NEW YORK (Reuters Health) – A review of the literature indicates that, far from being futile, radical prostatectomy improves outcomes when lymph nodes (LNs) are found to be positive in prostate cancer patients.

“Discontinuing surgery in the presence of positive nodes is no longer supported by current evidence, especially in patients with a limited LN tumor burden,” conclude the authors of the report in European Urology online May 23.

They note that radical prostatectomy for prostate cancer was often aborted when positive nodes were detected intraoperatively, but emerging data suggest radical prostatectomy can have a benefit in this setting. Furthermore, extended pelvic lymphadenectomy in lymph-node-positive prostate cancer may also be beneficial, based on experience with muscle-invasive bladder cancer.

Dr. Georgios Gakis, at Eberhard-Karls University Tubingen, Germany, and an international team therefore conducted a systematic review of the literature to assess current evidence in these areas. 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 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 5-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) .

Dr. Gakis and 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 (PCa).

Overall, they concluded, “Our understanding of surgery of the primary tumor in LN-positive PCa 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.”

SOURCE: The Role of Radical Prostatectomy and Lymph Node Dissection in Lymph Node–Positive Prostate Cancer: A Systematic Review of the Literature
Eur Urol 2013.