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Platinum Opinion

Salvage Lymph Node Dissection for Node-only Recurrence of

Prostate Cancer: Ready for Prime Time?

Nazareno Suardi, Alberto Briganti, Giorgio Gandaglia, Nicola Fossati, Francesco Montorsi


Department of Urology, Vita-Salute San Raffaele University, Milan, Italy

Biochemical recurrence (BCR) is common after both radical

prostatectomy and radiation therapy for organ-confined

prostate cancer (PCa)


. Although an indolent course can

be expected for the majority of patients with BCR, roughly

20% of them die of PCa within the next 5 yr. In order to

identify patients at risk of progression, it is extremely

important to identify both the site and the extent of

recurrence, since it has been clearly demonstrated that they

both have a significant impact on survival


. Conventional

computed tomography (CT) scans and bone scans have very

low sensitivity at low prostate-specific antigen (PSA)

values. However, the best results are obtained if salvage

therapies are delivered promptly


. After the introduction

of more sophisticated imaging modalities, the paradigm is

gradually changing. In particular, 11C-choline positron

emission tomography (PET)-CT scan showed high sensitivi-

ty in the identification of the site of recurrence even at low

PSA values


. Furthermore, with the rapid technological

advances in nuclear medicine research, a new set of tracers,

especially based on the prostate-specific membrane anti-

gen, have been shown to correctly characterize the site of

recurrence at very low PSA values (ie,


1 ng/ml)




Why the lymph nodes?

In a recent study from Australia, 70 consecutive patients

with BCR and a median PSA of 0.2 ng/ml were submitted to

68Ga-prostate-specific membrane antigen-PET/CT. The

authors found that the vast majority of recurrences outside

the prostatic fossa were located in the pelvic lymph nodes


. In patients with isolated nodal recurrence, the 5-yr

survival rate is 25–50%. Therefore, nodal recurrence of PCa

is frequent and can lead to both metastatic progression and

cancer-specific mortality (CSM). The current European

Association of Urology and National Comprehensive Cancer

Network Guidelines recommend the use of PET/CT scan in

patients with PSA


1 ng/ml and/or with short PSA doubling

time. However, when lymph node only recurrence is found,

there are no clear indications on the best management due

to the lack of specific studies addressing the treatment of

these patients, since they are considered as metastatic

patients. Therefore, to date a patient submitted to radical

prostatectomy with a BCR and the evidence of a single

lymph node recurrence at PET/CT scan is considered a

metastatic patient, but only 25–50% of these patients will

eventually progress to CSM


. Therefore, given the

variable prognosis of patients with nodal recurrence,

targeted treatment of patients with isolated nodal recur-

rences have been proposed.


A new treatment modality?

The first series of 25 patients submitted to salvage lymph

node dissection (sLND) was reported in 2007


. The study

reported for the first time the comparison between PET/CT

scan and histological verification of the metastatic lymph

nodes, showing sensitivity, specificity, positive predictive

value, negative predictive value, and accuracy of 64%, 90%,

86%, 72%, and 77%, respectively. In 2011, the peri-operative

and oncological outcomes of 72 consecutive patients

submitted to pelvic and/or retroperitoneal sLND between

2002 and 2009 were reported


. Subsequently, other

series of patients submitted to sLND were published

[5–7] .

When considering all available data together, complete

biochemical response after sLND was reported in 22–73% of

patients. However, these figures should be taken with

E U R O P E A N U R O L O G Y 7 1 ( 2 0 1 7 ) 6 9 3 – 6 9 4

ava ilable at

journal homepage:

* Corresponding author. Department of Urology, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy. Tel. +39 02 26437286;

Fax: +39 02 26437298.

E-mail address:

(F. Montorsi).



2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.