Management of prostate cancer patients with lymph node involvement: A rapidly evolving paradigm

Abstract

Although widespread PSA screening has inevitably led to increased diagnosis of lower risk prostate cancer, the number of patients with nodal involvement at baseline remains high (nearly 40% of high risk patients initially staged cN0). These rates probably do not reflect the true incidence of prostate cancer with lymph node involvement among patients selected for external beam radiotherapy (EBRT), as patients selected for surgery often have more favorable prognostic features. At many institutions, radical treatment directed only at the prostate is considered standard and patients known to have regional disease are often managed palliatively with androgen deprivation therapy (ADT) for presumed systemic disease. New imaging tools such as MR lymphangiography, choline-based PET imaging or combined SPECT/CT now allow surgeons and radiation oncologists to identify and target nodal metastasis and/or lymph nodes with a high risk of occult involvement. Recent advances in the field of surgery including the advent of extended nodal dissection and sentinel node procedures have suggested that cancer-specific survival might be improved for lymph-node positive patients with a low burden of nodal involvement when managed with aggressive interventions. These new imaging tools can provide radiation oncologists with maps to guide delivery of high dose conformal radiation to a target volume while minimizing radiation toxicity to non-target normal tissue. This review highlights advances in imaging and reports how they may help to define a new paradigm to manage node-positive prostate cancer patients with a curative-intent.

Does Choline PET/CT Change the Management of Prostate Cancer Patients With Biochemical Failure?

“…3,6 Few studies describe how labeled choline PET/CT imaging impacts decision making and treatment of patients with biochemical failure following definitive therapy. 3,[7][8][9][10] In this study we report the impact of labeled choline PET/CT scans on management decisions and subsequent treatment for 33 patients with rising PSA after failed primary or salvage therapy.…”

Three Dimensional Conformal Radiotherapy and Androgen Deprivation Therapy in Patients with Clinically Localized Prostate Cancer; Hacettepe University Experience

“…12 In RTOG 85-32 trial, LN positive patients that received whole pelvic RT (WPRT) with combined hormonal treatment, had better biochemical control rates at 5 and 9 years compared to WPRT only; 54% and 10% versus 33% and 4%, respectively. In our trial, although all of the outcomes were worse in LN positive patients compared to LN negative counterparts (p= 0.001), there were only 5 deaths because of prostate cancer in LN positive patients.…”

Total submission of pelvic lymphadenectomy tissues removed during radical prostatectomy for prostate cancer increases lymph node yield and detection of micrometastases

“…Conventional imaging modalities perform poorly in detecting lymph node metastases from prostate cancer, and 25–40% of patients who undergo radical prostatectomy with an extended pelvic lymphadenectomy have these identified by histology . For those patients with lymph node metastases detected after surgery, there is some evidence for improved recurrence‐free and cancer‐specific survival resulting from adjuvant radiotherapy; however, this has not yet been tested in a randomized controlled trial …”

“…1,14 For those patients with lymph node metastases detected after surgery, there is some evidence for improved recurrence-free and cancer-specific survival resulting from adjuvant radiotherapy 8 ; however, this has not yet been tested in a randomized controlled trial. 15 Although lymph node metastasis is a useful indicator of poor prognosis, biochemical disease recurrence develops in approximately one-third of patients with cancer that is histologically confined to the prostate at the time of radical prostatectomy. 16,17 The cause of recurrence in these patients has not been fully elucidated, but there is evidence that it is, in part, attributable to failure to detect lymph node metastases, owing to either the handling of the pathology specimen or the extent of the lymphadenectomy performed.…”