.042) and high-risk patients (51.1% vs 71.4%; p = 0.036).
"Extended pelvic lymph node dissection including the common iliac arteries should be offered to intermediate- and high-risk patients in order to improve nodal staging with a possible benefit in PSA progression-free survival by removing significant metastatic load," Dr. Gakis advised in an email to Reuters Health.
He and his colleagues also found evidence that adjuvant local radiotherapy and androgen deprivation therapy have the potential to improve survival further after radical prostatectomy in LN-positive prostate cancer.
Also, Dr. Gakis noted, "Age is a critical parameter for survival, as cancer-specific mortality exceeds overall mortality in younger patients (aged <60 an="" and="" as="" be="" cancer="" high-risk="" impetus="" p="" possible.="" prostate="" should="" thoroughly="" to="" treat="" with="" years="">
"Altogether," he concluded, "our understanding of surgery of the primary tumor in lymph node-positive prostate cancer 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."
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