Salvage Lymphadenectomy in the Treatment of Nodal Recurrence of Prostate Cancer Detected by Magnetic Resonance Imaging and PET-PSMA CT - Case Report
Rodrigo Galves Mesquita Martins, André Luiz Lima Diniz, Ulisses Lopes Guerra Pereira Sobrinho, Diogo Eugenio Abreu da Silva, Tomás Accioly de Souza and José Anacleto Dutra de Resende Júnior*
Department of Urology, Lagoa Federal Hospital, Rua Jardim Botânico, Brazil, USA
Submission: September 14, 2017; Published: October 31, 2017
*Corresponding author: José Anacleto Dutra de Resende Júnior, Department of Urology, Lagoa Federal Hospital. Rua Jardim Botânico 501-6° andar, Jardim Botânico, Rio de Janeiro, Brazil, USA, Tel:+55(21)3111.5363 ;
How to cite this article: Martins RGM, Diniz ALL, Sobrinho ULGP, Silva DEA, Souza TA, Resende Junior JAD. Salvage Lymphadenectomy in the Treatment of Nodal Recurrence of Prostate Cancer Detected by Magnetic Resonance Imaging and PET-PSMA CT - Case Report. JOJ uro & nephron. 2017; 4(2): 555632. DOI:10.19080/JOJUN.2017.04.555632
EFR, 63 years Diagnosis of prostate adeno carcinoma Gleason 6 (3+3) by biopsy indicated by elevation of PSA (4.8mg/dl), in 2011. Patient underwent Radical Prostatectomy (RP) by sampling obturator lymphadenectomy, whose histopathological report revealed ACP Gleason 8 (5+3) with free margins (pT2C) and lymph nodes with no malignancy (pN0). The PSA remained null during the three consecutive years, in 2014 PSA raised (3.14mg/dl). In 2016 PSA reached 17mg/dl. His disease was re-staged and 68Ga-PSMA-PET/CT revealed areas with anomalous increase of 68Ga-PSMA expression in periaortic and iliac lymph nodes on the left, suggestive of secondary neoplastic lesions. In august 2016, patient underwent retroperitoneal Salvage Lymphadenectomy. Lymph node enlargement was identified in the left obturator chain, left external iliac, paracaval and periaortic chain.
The histopathological report described metastatic bilaterally obturator chain carcinoma, left internal iliac, pre-sacral left and paraaortic. The 30-day postoperative PSA was 2.57. Salvage Lymphadenectomy is a path for treatment in patients with disease relapse limited to the LNM after RP, it is a method that can postpone androgen deprivation therapy and chemotherapy; clinical trials are needed to legitimize surgery in this specific scenario.
Prostate cancer (PC) still remains the most frequent oncologic disease in the urogenital tract, the second most frequently diagnosed cancer among men and the 5th leading cause of cancer death worldwide . Screening may increase the chances of detection of the disease in the early stages however, despite all the technological advances and debates on the management of localized disease RP remains a good treatment option . Unfortunately a successful surgery does not mean a disease-free status at the long term. A significant proportion of men undergoing curative treatment for PC will develop biochemical recurrence (BR) . Some studies have shown proportion ranging from 15% to 40% of BR between those men treated by RP, which can be associated with local or systemic remaining of the disease [4,5].
EFR, 63 years diagnosis of prostate adenocarcinoma Gleason 6 (3+3) by biopsy indicated by elevation of PSA (4.8mg/dl), in 2011.Patient underwent RP by sampling obturator lymphadenectomy, whose histopathological report revealed ACP Gleason 8 (5+3) with free margins (pT2C) and lymph nodes with no malignancy (pN0). The PSA remained null during the three consecutive years, in 2014 PSA raised (3.14mg/dl), clinical follow-up was choosed by assistents in his hometown. In 2016 he was referred to Federal Hospital of Lagoa Rio de Janeiro-Brazil, because PSA reached 17mg/dl. As inicial treatment received hormone-therapy, falling PSA to 10mg/dl. His disease was re-staged between june and july, results are bellow:
Bone 99mTechnetium scintigraphy: Low probability of
blast bone metastases.
MRI: Lymph nodes 3.4cm and 2.3cm, showing signs of
heterogeneous uptake by the contrast medium, at the level of
the external iliac chain on the left. A 3.5cm lymph node with
heterogeneous contrast uptake at the transition between the
abdominal aorta and the left common iliac artery (Figure 1).
68Ga-PSMA-PET/CT: Areas with anomalous increase
of 68Ga-PSMA expression in periaortic and iliac lymph
nodes on the left, suggestive of secondary neoplastic lesions
(Figure 2 & 3).
In august 2016, patient underwent retroperitoneal S-LND
(Figure 4A & 4B). Lymph node enlargement was identified in the
left obturator chain, left external iliac, paracaval and periaortic
chain. Procedure extended for 4 hours. Blood loss was minimal.
There were no intra operative or extra operative complications,
being discharged on the 6th day after surgery. The 30-day
postoperative PSA was 2.57. The histopathological report described metastatic bilaterally obturator chain carcinoma, left
internal iliac, pre-sacral left and paraaortic.
The improvement of imaging methods helped us to
understand the scenario of biochemical recurrence in patients
submitted to radical prostatectomy. Heidenreich et al. 
purposed oligometastatic PC as defined by three or less to five
metastatic lesions, no rapid spread to more sites, and feasibility
of targeted treatment of all metastatic lesions with surgery or
radiation therapy. Hövels et al.  perfomed a meta-analysis
including 24 studies and showed that CT and MRI have both a
poor performance on identifying LMN. For CT, pooled sensitivity
was 0.42 (0.26-0.56; 95% CI) and pooled specificity was 0.82
(0.8-0.83; 95% CI). For MRI, the pooled sensitivity was 0.39
(0.22-0.56 95% CI) and pooled specificity was 0.82 (0.79-0.83;
95% CI) . However, given the availability of access in our
environment, both techniques are still used. In the presented
case, the MRI was successful due to the high level of PSA and the
large lymphnode volume.
A tomography enhanced, the choline PET/CT, has been
employed; however, it also might underestimate nodal burden,
Passoni NM et al have repoted that only 35% of patients
undergoing salvage nodal dissection guidedby choline PET/ CT
scan have lymph node metastases limited to the positive spots
at preoperative imaging. But in times of precision medicine, it
creates an unique need of characterization and location of the
cancer . Image and treat’ strategy is possible with 68Ga-PSMAPET/
CT and so, a tailored path to the particular characteristics
of the individual cancer patient can be chosen . Rauscher I
et al. performed a retrospective study including 48 patients with
BR who underwent 68Ga-PSMA-PET/CT imaging, and found that
the specificity of 68Ga-PSMA-PET/CT and morphologic imaging
was 97.3% and 99.1%, respectively. However, 68Ga-PSMAPET/
CT detected LNM in 53 of 68 histopathologically proven
metastatic LN fields (77.9%) whereas morphologic imaging was
positive in only 18 of 67 (26.9%) .
In terms of surgery, Hadaschik et al.  brings a controvertial
point which is the extent of treatment once salvage therapy
based on PSMA imaging is initiated; in their opinion, the data
available today suggest that bilateral template-based surgery
should be performed to overcome the limitations of 68Ga-PSMAPET/
CT imaging in detecting micro metastases. S-LDN should be
performed according to the surgical team’s expertise and the
availability of methods. Montorsi et al.  reported their initial
experience with robot-assisted salvagenodal dissection for the
management of 16 patients with lymphnode recurrence after
radical prostatectomy. Median operative time, blood loss, and
length of hospital stay were 210min, 250ml, and 3.5 days. The
median number of nodes removed was 16.5 .
Positive lymph nodes were detected in 11 (68.8%) patients.
Overall, four (25.0%) and five (31.2%) patients experienced
intra operative and postoperative complications, respectively.
Overall, one (6.3%) and four (25.0%) patients had Clavien I and II
complications within 30 days after surgery respectively. Overall,
five (33.3%) patients experienced BR after robot assisted S-LDN.
Their study is limited by the small cohort of patients evaluated,
by method of lymph node detection which was by PET/CT and
by the short follow-up duration .
Despite any imaging method used for diagnosis, Abdollah et
al.  suggests that when a S-LDN is considered, it should be
extended to all regional lymph node stations and not limited to
the sites of positive spots at preoperative imaging. Accordingly
to their systematic review, data suggest that S-LND can delay
clinical progression and postpone hormonal therapy in almost
one-third of the patients, although the majority will have BCR. An
accurate and attentive preoperative patient selection may help
improve these outcomes. The most frequent complication after
S-LND was lymphorrhea (15.3%), followed by fever (14.5%) and
ileus (11.2%) [17,18].
The evolution of imaging systems is currently at increase,
year by year new methods are presented to scientific community. Those tools must be presented to patient carefully
. Prospective studies must be performed to increase the
level of evidence and help us to establish guidelines for the best
orientation of practitioners and patients. S-LND is a path for
treatment in patients with disease relapse limited to the LNM
after RP, it is a method that can postpone androgen deprivation
therapy and chemotherapy; clinical trials are needed to
legitimize surgery in this specific scenario. We must be careful to
treat the patient before treating his exams . The well-being
of those who entrust us to their health should be in the first
place. Hippocratic principles should never be forgotten.