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PLND in RP: Status in PSMA PET era?

Dr Tushar Aditya Narain

Max Smart Super-Speciality, Saket, New Delhi

Pelvic lymph node dissection (PLND) at the time of radical prostatectomy (RP) is one of the most debated topics of present times, evident from the fact that the authors recently had an article published in European urology against PLND during RP, and then debated in its favour during a recently organized Uro-oncology conference.(1) The house is still divided, with both groups having equally strong points in favor and against PLND, but then there are certain facts and guidelines which cannot be ignored.(1,2)

The EAU and NCCN both recommend PLND (extended) for high risk prostate cancer and using nomograms for guiding PLND for intermediate risk disease.(3,4) This is because of the fact that PSMA PET has high specificity but low sensitivity in picking up pelvic nodes, especially if the size is <5mm, and PLND remains the gold standard for staging of lymph nodes.(5) Lymph node positivity also directs adjuvant therapy, ADT and/or RT, and adjuvant treatment in pN1 patients has shown to improve CSS and OS, hence PLND should be performed as it’s the gold standard for staging the pelvis. Also, PLND during RP removes the micrometastatic disease, ensuring a R0 resection in true sense and, several authors have demonstrated a survival advantage with removal of higher number of nodes during PLND, emphasizing the oncological benefit of ePLND during RP.(6)

Opponents of PLND point out at the increased complication rate & operative time as the major argument against PLND, besides the fact that two randomized clinical trials comparing ePLND to limited PLND recently failed to show any benefit in terms of biochemical recurrence (hazard ratio [HR] 1.044, 95% confidence interval [CI] 0.93–1.15; p = 0.5 [7]; HR 0.91, 95% CI 0.63–1.32; p = 0.6 [8])

We, as clinicians, need to strike a balance between the benefits of PLND and the risk of complications, and find a middle path, till the time robust data are available against PLND and the sensitivity of PSMA PET improves to such an extent that it can be relied upon as a staging tool. Till then, we should continue to perform an extended PLND in high and intermediate risk prostate cancer patients in whom the probability of lymph nodal involvement as per the existing nomograms exceed 7%. Care should be taken not to go lateral to the external iliac artery, and distal clipping of the lymphatic channels before division might help to reduce the chances of significant lymphoceles and lymphoedema. Randomized control trials comparing ePLND to no PLND in intermediate and high risk prostate cancer patients hold the answer to the big question: Should pelvic lymph node dissection be done at the time of radical prostatectomy?

Figure 1: Templates for extended and standard PLND during RP

Templates for extended and standard PLND during RP

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