The influence of serial sections, immunohistochemistry, and extension of pelvic lymph node dissection on the lymph node status in clinically localized prostate cancer.
ABSTRACT Pelvic lymph node metastases indicate a poor prognosis for patients with clinically localized prostate cancer. The aim of the study was to investigate the value of extended histopathological techniques considering the extent of pelvic lymphadenectomy and preoperative risk factors.
Total of 194 patients with prostate cancer were examined. At first all patients had a sampling of the sentinel lymph nodes (SLN) followed in most cases by a modified or extended pelvic lymphadenectomy. Step sections, serial sections and immunohistochemistry (IHC, pancytokeratin antibody) were analyzed in all SLN and so-called non-SLN of the first 100 patients. Later serial sections and IHC of non-SLN were left out.
In 26.8% lymphatic metastases were found. The detection rate of lymph node-positive patients depend significantly on the chosen extension of pelvic lymphadenectomy. Limiting the histopathological investigation to the lymph node specimen of the obturator fossa only 44.2% of lymph node-positive cases would have been identified. An additional inclusion of all lymph nodes surrounding the external iliac vessels improves the sensitivity to 65.4% (46.7% and 73.3% for the first 100 patients). Compared to the extension of pelvic lymphadenectomy the diagnostic gain of serial section and IHC (13.8% versus 53.3%) was comparably low.
The extension of pelvic lymph node dissection is of outstanding value for the identification of node-positive patients. Limiting the number of lymph nodes to the ones with the highest probability of bearing lymphatic spread (SLN) makes the use of extensive histopathological techniques more feasible.
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ABSTRACT: Pelvic lymph node dissection (PLND) has been performed during radical prostatectomy in nearly all patients with clinically localized prostatic carcinoma (PCa), while the specific regions that needed to be removed demonstrated bifurcation among urologist. However, clinical studies comparing extended PLND (ePLND) with standard PLND (sPLND) and limited PLND (lPLND) reveal conflicting, or even opposing results. All controlled trials comparing ePLND with sPLND or lPLND were identified through comprehensive searches of the PubMed, Cochrane Library and Embase databases. A systematic review and meta-analysis of these studies were then performed. Eighteen studies with a total of 8,914 patients were included. Regardless of being compared with sPLND or lPLND, ePLND significantly improved LN retrieval [ePLND vs. sPLND: weighted mean difference (WMD) 11.93, 95 % confidence interval (CI) 9.91-13.95, p < 0.00001; ePLND vs. lPLND: WMD 8.27, 95 % CI 3.53-13.01, p = 0.0006] and the detection of more LNs positive of metastasis [risk ratio (RR) 3.51, 95 % CI 2.14-5.75, p < 0.00001; RR 3.50, 95 % CI 2.20-5.55, p < 0.00001, respectively]. EPLND decreased the complication rate, but the differences were not statistically significant (RR 1.52, 95 % CI 0.87-2.65, p = 0.14; RR 1.52, 95 % CI 0.67-3.45, p = 0.32, respectively). Operating time, estimated blood loss, length of hospital stay and biochemical recurrence (BCR) were statistically insignificant between techniques. ePLND shows benefits associated with increased LNs yield, LNs positivity, and safety, significantly with no risk of side effects. However, ePLND did not decrease BCR. Additional high-quality, well-designed randomized controlled trials and comparative studies with long-term follow-up results are required to define the optimal procedure for patients with clinically localized PCa.Journal of Cancer Research and Clinical Oncology 12/2013; · 2.91 Impact Factor
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ABSTRACT: OBJECTIVES: To stratify the rate and prediction of lymph node involvement in prostate cancer patients undergoing sentinel-lymphadenectomy depending on preoperative tumor characteristics, and to compare the outcome with the European Association of Urology Guideline indication for lymphadenectomy. METHODS: A total of 1229 patients (median age 66 years) were treated with open sentinel-lymphadenectomy and prostatectomy between 2005 and 2009. Median preoperative prostate-specific antigen was 7.4 ng/mL. The rate of lymph node involvement was analyzed for D'Amico risk groups. Multivariable logistic regression was used to estimate the probability of lymph node involvement. Predictor variables included preoperative prostate-specific antigen, clinical T-category and biopsy Gleason sum. Predictive accuracy has been quantified (area under the curve) and lymph node positive patients were verified under consideration of the recommended European threshold for lymphadenectomy (nomogram-predicted lymph node invasion risk of >7%). RESULTS: The median number of lymph nodes removed was 10 (interquartile range 7-13). Overall, 17.1% of patients had lymph node involvement; 3.2% in low-, 14.8% in intermediate- and 37.4% in high-risk disease. The predicted risk for lymph node involvement ranged from 2% (prostate-specific antigen ≤4 ng/mL, T1, Gleason sum ≤6) to 87% (prostate-specific antigen >20 ng/mL, T3, Gleason sum ≥8). The predictive accuracy was 82.1%. According to the European guidelines, 15.9% of all lymph node involved cases would not have been detected. CONCLUSIONS: The rate of lymph node involvement seems to be higher in the examined sentinel collective than expected according to the European Guideline nomogram. The first sentinel-based lymph node involvement prediction model can assist in deciding on the indication for sentinel-lymphadenectomy. The validation of a corresponding sentinel-based nomogram is still missing.International Journal of Urology 05/2013; · 1.73 Impact Factor
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ABSTRACT: Pathological examinations of lymph nodes (LN) in prostate cancer patients are handled differently at various institutions. The objective of this study is to provide means to improve the guidelines by examining the impact of step sectioning on LN status in patients with intermediate and high-risk prostate cancer. Two hundred ten patients who awaited curative indented therapy were included. We first performed a standard pathological examination of the LN, followed by an extended pathological examination of the patients who were LN negative in the standard examination. The extended pathological examination included a 100-μm-deep haematoxylin and eosin (HE) section followed by a slide stained with cytokeratin AE1/AE3 and then by four HE sections at 0.5-mm intervals.The standard pathological examination detected 41 patients with LN metastasis. The remaining 169 patients had 1,185 HE sections made at the standard examination, whereas the extended examination gave additional 7,110 slides and detected 5 additional patients with LN metastasis. In all, 1,158 LN were removed. The additional LN metastases were smaller than the LN metastases found at the standard examination, mean 1.2 mm vs. 7.8 mm.Our results indicate that an extended pathological examination of LN will improve the staging of intermediate- and high-risk prostate cancer patients; however, we acknowledge that it is both costly and time consuming. We do not recommend the use of cytokeratin staining in routine staining because the immunohistochemistry did not reveal new or further information. A detailed guideline on how to handle the LN specimens at the pathological department is needed.Archiv für Pathologische Anatomie und Physiologie und für Klinische Medicin 11/2013; · 2.68 Impact Factor