1. 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

2. 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

3. 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

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

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

6. 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

7. Surgical margins Surgical margins were positive in
10 (of 27) patients:
Apex cases
Bladder neck cases
Other cases

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

9. 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

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

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

12. 59% of patients with clinically node positive prostate cancer have got no adjuvant therapies!

13. 22 of 27 patients with clinically node positive prostate cancer currently have no bone metastasis

14. Incontinence At 3 monthes: Total incontinence 0 of (22) cases
Stress incontinence 6 (of 22) cases
Continent (of 22) cases
Currently:
Total incontinence (of 22) cases
Stress incontinence (of 22) cases
Continent (of 22) cases

15. 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

16. Case #1
Patient K. 67y. PSA 132ng/ml; Gleason 9 (5+4); cT2bN1M0 Radical prostatecomy with extended lymphadenectomy 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

17. Case #2
Patient J. 68y. PSA 44.2ng/ml; Gleason 9(5+4); cT4N+M0 Radical cistoprostatectomy with superextended lymphadeneqtomy and sigma-rectum pouch 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

18. 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 ; 19 lymph nodes/4 positive; surgical margins – positive Immediate androgen deprivation Currently: PSA 0.15; bone metastasis are reduced

20. Case #4
Patient R. 53y. PSA 100ng/ml; Gleason 10; cT2cN+M0 Radical cistoprostatectomy with extended lymphadeneqtomy 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!