Salvage lymph node dissection for nodal recurrence after radical prostatectomy
the incidence of recurrence after radical treatment of local prostate cancer (PCa) is frequent, occurring in 30-50% after radical prostatectomy and in up to 80% after extracorporal radiotherapy . An increase of PSA indicates a relapse but it cannot help to differenciate between local recurrence and systemic spread of the disease. These patients are normally managed with palliative androgen deprivation therapy (ADT), which is associated with significant toxicity and development of hormone refractory disease. Positron emission tomography with cholin tracer is a promising technique for restaging of these patients before they receive an ADT. The aim of this study is to examine the outcome of salvage lymph node dissection (LND) with evaluation of PSA in patients with only nodal recurrence documented with C-Choline-PET / CT.
Materials and Methods
Fifteen consecutive patients between 2007 and 2015 with biochemical failure and positive lymph node in C-Choline-PET/CT were retrospectively included in the study. Because of a prostate cancer (PCa), 12 patients had initially undergone a retropubic radical prostatectomy with LND and 3 a perineal prostatectomy without LND. The patients underwent a secondary open extended LAD, performed from 2 of our experienced surgeon. The extended LAD consisted in dissection of lymph nodes from the obturator fossa, the internal and external iliac artery, the paravesical lymph nodes and the common iliac artery. Biochemical response was defined as a prostate specific antigen less than 0.2 ng/ml 6 weeks after salvage surgery.
Mean PSA at the time of C-Choline-PET / CT before salvage LND was 2.1 ng/ml. Definitive histological metastases could be found in 12 of 15 patients but in 3 cases not where these were indicated by C-Choline-PET / CT; in further 3 cases no positive lymph nodes were found at all. All postoperative courses were uneventful without any major complications except in one case, with necessity of surgical reintervention. Median follow up after salvage lymph node dissection was 52 months. A total of 7 patients (46%) achieved a biochemical response. During follow up 3 patients (20%) remained free from recurrence (one of these patients died for another tumor 12 months after LND) while 2 another patients became adjuvant RT and ADT 6 and 72 months after LND and show actually no progression of disease. Only one patient died of disease 6 year after LND. The other 8 patients, who didn’t achieved a biochemical response, are actually managed with ADT.
C-Choline-PET / CT has been proved to be useful for restaging patients with increase of PSA after radical surgery even though its results could be influenced from PSA value [2-3]. Based on the findings of C-Choline-PET / CT, a selected group of patients could benefit of an extended secondary LAD. The current data suggest that about half of patients have an immediate postoperative response and one third of these patients can remain free of relapse for 5 years . Our results are similar to these findings and we believe that these procedure should be offered in highly selected cases.
Salvage LND may represent a therapeutic option for selected patients with biochemical recurrence and nodal pathologic uptake at C-Choline-PET / CT with improving cancer control and reducing the exposure time to ADT.
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