J. Edson PontesM.D. Professor Urologic Oncology WSU/KCI The Role of Lynphadenectomy in the Treatment of Prostate Cancer XVI Workshop Urologic Oncology J. Edson PontesM.D. Professor Urologic Oncology WSU/KCI

Introduction The pathways of Metastasis in PCA is not well understood. Is there a cascade of dissemination;to the L.N followed by Bone?Or is metastasis tumor dependent ie.Some tumors metastasizes via Lymphatic and other Hematogenous, or both ?

Lymphatic Metastasis in Radical Prostatectomy Specimens Since the introduction of PSA Screening the % of patients with L.N.+ has decreased from 10-20% in 1990 to <1% now. In view of this many authors have stopped doing L.N. dissections in patients with low risk disease.

Important questions for the Practicing Urologist Is it possible to detect L.N. Metastasis Pre Surgery? Is L.N. Dissection only of Staging Value? Is there a Therapeutic value? What is the Extend of L.N. Dissection?

Pre Operative Studies Pedal Lymphangiogram can Identify nodes in the area of Prostatic drainage . (Zoretic and Pontes) but is rarely used. CT Scan is unreliable for detecting L.N. Metastasis.The largest node was the site of N+ in 27% of cases while in 74% N+ where <1cm ( Cher et al. JU)

The case Against L.N. Dissection The low probability of N+ does not justify L.N.Dissection. The long term results of Perineal Prostatectomy for patients with localized PCA are comparable to RRP plus L.N. Dissection Significant Morbidity, specially when the Dissection is extended

The Case for L.N.Dissection Several recent Studies have shown the potential therapeutic benefit of L.N. Dissection. In a prospective randomized study 20% of patients with N+ in the observation arm where NED. If there is a benefit in L.N Dissection in a sub group of patients with Bladder Ca why not in PCA?

Relationship of PSA and N+. KCI / WSU Number:1,700 cases 1990-1995: 72 patients N+ Average PSA:32ng/ml 1996-2005: 30 patients N+ Average PSA:19ng/ml 2006-2007: 5 patients N+ Average PSA:10ng/ml

Case Report A 60 year old Chairman of a dept. at WSU/SOM, diagnosed wit PCA Gleason VII, underwent a RPP/LND showing M+, LN-. Post op PSA remained undetectable for 18 months, and developed progressive rise. Radiation therapy to the prostatic area decreased PSA to undetectable levels. One year later, a rise of PSA, led to an CT evaluation which detected a perirectal node. Excision led to an undetectable PSA for another 1 year.

Case Report Follow up and Conclusion One year later, a progressive elevation of PSA was observed. A CT of abdomen and pelvis, showed a single enlarged L.N. on the R iliac region, which had a previous negative dissection. Surgical excision of Node, led to an undetectable PSA, which has remained for the last 7 years!

Studies in L.N. Dissection Author Number L.N. % L.N.+ Ext. Limited Ext. Limited Golimbu 1987 43 21 ALL Stone 18 9 23% 7% Heidenreich 26% 12% Studer 2003 20 10 24%

CONCLUSIONS It appears that L.N Dissection can be curative in up to 20% of patients with N+ Extended L.N. Dissection remove 2 times as many nodes as Limited Dissection Presently there are no reliable pre op diagnostic tests to identify N+ Patients should be stratified pre operatively as to the need of extended Dissection.