Lymph node removal

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jym62
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Date Joined Apr 2013
Total Posts : 153
   Posted 6/25/2013 6:16 AM (GMT -7)   
How common is it to have lymph nodes removed(lymphadenectomy) during RALP for low risk disease? Is it necessary?
62
60 at 1st biopsy 11/22/11 one of 12 pos <5% gleason 6(3+3) psa 5.0
active surveillance 15 months
2nd biopsy 2/26/13 3of 24 pos <5% gleason 6(3+3)
psa 3/14/13 5.6

PeterDisAbelard.
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Date Joined Jul 2012
Total Posts : 5640
   Posted 6/25/2013 8:55 AM (GMT -7)   
jym62,

I dunno. I know my surgeon took a large number of nodes during my surgery and, at least going into it, I was believed to be fairly low risk. It may be that he found more cancer than he expected and decided to do the nodes on the spot, or it may be that he always does the nodes. I'm not sure. I'll add that to my list of questions for the next time I see him.

I was curious about your question and I googled a bit. I found this link that seems to open a chapter from a surgical urological oncology text

http://deepblue.lib.umich.edu/bitstream/handle/2027.42/85105/end_2009_0562.pdf;jsessionid=B8B42881FE018E6884D4EF20897D0325?sequence=1

It contains an interesting, if technical, discussion of the issue and ends with this conclusion:

Recommendations. In addition to having a diagnostic
benefit, patients who undergo a PLND with laparoscopic or
robot-assisted prostatectomy may have improved disease
recurrence and survival rates. An extended PLND, including
the external iliac, obturator, and internal iliac nodes, reflects
the true lymphatic drainage of the prostate, increases nodal
yield, results in more accurate disease staging, and promotes
early initiation of adjuvant therapy that has proven survival
benefit.53 Surgeons may choose to forgo node dissection
entirely in those patients with low-risk disease (ie,Gleason
6 disease, PSA10 ng=mL, clinical stageT2a), because
several studies have shown a low rate of node-positive disease
in these persons.36,54,55 If lymphadenectomy is performed,
however, a bilateral dissection is indicated even if a
patient has disease isolated to one lobe of the prostate on
biopsy. Prostate cancer is too frequently bilateral and has
variable lymphatic drainage to safely perform unilateral node
dissections. Ultimately, it is incumbent on those performing
minimally invasive surgery to adhere to strict oncologic
principles, maintain consistent PLND selection criteria, and
perform a node dissection that most benefits the patient.


So, for low risk disease, they leave it up to the surgeon but do recommend that if he does it he should do the whole job. So, I still dunno the answer to your question.
60
Slow PSA rise 2007-2012: 1.4=>8
4 bxs 2010-2012:
1)neg (some inflammation),
2)neg,
3)positive 1 of 14 GS6(3+3) 3-4%, 2nd opinion GS7(3+4)
4)neg.
Mild Pre-op ED
DaVinci RRP 6/14/12. left nerve spared
Path: pT3a pN0 R1 GS9(4+5) Pos margins on rt
Start 24 mo ADT3 7/26/12
Adjuvant IMRT 66.6 Gy 10/17/12 - 12/13/12
Leaky but better, Trimix, VED
Forum Moderator - Not a Medical Professional

bertb
Regular Member


Date Joined Aug 2011
Total Posts : 404
   Posted 6/25/2013 9:44 AM (GMT -7)   
I know you are talking about removal during RALP. Thought I would add my 2 cents for the rad. guys.
I'm a G9-10 and chose 3-dimensional CT scan with IMRT. I asked my rad. Onc. If I was getting my lymph nodes zapped as well. She said given my G# plus PSA #'s that the chances were only 7% that the Pca had spread to any of the lymph nodes. She didn't want to over treat. I had a problem with that given that I'm in a high risk category. Thought she would throw everything at it at once. Hopefully, I made the correct decision. Time will tell I guess.
Good luck, bertb
AGE: 60, now 62
PSA: 5.3 up from 3.3 around 18 months earlier
DX: 3/11
4 of 12 positive Gleason 10 downgraded to 9 on second look, (big deal)
Stage: T1c
CT: clear
Bone scan: clear
Treatment: Lurpron, Casodex + 44 IMRT (started 8/11 ended 10/11)
1st post PSA 11/10/11 0.010 !!
2nd post PSA 02/21/12 0.008 !!
3rd post PSA 15/12 0.010 :)
4th post PSA 11/12 0.008 :)!
5th post PSA 3/13. 0.064. ?

zufus
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Date Joined Dec 2008
Total Posts : 3149
   Posted 6/25/2013 10:29 AM (GMT -7)   
bertb- did you plug your numbers into any nomograms and compare to what this doc's thinking was about 7%, doesn't seem to pass the smell test right now....

bertb
Regular Member


Date Joined Aug 2011
Total Posts : 404
   Posted 6/25/2013 10:50 AM (GMT -7)   
zufus..... Don't want to hijack this thread. But, she showed me several and decided it wasn't worth the added risk. But, I still can't help but think about it.
AGE: 60, now 62
PSA: 5.3 up from 3.3 around 18 months earlier
DX: 3/11
4 of 12 positive Gleason 10 downgraded to 9 on second look, (big deal)
Stage: T1c
CT: clear
Bone scan: clear
Treatment: Lurpron, Casodex + 44 IMRT (started 8/11 ended 10/11)
1st post PSA 11/10/11 0.010 !!
2nd post PSA 02/21/12 0.008 !!
3rd post PSA 15/12 0.010 :)
4th post PSA 11/12 0.008 :)!
5th post PSA 3/13. 0.064. ?

njs
Regular Member


Date Joined Jun 2013
Total Posts : 290
   Posted 6/25/2013 11:29 AM (GMT -7)   
I was clinically low-risk (PSA 1.2, G6 on biopsy) and the first two surgeons I talked with locally recommended omitting lymph node dissection. I was not comfortable with this because I knew Gleason score is upgraded about 30% of the time on final pathology and in the case of higher-grade disease lymph node dissection improves chance of a cure.

Dr. Walsh addresses this in his book and states that due to the potential benefit and low rate of complications (which are typically easily manageable when they due occur) it was made institutional policy at Johns Hopkins to perform lymph node dissection for all patients. Dr Burnett from Hopkins who did my surgery also stressed the potential benefit benefit.

Another Doctor with whom I consulted, Arieh Shalhav (Chief of Urology at University of Chicago) was adamant that I should have lymph node dissection because he said he had been “burned too many times” by apparently low risk patients whose finally pathology turns out significantly worse.

My opinion is for a young healthy guy who is going to go through surgery the small incremental risk is negligible and well worth it for maximizing the possibility of cure.

I had very minimal pain even though I had a complicated (due to prior mesh hernia repair) open surgery and 11 nodes taken out.
Jan '13: PSA 1.23, small nodule on DRE (1st screening @ age 40)
Mar '13: Biopsy 2/12 cores positive GS 3+3: rt mid 10% and rt apex 20% w/ PNI+ Stage cT2a
Apr '13: Biopsy confirmed by Dr. Epstein @ Hopkins
May '13: open RRP by Dr. Burnett @ Hopkins. Both nerves spared.
Final Pathology: GS 3+3, organ confined (tumor extent moderate), SV and 11 nodes all negative (pT2a). Negative margins!

Tall Allen
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Date Joined Jul 2012
Total Posts : 8956
   Posted 6/25/2013 11:38 AM (GMT -7)   
jym62,

The issue is whether it is worth sampling some lymph nodes to get a pathology report (a procedure that is commonly done for breast cancer). For low risk disease, there is an old formula that has been used called the "Roach" formula with a cut-off at 15%

(2/3*PSA) + (Gleason Score-6)*10

So if your PSA is 5.6, and your Gleason score is 6, your risk of nodal involvement is 3.7%, which is well below the 15% cut-off. Because that formula was validated before the PSA screening era, most think it is way too high - for your case by 4.5 fold to 16-fold, which would mean your revised risk is well under 1%:

Predicting the risk of pelvic node involvement among men with prostate cancer in the contemporary era.
Predicting pelvic lymph node involvement in current-era prostate cancer.

I don't think many surgeons would sample your lymph nodes with that low a risk. But with your insignificant amounts of PC, I think you will have many more years, if not a lifetime, on AS before you have to worry about it.

- Allen
Allen - not an MD - I talk the talk but don't walk the walk
•3rd biopsy (4/2010):
PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
•SBRT (5x8Gy) at UCLA, 10/2010 at age 57
•PSA since treatment:
+3 mos:3.9 +7 mos:3.0 +10 mos:3.7 +19 mos:1.18 +23 mos:1.29 +29 mos:.37
• SEs of treatment:
+2 wks: mild urinary & rectal - last 1 wk
+1 yr: mild urinary - last 2 months
no ED

jym62
Regular Member


Date Joined Apr 2013
Total Posts : 153
   Posted 6/25/2013 1:40 PM (GMT -7)   
Thanks everyone for sharing your knowledge .

njs, good info , I had seen a lot of post on here where people had lymph nodes removed . I thought it was part of the prostatectomy. Now I understand it is a separate procedure and from what I had read it doesn't seem necessary for low risk. But I'm just learning about all this!


Tall Allen
After my 2nd biopsy, my uro suggest time for therapy. He allows up to 2 cores to be positive, when I went to 3 he suggest coming off AS. The surgeon I saw mentioned lymph nodes but I just thought it was part of prostatectomy. Now I find out it is an additional procedure , and I'm not sure it is needed. I have been over three months deciding on therapy, and picking surgery was not an easy choice for me. I prefer the least amount of treatment , but had issues with the other choices. Now I'm learning some surgeons do lymphadenectomys and others don't?
62
60 at 1st biopsy 11/22/11 one of 12 pos <5% gleason 6(3+3) psa 5.0
active surveillance 15 months
2nd biopsy 2/26/13 3of 24 pos <5% gleason 6(3+3)
psa 3/14/13 5.6

bertb
Regular Member


Date Joined Aug 2011
Total Posts : 404
   Posted 6/25/2013 2:08 PM (GMT -7)   
jmy62, have you really looked into IMRT? Given your stats, I think you would be a poster boy for that procedure. Given that I was a G9-10 I didn't have much of a choice. But, I sort of like the No Cut, No Catheter, No Diaper approach.
But to each his own and I wish you the best results.
bertb
AGE: 60, now 62
PSA: 5.3 up from 3.3 around 18 months earlier
DX: 3/11
4 of 12 positive Gleason 10 downgraded to 9 on second look, (big deal)
Stage: T1c
CT: clear
Bone scan: clear
Treatment: Lurpron, Casodex + 44 IMRT (started 8/11 ended 10/11)
1st post PSA 11/10/11 0.010 !!
2nd post PSA 02/21/12 0.008 !!
3rd post PSA 15/12 0.010 :)
4th post PSA 11/12 0.008 :)!
5th post PSA 3/13. 0.064. ?

jym62
Regular Member


Date Joined Apr 2013
Total Posts : 153
   Posted 6/25/2013 2:51 PM (GMT -7)   
bertb
I have always had trouble with dental X-rays let alone radiation, but maybe I need to reconsider.
I certainly fear the side effects you mentioned.

Tall Allen
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Date Joined Jul 2012
Total Posts : 8956
   Posted 6/25/2013 3:33 PM (GMT -7)   
jym62,

You might want to get another opinion about coming off AS. I would hate to see you suffer the side effects of any treatment when your cancer is apparently insignificant and indolent. A second opinion from a doctor who has had extensive experience with AS might lead you in a different direction.

On AS programs, there are different criteria for going on AS than for coming off it. For going on AS, some programs want to see no more than 2 cores typically out of 12 cores and no more than 50% in any one core -- this is called "very low risk." However, NCCN (many of the top tertiary care hospitals in the US) has relaxed that to include any low risk. This is based on long-term success with such patients.

As an indicator that it's time to come off AS, there are no major AS programs I know of that doesn't require at least set some GS3+4, and some are moving to GS4+3.

The second biopsy is considered a confirming biopsy. Because you had 24 cores taken, it is not surprising that 3 were positive. That is probably no change from the biopsy you had 15 months earlier. And the fact that your PSA is virtually unchanged from 15 months earlier (well within natural variability), seems to indicate that the cancer remains indolent.

The removal of the lymph glands during surgery is only for diagnostic purposes only. If the cancer has spread there, radiation must be used to get it.
Allen - not an MD - I talk the talk but don't walk the walk
•3rd biopsy (4/2010):
PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
•SBRT (5x8Gy) at UCLA, 10/2010 at age 57
•PSA since treatment:
+3 mos:3.9 +7 mos:3.0 +10 mos:3.7 +19 mos:1.18 +23 mos:1.29 +29 mos:.37
• SEs of treatment:
+2 wks: mild urinary & rectal - last 1 wk
+1 yr: mild urinary - last 2 months
no ED

Putt
Regular Member


Date Joined Aug 2010
Total Posts : 154
   Posted 6/25/2013 3:57 PM (GMT -7)   
My Uro advised after he opened for the RRP, the first thing he did was to check for involvement of the local lymph nodes.  If the lab indicated postive, he would have closed the incision and not completed the surgery.  Surgery would not have been a total containment of the cancer for me.
PSA at Dx 105 at age 68, 4/04. ADT (Lupron only), RRP, 5/04. 66 grms, SVI, GS 4+5=9, Staged pT3b NO MO, 3D rad, 40 treatments, 8/04. PSA <0.01 1/05, <0.01 7/06, End ADT. PSA 0.03 12/08, 0.07 4/09, 0.13 8/09, 0.19 12/09, 0.30 4/10, 0.42 8/10, 0.47 12/10, 0.60 4/11, 0.64 8/11, 1.10 12/11, 1.03 1/12, 0.95 2/12, 0.92 4/12, 0.86 8/12, 0.757 11/12, 0.92 3/13. Will start ADT3 after PSA reaches 1.2.

njs
Regular Member


Date Joined Jun 2013
Total Posts : 290
   Posted 6/25/2013 6:50 PM (GMT -7)   
My understanding is that when the nodes turn out to be positive removing them is therapeutic and potentially curative.

Dr. Catalona said that if nodes are positive there is still approximately a 15% chance of cure from removing them and continuing with the prostatectomy.

The following from Hopkins suggests the cure rate is only ~7% or less for men with positive nodes: urology.jhu.edu/newsletter/2013/prostate_cancer_2013_21.php

Since it is not known ahead of time whether the nodes are positive and, in fact, they would usually be much more likely to be clear, the expected improvement for the average patient whose node status is unknown pre-operatively is significantly less than these figures, but it is an improvement nonetheless.

Even though I was low-risk, being 40 years old I knew that if I was not cured my life span was likely to be significantly impacted so I wanted every last incremental improvement in cure probability I could possibly get ("belt and suspenders"). But for some this may be less important.


All the proceeding has to do with unconditional node dissection. The approach Putt refers to is different. Only a few nodes are removed and sent for frozen section before continuing with the operation. This increases risk by lengthening the operation and I believe this is less commonly done nowadays. If you agree to this you are saying in the event your nodes are positive you are willing to sacrifice the 7-15% chance of a cure that would be available by continuing. This clearly makes no sense for the low risk patient as the nodes are unlikely to be positive but they still incur the additional delay of the frozen section.
Jan '13: PSA 1.23, small nodule on DRE (1st screening @ age 40)
Mar '13: Biopsy 2/12 cores positive GS 3+3: rt mid 10% and rt apex 20% w/ PNI+ Stage cT2a
Apr '13: Biopsy confirmed by Dr. Epstein @ Hopkins
May '13: open RRP by Dr. Burnett @ Hopkins. Both nerves spared.
Final Pathology: GS 3+3, organ confined (tumor extent moderate), SV and 11 nodes all negative (pT2a). Negative margins!

njs
Regular Member


Date Joined Jun 2013
Total Posts : 290
   Posted 6/25/2013 8:36 PM (GMT -7)   
jym62 said...
Now I understand it is a separate procedure


It might be billed as a separate procedure but, to be clear, it is done as part of the same surgery.

Putt
Regular Member


Date Joined Aug 2010
Total Posts : 154
   Posted 6/25/2013 10:34 PM (GMT -7)   
njs said "My understanding is that when the nodes turn out to be positive removing them is therapeutic and potentially curative."
 
I'll have to pass this on to my wife and her Oncologist, since she is struggling with last stage lung cancer that has recently exploded into her lymph system in her chest.  Well, maybe I won't.  After a year of various chemo treatments that have not worked out too well, I'll keep it to my self and blow it off as just another example of internet fuzz.
 
I made my earlier comment because I was NOT a low risk patient.  It had already invaded the SVI's and nerve bundles, which were also removed.  Without node involvement, my Uro thought with followup treatments after surgery I might have a good chance of another 10 years without major mets showing up somewhere.  So far so good.  PSA is playing games but what the h***, I have cancer.............
PSA at Dx 105 at age 68, 4/04. ADT (Lupron only), RRP, 5/04. 66 grms, SVI, GS 4+5=9, Staged pT3b NO MO, 3D rad, 40 treatments, 8/04. PSA <0.01 1/05, <0.01 7/06, End ADT. PSA 0.03 12/08, 0.07 4/09, 0.13 8/09, 0.19 12/09, 0.30 4/10, 0.42 8/10, 0.47 12/10, 0.60 4/11, 0.64 8/11, 1.10 12/11, 1.03 1/12, 0.95 2/12, 0.92 4/12, 0.86 8/12, 0.757 11/12, 0.92 3/13. Will start ADT3 after PSA reaches 1.2.

HighlanderCFH
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Date Joined Dec 2012
Total Posts : 677
   Posted 6/25/2013 11:41 PM (GMT -7)   
jym62 said...
How common is it to have lymph nodes removed(lymphadenectomy) during RALP for low risk disease? Is it necessary?


I believe it is quite common to do this, just to be on the safe side. I also was a Gleason 6, described as "low risk," etc. In spite of this, my surgeon still removed 5 lymph nodes during my da Vinci procedure at Mayo.

So I would not be too concerned that this was done in your surgery. I'm sure it's just a good doctor who wanted to be as complete & certain as possible.

Here's hoping you enjoy a very fast, complete rcovery.
Chuck

Resident of Highland, Indiana just outside of Chicago, IL.
July 2011 local PSA lab reading 6.41 (from 4.1 in 2009). Mayo Clinic PSA Sept. 2011 was 5.7.
Local urologist DRE revealed significant BPH, but no lumps.
PCa Dx Aug. 2011 at age of 61.
Biopsy revealed adenocarcinoma in 3 of 20 cores (one 5%, two 20%). T2C.
Gleason score 3+3=6.
CT of abdomen, bone scan both negative.
DaVinci prostatectomy 11/1/11 at Mayo Clinic (Rochester, MN), nerve sparing, age 62.
My surgeon was Dr. Matthew Tollefson, who I highly recommend.
Final pathology shows tumor confined to prostate.
5 lymph nodes, seminal vesicles, extraprostatic soft tissue all negative.
1.0 x 0.6 x 0.6 cm mass involving right posterior inferior,
right posterior apex & left mid posterior prostate.
Right posterior apex margin involved by tumor over a 0.2 cm length, doctor says this is insignificant.
Prostate 98.3 grams, tumor 2 grams. Prostate size 5.0 x 4.7 x 4.5 cm.
Abdominal drain removed the morning after surgery.
Catheter out in 7 days. No incontinence, occasional minor dripping.
Post-op exams 2/13/12, 9/10/12, PSA <0.1. PSA tests now annual.
Semi-firm erections now happening 14 months post-op & VERY slowly getting a bit stronger.

rob2
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Date Joined Apr 2008
Total Posts : 1131
   Posted 6/26/2013 5:09 AM (GMT -7)   
My surgeon removed one and tested it for cancer. I always wondered why just one. As noted above, some doctors take more than one or none.
Age 48 at diagnosis (52 now)
occupation accountant
PSA increased from 2.6 to 3.5 in one year
biopsy March 2008 - cancer present gleason 7
Robotic Surgery May 9, 2008 - Houston, TX (Methodist Hospital)
Pathology report -gleason 8, clear margins
PSA since surgery <.04
continent at 10 weeks (no pads!)
ED is still an issue

jym62
Regular Member


Date Joined Apr 2013
Total Posts : 153
   Posted 6/26/2013 7:16 AM (GMT -7)   
Thanks again everyone!

HighlanderCFH: Just to clarify I haven't had surgery yet. Trying to keep my courage up.
Thanks for your input.

bertb
Regular Member


Date Joined Aug 2011
Total Posts : 404
   Posted 6/26/2013 8:06 AM (GMT -7)   
jum62 hope this helps...

62
60 at 1st biopsy 11/22/11 one of 12 pos <5% gleason 6(3+3) psa 5.0
active surveillance 15 months
2nd biopsy 2/26/13 3of 24 pos <5% gleason 6(3+3)
psa 3/14/13 5.6

Taken fro the Partin table given your stats.
Probability of Pathologic Stage (%)
PSA = 4.1 – 10.0 ng/ml
Clinical Stage
Gleason score Pathologic stage T1a T1b T1c T2a T2b T2c T3a
2 - 4 Organ-confined disease 84 70 83 71 61 66 43
Established capsular penetration 14 27 15 26 35 29 44
Seminal vesicle involvement 1 2 1 2 4 5 10
Lymph node involvement 0 1 0 0 1 1 1
AGE: 60, now 62
PSA: 5.3 up from 3.3 around 18 months earlier
DX: 3/11
4 of 12 positive Gleason 10 downgraded to 9 on second look, (big deal)
Stage: T1c
CT: clear
Bone scan: clear
Treatment: Lurpron, Casodex + 44 IMRT (started 8/11 ended 10/11)
1st post PSA 11/10/11 0.010 !!
2nd post PSA 02/21/12 0.008 !!
3rd post PSA 15/12 0.010 :)
4th post PSA 11/12 0.008 :)!
5th post PSA 3/13. 0.064. ?

njs
Regular Member


Date Joined Jun 2013
Total Posts : 290
   Posted 6/29/2013 10:11 PM (GMT -7)   
Here are a few articles suggesting lymph node dissection can have therapeutic value:

www.ncbi.nlm.nih.gov/pmc/articles/PMC2997840/
www.ncbi.nlm.nih.gov/pmc/articles/PMC1950746/
www.ncbi.nlm.nih.gov/pubmed/?term=15540734

While the therapeutic value of lymph node dissection remains somewhat controversial, given the low incremental risk to someone already undergoing RP, it seems wise not to omit it in most cases.

Post Edited (njs) : 6/29/2013 11:17:08 PM (GMT-6)


Tall Allen
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Date Joined Jul 2012
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   Posted 6/29/2013 11:01 PM (GMT -7)   
lymphadema?

njs
Regular Member


Date Joined Jun 2013
Total Posts : 290
   Posted 6/30/2013 8:03 AM (GMT -7)   
Several surgeons I consulted with stated incidence of lymphocele was low and that it is easily managed.

Dr Walsh says "one out of one hundred times, lymph nodes turn out to be positive in a patient in whom you would least expect it. Because we have found that these are also the exact patients who would benefit most from having these lymph nodes removed, we continue to do lymph node dissections in all patients. We are emboldened to do this because of the extremely low risk of complications associated with this, the ease with which a complete lymph node dissection can be performed in a short time, and the fact that more good can come from it than not."
Jan '13: PSA 1.23, small nodule on DRE (1st screening @ age 40)
Mar '13: Biopsy 2/12 cores positive GS 3+3: rt mid 10% and rt apex 20% w/ PNI+ Stage cT2a
Apr '13: Biopsy confirmed by Dr. Epstein @ Hopkins
May '13: open RRP by Dr. Burnett @ Hopkins. Both nerves spared.
Final Pathology: GS 3+3, organ confined (tumor extent moderate), SV and 11 nodes all negative (pT2a), negative margins!

Post Edited (njs) : 6/30/2013 9:06:31 AM (GMT-6)


logoslidat
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Date Joined Sep 2009
Total Posts : 5383
   Posted 6/30/2013 11:38 AM (GMT -7)   
Lymphadema is usually associated with breast cancer and changes the cost/benefit analysis of dissection there.
Not so with prostate cancer. Lymphocels and elongated pratt drainage are the S/E mostly associated with Pca. Easily managed is very descriptive of them.
44 mos post op <.1 Pathology 4+3 tertiary5 pni+organ confine 27nodes disected-svi margin- age 70 " I know the night is fading and I know the time's gonna fly, and I'm never gonna tell you everything I gotta tell you, But I know I gotta give it a try" Air Supply

Redwing57
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Date Joined Apr 2013
Total Posts : 2306
   Posted 6/30/2013 12:26 PM (GMT -7)   
bertb said...
I know you are talking about removal during RALP. Thought I would add my 2 cents for the rad. guys.
I'm a G9-10 and chose 3-dimensional CT scan with IMRT. I asked my rad. Onc. If I was getting my lymph nodes zapped as well. She said given my G# plus PSA #'s that the chances were only 7% that the Pca had spread to any of the lymph nodes. She didn't want to over treat. I had a problem with that given that I'm in a high risk category. Thought she would throw everything at it at once. Hopefully, I made the correct decision. Time will tell I guess.
Good luck, bertb

Also not to hijack this thread, but some more perspective on risk of LN+....

My lymph nodes are being zapped. My RO was unequivocal about doing them with my stats.

The "older" Roach equation says my risk of LN+ is 34%. Roach says people claim the formula overstated actual lymph node involvement only because they weren't removing *all* of the lymph nodes. When they're all removed, he says the equation correlates well. I dunno...

An equation called the Yale Formula (http://www.ncbi.nlm.nih.gov/pubmed/20594769) says my risk is 19%, and anything over 15% is "high risk".

Another study, using the Roach equation but with a different data set (http://www.ncbi.nlm.nih.gov/pubmed/7505775?dopt=Abstract), indicates for me my actual risk to be around 40%.

So, we're zapping my lymph nodes and I'm comfortable with that. My bulky G9 tumor load, PNI confirmed, neurovascular bundle involvement indicated by MRI, some cores 100% PCa, all add up to confirm that high risk level. I'm glad to have them being irradiated.

With either radiation or surgery, indications this high seems like it would be worth going after the lymph nodes one way or another.

I did ask about surgically going after a couple key lymph nodes first just to verify positive or not, but again the significant risks even with that limited surgery aren't worth taking. If the risk is high enough to warrant that, then just treat them.
IGRT by IMRT started 6/26/13: 40-50 Gy pelvic nodes, 79.2 Gy to prostate
CAB: Lupron 5/1/13 (2 yrs), +Casodex 6/25/13 (1 yr? 2?)
Bilateral EPE per 3T MRI, but SV and LN "normal"
Age 55, Dx 4/16/13
Bx w/12, one side all G9=5+4 (80%, 60%), 4+5 (2 at 100%, 80%, 10%), PNI confirmed
Date PSA fPSA
3/13 5.2 12% PCA3=31
9/12 4.1 15%
history... since 2002 high/varying PSAs, incl 3 neg biopsies

Tall Allen
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Date Joined Jul 2012
Total Posts : 8956
   Posted 6/30/2013 12:53 PM (GMT -7)   
I think Walsh is seriously underestimating the dangers. Taking out additional organs at risk "while we're in there" strikes me as an unnecessary risk. Routine lymphadectomy (PLND) strikes me as a reckless policy, especially for a procedure that is of questionable life-increasing benefit in most cases.

It seems that others at Johns Hopkins disagree with Walsh:
"However, the incidence of node positivity is declining, and accordingly a greater number of lymphadenectomies must be performed to benefit 1 patient. In addition to the associated cost, PLND has the potential for morbidity, including lymphoceles, thromboembolic events, ureteral injury, and neurovascular injury. Patients and physicians should therefore assess the risk to benefit ratio associated with PLND on an individual basis to permit informed treatment decisions."
Complications of Pelvic Lymphadenectomy: Do the Risks Outweigh the Benefits?

The AUA Guidelines recommend against it in most cases:
AUA said...
Pelvic lymph node dissection for clinically localized prostate cancer may not be necessary if the PSA is less than 10.0 ng/mL and the Gleason score is less than or equal to 6.

Although pelvic lymph node dissection is often routinely performed in conjunction with radical prostatectomy, its morbidity, even if limited, must be considered. This is especially true in cases where it offers little additional information. A benefit to standard lymph node dissection has not been conclusively shown. Several studies have shown increased sensitivity; in addition, that there may be a recurrence and survival benefit associated with extended lymph node dissection, especially in intermediate- to high-risk patients, even when all nodes are negative. In extended lymphadenectomy, the area of additional dissection involves the region from the external iliac vein to the internal iliac vein medially, and to the bifurcation of the common iliac artery superiorly, rather than to just the obturator fossa. The benefit accruing to this more extended dissection must be balanced against the potential for increased morbidity, however, making careful patient selection critical.

Measurement of pretreatment PSA level, supplemented with clinical stage and Gleason score information, can identify a subset of patients in whom the incidence of nodal metastases is very low (3% to 5%). Patients with a pretreatment PSA level <10.0 ng/mL and a Gleason score =6 rarely have nodal metastases, and it may be appropriate to omit lymphadenectomy in this group. These observations have been made in several large series of patients.


NCCN said...
The decision to perform PLND should be guided by the probability of nodal metastases.


From Vanderbilt:
"In the setting of this debate, concern over morbidity directly attributable to this procedure is of paramount importance. This review focuses on the complications associated with PLND, including lymphocele, thromboembolic events, ureteral injury, nerve injury, vascular injury, and lymphedema."
www.ncbi.nlm.nih.gov/pubmed/21394597

From Albert Einstein:
"In addition to the associated cost, pelvic lymph node dissection (PLND) has the potential for morbidity. This article focuses on the complications associated with PLND, including lymphocele, thromboembolic events, ureteral injury, nerve injury, vascular injury, and lymphedema."
www.ncbi.nlm.nih.gov/pubmed/22045181

From NYU:
"Extended PLND has complications that increase with extent of dissection... However, for patients with low risk disease, PLND is not necessary and is not recommended, because the chance of metastasis is low."
www.ncbi.nlm.nih.gov/pubmed/21504645

From U of Chicago:
"The benefit of PLND during RARP should be weighed against the elevated risk of lymphocele formation and its potential complications."
www.ncbi.nlm.nih.gov/pubmed/21489117

From Harvard/ Brigham and Women's Hospital:
"A total of 55 complications (15%) occurred: 14 were noted in the intraoperative and 41 in the postoperative period. Of these patients 13 required open surgical intervention for the treatment of a complication. Complications included vascular injury (11 patients), viscus injury (8), genitourinary problems (10), functional/mechanical bowel obstruction (7), lower extremity deep venous thrombosis (5), infection/wound problem (5), lymphedema (5), anesthetic complications (2) and obturator nerve palsy (2). "
www.ncbi.nlm.nih.gov/pubmed/8426411
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