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March 2017 #urojc summary: Pelvic Lymph Node Dissection with Radical Prostatectomy – Is there enough evidence for and against?

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The twitter-based international urology journal club @iurojc #urojc is back with a splash after a brief hiatus. For the March 2017 #urojc, a lively discussion takes the theme of pelvic node dissection (PLND) on radical prostatectomy (RP) reviewing a timely article by Nicola Fossati et al. The paper was made available open access courtesy of European Urology @EUplatinum.

A systematic review of the literature was performed including all comparative studies of both randomized and non randomized studies, with at least one experimental and one control arm. This summarised 66 studies including more than 250.000 patients with particular focus on different extents of pelvic lymphadenectomy as proposed by the European Association of Urology. Outcome measures studied included oncological features of biochemical recurrence, development of metastases, cancer-specific survival, and overall survival. Adverse events were covered under secondary outcomes, both intra- and postoperatively observed. Finally, quality of PLND was addressed in terms of total number of nodes and total number of positive nodes. Risk of bias was assessed for all studies judging on basis of specific confounders.

The journal club ran for 48 hours from Sunday 5th march. The central question addressed is balance of benefits and drawbacks of lymph node dissection. The corresponding author of the manuscript, Steven Joniau from the University Hospitals of Leuven, Belgium highlighted the role of lymph nodes in prostate cancer recurrence.

However despite this idea, the benefit of PLND is heavily scrutinized from the start. Long term data from a single centre  suggested limited benefit.

 

However PLND has since earlier times been employed as a diagnostic tool, where an optimal template (presacral in addition to extended LND) may be optimal for staging and removal of lymph nodes.

Despite the current state of evidence, PLND is frequently mentioned in the various guidelines available for prostate cancer. However the exact situations when to employ them is questioned by some participants.

The various therapeutic options for lymph node metastases also coloured the discussion.

The discussion further continued to the important issue of morbidity, and the associated question of performing an extended PLND (ePLND).

Despite the current state of evidence, PLND is frequently mentioned in the various guidelines available for prostate cancer. However the exact situations when to employ them is questioned by some participants.

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The discussion further continued to the important issue of morbidity, and the associated question of performing an extended PLND (ePLND).

The increasing use of PSMA PET/CT provided other spread pattern data to be considered. And finally temporal changes in PSA testing is observed to affect the need for LND.

 

From the poll which ran during the discussion, about half responders would perform extended PLND for staging, while the rest were divided almost equally between therapeutic benefit and adherence to guideline recommendations.

Probably all participants of the discussion agrees for the need of a proper randomised study addressing role of PLND.

At the end of a busy 48 hours, the discussion had been joined by top experts in the field of prostate cancer, generated more than 200 tweets and reached more than 700 thousand impressions the world over.

Yodi Soebadi (@yodisoebadi) is an Indonesian urologist, trained at Universitas Airlangga, currently pursuing doctoral research at KU Leuven in Belgium.

 

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