Association Between Pelvic Lymph Node Dissection and Survival Among Patients with Prostate Cancer Treated with Radical Prostatectomy
Isaac E. Kim, Jr., ScB1, Aaron H. Wang, AB1, George S. Corpuz, BA2, Preston C. Sprenkle, MD3, Michael S. Leapman, MD, MHS3, Joseph M. Brito, III, MD3, Joseph F. Renzulli, MD, FACS3, Isaac Y. Kim, MD, PhD, MBA3.
1Alpert Medical School of Brown University, Providence, RI, USA, 2Weill Cornell Medical College, New York, NY, USA, 3Yale School of Medicine, New Haven, CT, USA.
BACKGROUND: Pelvic lymph node dissection (PLND) is an accepted standard in prostate cancer patients undergoing radical prostatectomy (RP). Although the clinical benefits of pelvic lymph node dissection (PLND) at the time of RP for prostate cancer remain uncertain, major guidelines recommend PLND based on the risk profile. Thus, the objective of this study was to examine the association between PLND and survival among patients undergoing RP stratified by Gleason grade group (GG) with the aim of allowing patients and physicians to make more informed care decisions about the potential risks and benefits of PLND.
METHODS: From the SEER-17 database, we examined overall (OS) and prostate cancer-specific (PCSS) survival of prostate cancer patients who underwent RP from 2010 to 2015 stratified by clinical Gleason score (cGS) (3+3, 3+4, 4+3, 4+4, 4+5, and 5+4). We applied propensity score matching to balance pre-operative characteristics including race, age, and PSA between patients who did and did not undergo PLND for each cGS. Statistical analyses included log-rank test and Kaplan-Meier curves using Stata.
RESULTS: We extracted a matched cohort from 79,222 patients who underwent RP with cGS ranging from 3+3 to 5+4. The median PSA value was 6.0 ng/mL, and the median age was 62-years-old. 48,495 patients underwent PLND (61.21%), while 30,727 (38.79%) did not undergo PLND. There was no difference in OS and PCSS between patients who received PLND and those who did not undergo PLND for all cGS categories (OS - 3+3: p=0.54, 3+4: p=0.47, 4+3: p=1.00, 4+4: p=0.45, 4+5: p=0.76, 5+4: p=0.20; PCSS - 3+3: p=0.05, 3+4: p=0.71, 4+3: p=0.91, 4+4: p=0.44, 4+5: p=0.78, 5+4: p=0.51) (Figure 1). Similarly, patients who underwent adequate PLND with 3 or more lymph nodes removed did not observe a difference in OS nor PCSS compared to their matched counterparts who did not undergo PLND with the exception of 3+3 patients with adequate PLND who actually experienced worse PCSS (OS - 3+3: p=0.51, 3+4: p=0.10, 4+3: p=0.79, 4+4: p=0.95, 4+5: p=0.87, 5+4: p=0.07; PCSS - 3+3: p=0.02, 3+4: p=0.60, 4+3: p=0.90, 4+4: p=0.26, 4+5: p=0.37, 5+4: p=0.38) (Figure 2).
CONCLUSIONS: In this observational study, PLND at the time of RP as well as generally an adequate PLND with 3 or more lymph nodes removed was not associated with improved OS or PCSS among patients with cGS of 3+3, 3+4, 4+3, 4+4, 4+5, and 5+4. These findings suggest that until definitive clinical trials are completed, prostate cancer patients who have elected RP should be appropriately counseled on the potential risks and the lack of proven survival benefit of PLND. 
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