Carcinoma Prostate has been risk stratified and management based on the same is well established.
However, clinically T3a disease still remains a "grey zone" in the management strategies, in order to achieve the "Prostatic trifecta"".
With emerging radiological evidence that long capsular contact as well as capsular bulge (on MRI) should be considered as clinically T3a disease, the T2 disease paradigm also has had a dramatic shift.
What should be the ideal treatment strategy- Radical Prostatectomy or Radical Radiotherapy?
Would depend on the Gleason's score, N score and M score. If these are favourable, all options could be on the cards, the final option depending on the patieht's informed choice.
I fully agree with Deepak.
However, let the patient decide. Surgery has many more collateral effects. This should be clearly explained to the patient.
Sure it depends on the age of the patient and his life expectancy. If the imaging shows a localised operable cancer in a young patient, I would advise radical surgery if not radiation therapy would be a good alternative.
Of course You follow the patient, because radiation th. could be needed! But we have better results with selected patients (3a) after radical operation and strong check up, may be with radiation, comparing the others, with only radiation!
A short answer is much harder than a longer one! Not only the patient's age, weight, other illnesses, Gleason score, local spread, patient collaboration, etc. is important, but there are other aspects too! The operating surgeon's and the pathologist's experience, the level and accuracy of the radiologist's background, and the accuracy and availability of routine controls such as bone isotope, CT, Colin / PSMA PET CT, etc. Last but not least, an aspect that often overlooks our attention is not only called oncopsychology alone, but can also be referred to as Whole Person Care in the context of a change in our health culture. Based on the experiance of my several patients -following them with correct uro-oncology professionalism,- I can state that if I can combine holistic, soul and spirit aspects, the fate of more patients will be better than predicted in the rule books! Let me give you an example of a simple hypothesis, ( L Rózsa The microbiome mutiny hypothesis: can our microbiome turn against us when we are old or seriously ill? Biology Direct 201510: 3 https://doi.org/10.1186/s13062-014-0034-5) which I believe until I get a better hypothesis or a resolution. I do belive, that more complex solution is not only provided by uro-oncology but also influenced by disciplines that we have not focused so far on! So the question is very complicated! Sorry for the long answer!
As always prostate cancer remains an individual disease.
Whats the grade group?
Any mets?
ECOG?
Co morbidties?
Ultimately patient preference once everything explained and considered including side effect management and long term follow up.
In essence, we are not in dispute, but I try to study the question from a different perspective, as well!
Very important: Total resection of the prostate (R0). Dont care so much to lymphnodes : They do not metasize. pLND is not a must have. Radiation only, if no R0. Do you agree, Mr.Varga?
Our aim with surgery is to have R0 N0 M0 disease. So extended PLND is also indicated during surgery.
Otherwise do radiation therapy
Why N0 with surgery.Positive lymphnodes do not create M1. See literature.See breastcancer.Less than two positive LN no axilla LND.German guidelines.
True N1 in the pelvis does not make M1 in prostate cancer. This is only to plan the later management. Now the trend to go and operate oligometastatic prostate cancer.
It's a locally advanced cancer, so you have to be aggressive with your treatment
Fully right, pLNDs impact is only to plan the therapy until today. BUT now exists a new possibility to see positivity of LN without removing a lot of LN with epLND (side effects!): The 68 Ga PSMA-Pet/MRI with a sensitivity and specifity of nearly 90%, you certainly know (see german guidelines). Now pLND has no further impact. Even now you can -positive LN do not metasize - take these formulas (Roach, Briganti etc) to calculate the risk. My opinion: That is enough accuracy for a not so great number of different therapies. Do you agree?
You mean to apply the sentinelle LND
to the PLND Like in the breast surgery.
I agree
Yes,.To see, if the Sentinel LNs are positive, you can use this radiographic method too. It is not necessary for the planing of management to dissect ("all") pelvic LN (pLND). In breast cancer they are leaving in patients with N0 of Sentinel LN or til two Sentinels are positiv the axillary dissektion of "all" LN. Not yet in all hospitals...
This is a only
first step. My opinion: Next step is deciding on radiographic methods praeoperatively positivity of LN in PCa for staging and leave pLND (pelvic lymph node dissection) at all.
Good
Maybe it should be in the contest of clinical comparative studies.
Comparative studies exist..but no study shows a significant, statistical sure benefit of pLND for oncological parameters (OS,CSS). The benefit don't exist or is so marginal, that it is irrelevant in a clinical sense. Many studies exist, where no benefit was found..
Eliminating the primary tumor is the most important therapy. Do you know, that ten years ago, the surgeons dissect ONLY the positive LN and not the primarius?
Yes we used to stop the surgery if the LND 's were positive on frozen section
Hm. Strange. And now surgeons want to continue epLND ..How to convince them to stop epLND without any benefit ? To dissect 10 instead 4 LN gives a very little benefit, resulting from better (more exact ) diagnosis, for instance for the diagnose N0 of the PCa. Volume (and time) to grow of the tumor correlate with number of positive LN (shown again for breast cancer sept 2019). The number of N+ has no other impact. Worser staging for higher number is the result of tumorcells of the primary tumor(only!).It spreads also to organ metastases before elimination. N1 do not create M1. M1 has 2-3y you certainly know.
Dear Dr. Roloff
A surgeon like me during a radical prostatectomy the whole pelvis area is exposed, automatically we remove the LND's as much as we can. So by low and intermediate risk cancer, we can proceed without the lymphadenectomy. In high risk cases we do LND dissection. This is the trend. Complications of the LND'S dissection can be avoided by performing a peritoneal window.
" automatically we remove the LND's as much as we can"
Why? What is the reason beyond diagnosis elsewhere available?
Staging works with formulas or this radiografic PSMA Pet. Number of positive LN correlate with tumor volume, they do not metasize. You don't need to eliminate "all" LN positive or not! It is useless.High risk - for R0 operating is difficult - needs radiation and ADT (radiation seems only to work with ADT, Abdollah 2018, benfit only for positive margins) .So further local tumorspread of the primary tumor will be enhanced. Also "high risk" LN do not metasize, why the dissection?
You know the "trend". Thanks for discussion.
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