To what extent?

Top Line: Should men with intermediate and high risk prostate cancer have extended pelvic node dissection during radical prostatectomy?

The Study: Analogous to the unending debate over pelvic nodal irradiation, urologists debate the benefit of extended pelvic node dissection (EPLND) for intermediate and high risk disease. Here is a single center randomized trial comparing biochemical recurrence-free survival for limited (LPLND) versus extending pelvic node dissection (EPLND) in 300 men with intermediate and high risk disease. Pre-operative pelvic imaging was performed for patients with unfavorable intermediate and high risk disease and had to be negative for clinically positive nodes. The LPLND included bilateral obturator nodes. The EPLND included obturators, internal iliacs, external iliacs (caudally to the deep circumflex vein), common iliacs, and presacral nodes. Median nodes dissected was 3 for LPLND and 17 for EPLND. In a similar fashion, the rate of nodal metastasis was significantly higher with EPLND (3.4→ 17%). That’s probably because, in addition to more nodes, EPLND samples regions like the internal iliac nodes that had a higher frequency of positivity than the obturators. Despite significantly improved nodal staging, EPLND did not improve median BCRFS nor any other clinical outcome. There did appear to be a benefit, though, among patients with grade group 3+ disease.

TBL: Among a broad group of patients with intermediate and high risk prostate cancer, EPLND detects more nodal metastases but does not improve treatment outcomes. | Lestingi, Eur Urol 2020