Urologic Oncology: Seminars and Original Investigations
Original articleClinical—prostatePathologic implications of prostatic anterior fat pad☆
Introduction
After radical prostatectomy in patients with prostate cancer [1], regional lymph node status is an important predictor of prognosis. Indeed, nodal status has significant implications for prognosis and management of these patients following radical prostatectomy. Currently, pelvic lymph node dissection (PLND) at the time of radical prostatectomy is the recommended procedure for staging prostate cancer because PLND is the most reliable method for determining the presence of nodal metastasis. In addition to the staging implications, PLND may provide valuable information needed for timing the initiation of additional therapies including adjuvant radiotherapy and androgen deprivation therapy [2]. Moreover, PLND may cure microscopic metastasis in selected patients [3].
Prostatic anterior fat pad (PAFP) refers to the adipose tissues located anterior to the prostate. Complete dissection and removal of PAFP has been traditionally advocated for better visualization of the anatomy, particularly the apex of the prostate, the anterior surface of the dorsal venous complex, and the puboprostatic ligaments [4], [5]. With better visualization of the apical anatomy, there is also a potential benefit of reducing the positive surgical margin rate at the apex [6]. Recently, PAFP has been reported to contain lymph nodes and that pathologic analysis of PAFP may yield a more accurate staging in patients with prostate cancer.
Over a 2-year period, we have performed PAFP excision during RARP in patients with prostate cancer in an effort to study the staging implications and the clinical significance of PAFP. We report that PAFP often contains lymph nodes, and that routine dissection and removal of AFP may benefit some patients with micrometastasis.
Section snippets
Patient selection
This study was approved by the Institutional Review Board at our institution, and patient data collection was done retrospectively. A total of 258 consecutive patients underwent PAFP excision during RARP procedure between July 2007 and June 2009. National Comprehensive Cancer Network (NCCN) guideline was used to determine the necessity of pelvic lymph node dissection. In addition, any patients with serum PSA level ≥10, biopsy Gleason scores ≥8, or clinical stage ≥T2b underwent standard pelvic
Results
Perioperative patient characteristics of 258 patients in this study are summarized in Table 1. Of these patients, 30 (11.6%) had 1 or 2 PAFP lymph nodes, whereas 228 (88.4%) men showed no lymphoid tissue in their PAFP. Preoperatively, mean PSA level was the only parameter with significant difference between the 2 groups: mean PSA level was 7.70 ng/ml in the former group and 6.01 ng/ml in the latter group (P = 0.039). All other preoperative and intraoperative parameters, including age, body mass
Discussion
Our data have demonstrated that in 258 patients who underwent RARP over a 2 year period, 11% contained PAFP lymph nodes and 3 were found to have metastatic prostate cancer. Of these latter 3 patients, 1 was upstaged as a result of the PAFP pathologic examination. These observations suggest that performing a thorough pathologic examination of PAFP may lead to a more accurate staging without additional morbidity.
Meticulous dissection of PAFP facilitates exposure of the bladder neck and prostatic
Conclusions
This study describes the benefit of PAFP dissection during radical prostatectomy in patients with prostate cancer. Overall, 30 of 258 patients (11.6%) were found to have lymph nodes within the PAFP, and 3 of these 30 men had lymph nodes positive for metastatic disease. In 1 patient with negative pelvic lymph nodes, prostate cancer was upstaged based on positive PAFP lymph nodes; this patient remains free of biochemical recurrence 2 years later. All 3 patients with positive PAFP lymph node had
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Cited by (19)
Presence of lymph nodes and metastasis within prostatic anterior fat pad in radical prostatectomy patients: A single Chinese institution experience and literature review
2023, European Journal of Surgical OncologyDetailed analysis of patients with metastasis to the prostatic anterior fat pad lymph nodes: A multi-institutional study
2013, Journal of UrologyCitation Excerpt :The most obvious benefit of removing and analyzing the PAFP is the increased accuracy of pathological staging. Published series of metastatic PCa to the PAFP lymph nodes after RP show a 1.2% to 2.5% prevalence rate.5–7 Consistent with those data, this series includes 8 centers with a PAFP lymph node metastasis rate of 0.5% to 2% and an overall 0.94% rate in the 4,261 patients who underwent RP.
Landscape and metastases of the lymph nodes in prostatic anterior fat pad at radical prostatectomy
2022, Zhonghua Wai Ke Za Zhi / Chinese Journal of SurgeryAnterior prostate fat resection during prostatectomy: a histopathologic review
2021, Journal of Robotic Surgery
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This work was supported in part by generous grants from the Tanzman Foundation, the Jon Runyan's Score for the Cure, and Korea Science and Engineering Foundation (KOSEF) grant funded by the Korean government (MEST) (no. R11-2008-014-00001-0).