Clinical nodal staging scores for prostate cancer: a proposal for preoperative risk assessment

Abstract

Background:Pelvic lymph node dissection in patients undergoing radical prostatectomy for clinically localised prostate cancer is not without morbidity and its therapeutical benefit is still a matter of debate. The objective of this study was to develop a model that allows preoperative determination of the minimum number of lymph nodes needed to be removed at radical prostatectomy to ensure true nodal status.Methods:We analysed data from 4770 patients treated with radical prostatectomy and pelvic lymph node dissection between 2000 and 2011 from eight academic centres. For external validation of our model, we used data from a cohort of 3595 patients who underwent an anatomically defined extended pelvic lymph node dissection. We estimated the sensitivity of pathological nodal staging using a beta-binomial model and developed a novel clinical (preoperative) nodal staging score (cNSS), which represents the probability that a patient has lymph node metastasis as a function of the number of examined nodes.Results:In the development and validation cohorts, the probability of missing a positive lymph node decreases with increase in the number of nodes examined. A 90% cNSS can be achieved in the development and validation cohorts by examining 1–6 nodes in cT1 and 6–8 nodes in cT2 tumours. With 11 nodes examined, patients in the development and validation cohorts achieved a cNSS of 90% and 80% with cT3 tumours, respectively.Conclusions:Pelvic lymph node dissection is the only reliable technique to ensure accurate nodal staging in patients treated with radical prostatectomy for clinically localised prostate cancer. The minimum number of examined lymph nodes needed for accurate nodal staging may be predictable, being strongly dependent on prostate cancer characteristics at diagnosis.

Contemporary Patterns of Care and Outcomes of Men Found to Have Lymph Node Metastases at the Time of Radical Prostatectomy

“…9,10 Given the expected reverse stage migration precipitated by the US Preventive Services Task Force recommendations against prostate cancer screening, the shift towards performing RP on more high-risk patients and the increasing utilization of extended LND, the number of men with pN1 prostate cancer is expected to increase. These temporal trends, along with the unequivocally detrimental impact of LN metastases on survival, 11 make understanding the natural history of and defining the optimal management strategy for pN1 prostate cancer issues of increasing importance.…”

Clinical Factors Predicting Bilateral Lymph Node Invasion in High-Risk Prostate Cancer

“…However, the rate of multiple lymph node metastases has rarely been reported and ranges between 4 and 17% of cases [5]. Moreover, the rate of bilateral lymph node metastases is not reported in modern series [2,3,5,[15][16][17]. A large multicenter retrospective study including an old cohort has shown that in high-risk selected patients with at least 10 nodes removed (median 15), the rate of LNI was 36.1%, which included ROC, receiverreceiver operating characteristic; AUC, area under the curve; pN, pathologic nodal staging status; pN0, absence of nodal metastases; pN1(u), prostate cancer with unilateral metastatic nodes; pN1(b), prostate cancer with bilateral nodal metastases; PSA, prostate-specific antigen; P(p), proportion of biopsy positive cores.…”

Prediction of Micrometastasis (< 1 cm) to Pelvic Lymph Nodes in Prostate Cancer: Role of Preoperative MRI

“…In prostate cancer, there are several predictive nomograms, including the Partin nomogram, for preoperative prediction of final pathologic status (i.e., organ-confined prostate cancer, extracapsular extension, seminal vesicle invasion, or LN metastasis) by use of clinical parameters [28][29][30]. In these nomograms, serum PSA, clinical stage, and biopsy findings are usually investigated because they are known to be associated with the final pathologic stage of prostate cancer.…”