Professor Guram Karazanashvili MD, KMSc, DMSc MMT Hospital Radical prostatectomy and lymphadenectomy in clinically node positive prostate cancer patients Professor Guram Karazanashvili MD, KMSc, DMSc MMT Hospital

Patients Surgery from 2011 to 2014, by single surgeon 27 Patients with clinically node positive (N+) Prostate cancer were selected for the surgery T2 - 11patients T3 – 11 patients T4 – 5 patients

Patients Lymph node involvement was suspected either because of high PSA or CT/MRI Bone scan was positive in 2 cases Patient age: 50-60 years – 5 cases 60-70 years – 14 cases 70-75 years – 8 cases

Preoperative data All patients with clinically N+ prostate cancer had PSA levels above 30ng/ml: 30-50ng/ml 17 cases 50-100ng/ml 6 cases >100ng/ml (max. 153ng/ml) 4 cases

Preoperative data Gleason scores were higher in N+ compared to locally advanced prostate cancers Gl. 6 (3+3) 4 cases Gl. 7 (3+4) 0 cases Gl. 7 (4+3) 11 cases Gl. 8 (4+4) 5 cases Gl.9 (5+4) 7 cases

Tipe of Surgery Radical prostatectomy with extended lymphadenectomy (along internal and external iliac vessels) – 20 cases Radical prostatectomy with bladder neck resection, and extended lymphadenectomy (along internal and external iliac vessels) – 2 cases Radical cystoprostatectomy, superextended lymphadenectomy – 5 cases Sigma-rectum pouch – 2case Ileal conduit (Briker’s operation) - 2 cases Bilateral ureterocutaneostomy – 1 case

Surgical margins Surgical margins were positive in 10 (of 27) patients: Apex 2 cases Bladder neck 5 cases Other 3 cases

Stage migration preoperative stage T stage migration occurred in 30% of cases: Downstaging 8 cases Overstaging 0 cases Preoperative N stage migration occurred in 33% of cases: Overstaging 9 cases

Stage migration In 5 (of 9) N overstaged cases PSA was between 50 and 100ng/ml. In 1(of 9) N overstaged case PSA was 100ng/ml In 3 (of 9) PSA was between 30-50ng/ml preoperatively Thus 33% of clinically N+ prostate cancer and high PSA levels, were not N+. They might be cured with the surgery alone

PSA > 0.2ng/ml at 3 monthes Bone Mts and positive surical margins 2cases N+ and positive surgical margins 4 cases N+ 3 cases N- and negative surgical margins 2 cases Overall in 41% of cases PSA>0.2ng/ml at 3 monthes

Adjuvant therapies Antiandrogens 4 cases Intermittent androgen deprivation 1 case Medical or surgical castration 3 cases Radiation therapy+medical castration+chemotherapy 3 cases No adjuvant therapies 16 cases

59% of patients with clinically node positive prostate cancer have got no adjuvant therapies!

22 of 27 patients with clinically node positive prostate cancer currently have no bone metastasis

Incontinence At 3 monthes: Total incontinence 0 of (22) cases Stress incontinence 6 (of 22) cases Continent 16 (of 22) cases Currently: Total incontinence 0 (of 22) cases Stress incontinence 1 (of 22) cases Continent 21 (of 22) cases

Conclusions Significant number of patients can be saved from unnecessary hormonal therapy or this can be delayed due to surgery in clinically node positive prostate cancer patients Multimodal therapy including surgical excision of primary tumor and lymphatics might prolong survival of node positive prostate cancer patients

Case #1 Patient K. 67y. PSA 132ng/ml; Gleason 9 (5+4); cT2bN1M0 Radical prostatecomy with extended lymphadenectomy 11.10.2011 pT3bN+M0; 21 lymph nodes/2 positive; Surgical margins –negative PSA nadir 4.42 at 3 monthes Antiandrogens Currently: PSA 1.96; No bone metastasis

Case #2 Patient J. 68y. PSA 44.2ng/ml; Gleason 9(5+4); cT4N+M0 Radical cistoprostatectomy with superextended lymphadeneqtomy and sigma-rectum pouch 7.6.2012 pT4N+M0; 28 lymph nodes/4 positive; surgical margins – negative PSA nadir 9.3ng/ml at 3 months Intermittent androgendeprivation; last 6 month no hormonal therapy Currently: PSA 1,65ng/ml; No bone metastasis

Case #3 Patint M. 54y PSA 153ng/ml; Gleason 9(%+4); cT3aN+M+ metastasis in os. Pubis and os.sacrum Urinary retention, suprapubic drainage Radical prostatectomy with extended lymphadeneqtomy 1.10.2013; 19 lymph nodes/4 positive; surgical margins – positive Immediate androgen deprivation Currently: PSA 0.15; bone metastasis are reduced

Case #4 Patient R. 53y. PSA 100ng/ml; Gleason 10; cT2cN+M0 Radical cistoprostatectomy with extended lymphadeneqtomy 03.11.1011 pT2cN0M0; 15 lymph nodes/0 positive; surgical margins – positive PSA nadir 0.04ng/ml at 3 monthes No adjuvant therapy Currently: PSA 0.01ng/ml; No bone metastasis Patient has got a sun via in vitro fertilization. Now he is about 1 years old!