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caution, since significant biases related to both the
additional androgen deprivation therapy that was admin-
istered in significant proportions of patients in almost all
reported series and to the different definition of complete
PSA response in the different studies
[4–7]. When analyzing
the biochemical outcome in patients who had complete PSA
response to surgery, 5 yr after sLND the majority of them
develop a new BCR with a median time of 12–21 mo. In all
available series, the development of a new clinical
recurrence (CR) is delayed, and it is of note that 5 yr after
sLND 25–52% of these patients with established CR before
surgery are actually free from CR. However, the long-term
outcomes of patients treated with sLND have been reported
in a single study that was published in 2015. At a median
follow-up of 81.1 mo, 8-yr CR- and CSM-free survival rates
were 38% and 81%, respectively
[8].
3.
For whom?
All studies tried to identify prognostic factors in order to
select the
perfect
candidate to sLND. Complete PSA response
to sLND, the absence of retroperitoneal involvement, PSA
value
<
4.0 ng/ml, and the number of positive nodes has
been demonstrated to be positive-independent prognostic
factors. However, there are conflicting results in terms of
the reported prognostic factors in the different series
[5–8].
These conflicting results may be attributable to the limited
numbers of patients included, to the inclusion of patients
with highly variable past history, to the differences in
surgical technique (LND template, surgical approach), as
well as to the nonstandardized use of additional therapies
both before and after sLND.
In 2015, two systematic reviews have analyzed the
outcomes of patients with BCR and lymph nodal recurrence
of PCa
[9,10]. The main conclusions of these manuscripts
confirm that a metastases-directed treatment is a promis-
ing approach for oligometastatic PCa recurrence, although
high-level evidence studies are currently missing.
Regarding the complications of sLND, it needs to be
acknowledged that the reported Clavien-Dindo IIIA and IIIB
complications are 9.7–17.9% and 0–4.1%, respectively.
These figures are significantly higher than in patients
submitted to LND at the time of radical prostatectomy,
suggesting that this surgery might be demanding. This
needs to be taken into account especially when such an
experimental procedure is proposed.
In the future, the introduction of new tracers for PET/
CT scan will certainly improve the results in terms of
positive lymph node retrieval at surgery and eventually
[1_TD$DIFF]
reduce the need for extensive templates which invariably
increase the morbidity of surgery. However, to date, we
strongly suggest that whenever a sLND is planned, this
should be extensive and must not be limited to the site of
the PET/CT positivity, since additional metastatic lymph
nodes are often found outside the field of imaging
positivity
[3] .In conclusion, despite the lack of strong evidence, several
studies have shown that sLND might represent a viable
treatment modality for node-only recurrent PCa. However,
as long as high quality data are not available, sLND should
be still considered experimental.
Conflicts of interest:
The authors have nothing to disclose.
References
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[2]
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[3]
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