Pathologic nodal staging scores in patients treated with radical prostatectomy: a postoperative decision tool

Luis A Kluth; Firas Abdollah; Evanguelos Xylinas; Malte Rieken; Harun Fajkovic; Maxine Sun; Pierre I Karakiewicz; Christian Seitz; Paul Schramek; Michael P Herman; Andreas Becker; Wolfgang Loidl; Karl Pummer; Alessandro Nonis; Richard K Lee; Yair Lotan; Douglas S Scherr; Daniel Seiler; Felix K-H Chun; Markus Graefen; Ashutosh Tewari; Mithat Gönen; Francesco Montorsi; Shahrokh F Shariat; Alberto Briganti

doi:10.1016/j.eururo.2013.06.041

Pathologic nodal staging scores in patients treated with radical prostatectomy: a postoperative decision tool

Eur Urol. 2014 Sep;66(3):439-46. doi: 10.1016/j.eururo.2013.06.041. Epub 2013 Jul 2.

Authors

Luis A Kluth¹, Firas Abdollah², Evanguelos Xylinas³, Malte Rieken⁴, Harun Fajkovic⁵, Maxine Sun⁶, Pierre I Karakiewicz⁶, Christian Seitz⁵, Paul Schramek⁷, Michael P Herman⁸, Andreas Becker⁹, Wolfgang Loidl¹⁰, Karl Pummer¹¹, Alessandro Nonis¹², Richard K Lee⁸, Yair Lotan¹³, Douglas S Scherr⁸, Daniel Seiler¹⁴, Felix K-H Chun¹⁵, Markus Graefen¹⁶, Ashutosh Tewari⁸, Mithat Gönen¹⁷, Francesco Montorsi², Shahrokh F Shariat¹⁸, Alberto Briganti²

Affiliations

¹ Department of Urology, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, NY, USA; Department of Urology, University Medical-Center Hamburg-Eppendorf, Hamburg, Germany.
² Department of Urology, Vita-Salute San Raffaele University, Milan, Italy.
³ Department of Urology, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, NY, USA; Department of Urology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, Paris, France.
⁴ Department of Urology, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, NY, USA; Department of Urology, University Hospital of Basel, Basel, Switzerland.
⁵ Department of Urology, Medical University of Vienna, Vienna, Austria.
⁶ Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada.
⁷ Department of Urology, Krankenhaus der Barmherzigen Brueder, Vienna, Austria.
⁸ Department of Urology, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, NY, USA.
⁹ Department of Urology, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, NY, USA; Prostate Cancer Center, Martini Clinic, Hamburg, Germany.
¹⁰ Prostate Cancer Center, Krankenhaus Barmherzige Schwestern Linz, Linz, Austria.
¹¹ Department of Urology, Medical University of Graz, Graz, Austria.
¹² University Centre for Statistics in the Biomedical Sciences, Vita-Salute San Raffaele University, Milan, Italy.
¹³ Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
¹⁴ Department of Urology, Kantonsspital Aarau, Aarau, Switzerland.
¹⁵ Department of Urology, University Medical-Center Hamburg-Eppendorf, Hamburg, Germany.
¹⁶ Prostate Cancer Center, Martini Clinic, Hamburg, Germany.
¹⁷ Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
¹⁸ Department of Urology, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, NY, USA; Division of Medical Oncology, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, NY, USA; Department of Urology, Medical University of Vienna, Vienna, Austria. Electronic address: sfshariat@gmail.com.

PMID: 23850255
DOI: 10.1016/j.eururo.2013.06.041

Abstract

Background: Nodal metastasis is the strongest risk factor of disease recurrence in patients with localized prostate cancer (PCa) treated with radical prostatectomy (RP).

Objective: To develop a model that allows quantification of the likelihood that a pathologically node-negative patient is indeed free of nodal metastasis.

Design, setting, and participants: Data from patients treated with RP and pelvic lymph node dissection (PLND; n=7135) for PCa between 2000 and 2011 were analyzed. For external validation, we used data from patients (n=4209) who underwent an anatomically defined extended PLND.

Intervention: RP and PLND.

Outcome measurements and statistical analysis: We developed a novel pathologic (postoperative) nodal staging score (pNSS) that represents the probability that a patient is correctly staged as node negative based on the number of examined nodes and the patient's characteristics.

Results and limitations: In the development and validation cohorts, the probability of missing a positive node decreases with an increasing number of nodes examined. Whereas in pT2 patients, a 90% pNSS was achieved with one single examined node in both the development and validation cohort, a similar level of nodal staging accuracy was achieved in pT3a patients by examining five and nine nodes, respectively. The pT3b/T4 patients achieved a pNSS of 80% and 70% when 17 and 20 nodes in the development and validation cohort were examined, respectively. This study is limited by its retrospective design and multicenter nature. The number of nodes removed was not directly correlated with the extent/template of PLND.

Conclusions: Every patient needs PLND for accurate nodal staging. However, a one-size-fits-all approach is too inaccurate. We developed a tool that indicates a node-negative patient is indeed free of lymph node metastasis by evaluating the number of examined nodes, pT stage, RP Gleason score, surgical margins, and prostate-specific antigen. This tool may help in postoperative decision making.

Keywords: Extended lymph node dissection; Lymph node metastasis; Nodal yield; Pelvic lymph node dissection; Prostate cancer.

Publication types

Validation Study

MeSH terms

Aged
Aged, 80 and over
Decision Support Techniques*
False Negative Reactions
Humans
Lymph Node Excision*
Lymph Nodes / pathology*
Lymph Nodes / surgery
Lymphatic Metastasis
Male
Middle Aged
Neoplasm Staging
Pelvis
Postoperative Period
Probability
Prostatectomy
Prostatic Neoplasms / pathology*
Prostatic Neoplasms / surgery
Retrospective Studies