Salvage-Lymphadenektomie des lymphogenen Prostatakarzinomrezidivs

Zusammenfassung

Das lymphogene Prostatakarzinomrezidiv kann seit der Einführung funktioneller Bildgebung wie der PSMA PET/CT oft frühzeitig diagnostiziert werden. Aktuelle Studien zur lokalen Behandlung der Lymphknotenmetastasen legen einen positiven Einfluss auf die Prognose bei ausgewählten Patienten nahe. Dennoch ist die Mehrzahl der Studien retrospektiv und aus Mangel an höhergradiger Evidenz gilt die Salvage-Lymphadenektomie (LA) als nicht-leitlinienkonform.

Ziel dieser Arbeit ist die kritische Zusammenfassung der aktuellen Datenlage zur Salvage-LA des lymphogenen Prostatakarzinomrezidivs mit dem Fokus auf die bildgebenden Verfahren, die Ausdehnung der LA und den onkologischen Verlauf.

Die europäischen Leitlinien empfehlen die Durchführung der Cholin- oder PSMA PET/CT-Bildgebung bei einem Verdacht auf ein Prostatakarzinomrezidiv. Die PSMA-PET/CT ist der Cholin-PET/CT in Sensitivität und Spezifität überlegen und sollte dabei favorisiert werden.

Wird eine Salvage-LA dennoch durchgeführt, ist die gängige Praxis eine bilaterale LA – auch bei einem im PSMA-PET/CT nachgewiesenen einseitigen Lymphknotenbefall. Allerdings kann ebenfalls die unilaterale LA in Erwägung gezogen werden. Eine aktuell eingeleitete randomisierte prospektive Studie (ProSTone) soll diese Fragestellung beantworten.

Ein neuer vielversprechender chirurgischer Ansatz scheint die PSMA-radioguided surgery zu sein. Sie erleichtert das intraoperative Auffinden von Lymphknotenmetastasen. Langzeitdaten sind aber noch abzuwarten.

Insgesamt erreicht die Salvage-LA bei sorgfältig ausgewählten Patienten eine respektable biochemische Ansprechrate. Dennoch sind für die Zukunft prospektive Studien notwendig, um den Stellenwert genauer definieren zu können.

Abstract

Recent advances in functional imaging, such as prostate-specific membrane antigen positron emission tomography (PSMA PET/CT), provide earlier detection of nodal recurrent prostate cancer. Current studies on metastasis-directed therapy in patients with node-only recurrence suggest a positive influence on the prognosis in selected patients. Nevertheless, most studies are retrospective and, due to a lack of high-level evidence, salvage lymph node dissection (SLND) is not recommended by current guidelines.

The aim of this work is to provide a critical summary of the current data on SLND in patients with nodal recurrent prostate cancer with a focus on imaging procedures, extent of SLND and oncological outcome.

European guidelines recommend the use of choline or PSMA PET/CT imaging if prostate cancer recurrence is suspected. PSMA PET/CT is superior to choline PET/CT in sensitivity and specificity and should be the preferred approach.

Nevertheless, if SLND is performed, common practice is bilateral SLND – even if only unilateral lymph node involvement is detected by PSMA PET/CT. However, unilateral SLND can also be considered. A randomised prospective trial (ProSTone) is being initiated for clarification.

PSMA radioguided surgery seems to be a new promising surgical approach. It facilitates the intraoperative detection of lymph node metastases. However, long-term data are still awaited.

All in all, SLND achieves a respectable biochemical response rate in carefully selected patients. Nevertheless, prospective studies are necessary in the future in order to define the clinical usefulness more precisely.

Schlüsselwörter

Salvage-Lymphadenektomie - Prostatakarzinom - lymphogenes Rezidiv - Salvage-Behandlung - radioguided

Keywords

lymph node dissection - prostate cancer - salvage treatment - radioguided - nodal recurrence

Publication History

Article published online:
26 March 2020

• Literatur

• 1 Federmann J. S3-Leitlinie Prostatakarzinom. Leitlinienprogramm Onkologie. Version 5.1. Mai 2019. 345
• 2 Maurer T, Eiber M, Schwaiger M. et al. Current use of PSMA–PET in prostate cancer management. Nat Rev Urol 2016; 13: 226-235 DOI: https://doi.org/10.1038/nrurol.2016.26.
• 3 Perera M, Papa N, Roberts M. et al. Gallium-68 Prostate-specific Membrane Antigen Positron Emission Tomography in Advanced Prostate Cancer-Updated Diagnostic Utility, Sensitivity, Specificity, and Distribution of Prostate-specific Membrane Antigen-avid Lesions: A Systematic Review and Meta-analysis. Eur Urol 2019; DOI: 10.1016/j.eururo.2019.01.049.
• 4 Professionals S-O. EAU Guidelines: Prostate Cancer. Uroweb n.d.. DOI: https://uroweb.org/guideline/prostate-cancer/ (accessed August 6, 2019)
• 5 Tilki D, Mandel P, Seeliger F. et al. Salvage lymph node dissection for nodal recurrence of prostate cancer after radical prostatectomy. J Urol 2015; 193: 484-490 DOI: 10.1016/j.juro.2014.08.096.
• 6 Passoni NM, Suardi N, Abdollah F. et al. Utility of [11C]choline PET/CT in guiding lesion-targeted salvage therapies in patients with prostate cancer recurrence localized to a single lymph node at imaging: results from a pathologically validated series. Urol Oncol 2014; 32: 38.e9-16 DOI: 10.1016/j.urolonc.2013.03.006.
• 7 Afshar-Oromieh A, Zechmann CM, Malcher A. et al. Comparison of PET imaging with a (68)Ga-labelled PSMA ligand and (18)F-choline-based PET/CT for the diagnosis of recurrent prostate cancer. Eur J Nucl Med Mol Imaging 2014; 41: 11-20 DOI: 10.1007/s00259-013-2525-5.
• 8 Jilg CA, Drendel V, Rischke HC. et al. Diagnostic Accuracy of Ga-68-HBED-CC-PSMA-Ligand-PET/CT before Salvage Lymph Node Dissection for Recurrent Prostate Cancer. Theranostics 2017; 7: 1770-1780 DOI: 10.7150/thno.18421.
• 9 Suardi N, Gandaglia G, Gallina A. et al. Long-term outcomes of salvage lymph node dissection for clinically recurrent prostate cancer: results of a single-institution series with a minimum follow-up of 5 years. Eur Urol 2015; 67: 299-309 DOI: 10.1016/j.eururo.2014.02.011.
• 10 Rigatti P, Suardi N, Briganti A. et al. Pelvic/retroperitoneal salvage lymph node dissection for patients treated with radical prostatectomy with biochemical recurrence and nodal recurrence detected by [11C]choline positron emission tomography/computed tomography. Eur Urol 2011; 60: 935-943 DOI: 10.1016/j.eururo.2011.07.060.
• 11 Siriwardana A, Thompson J, van Leeuwen PJ. et al. Initial multicentre experience of 68gallium-PSMA PET/CT guided robot-assisted salvage lymphadenectomy: acceptable safety profile but oncological benefit appears limited. BJU Int 2017; 120: 673-681 DOI: 10.1111/bju.13919.
• 12 Horn T, Krönke M, Rauscher I. et al. Single Lesion on Prostate-specific Membrane Antigen-ligand Positron Emission Tomography and Low Prostate-specific Antigen Are Prognostic Factors for a Favorable Biochemical Response to Prostate-specific Membrane Antigen-targeted Radioguided Surgery in Recurrent Prostate Cancer. Eur Urol 2019; 76: 517-523 DOI: 10.1016/j.eururo.2019.03.045.
• 13 Maurer T, Robu S, Schottelius M. et al. 99mTechnetium-based Prostate-specific Membrane Antigen–radioguided Surgery in Recurrent Prostate Cancer. Eur Urol 2019; 75: 659-666 DOI: 10.1016/j.eururo.2018.03.013.
• 14 Herlemann A, Kretschmer A, Buchner A. et al. Salvage lymph node dissection after 68Ga-PSMA or 18F-FEC PET/CT for nodal recurrence in prostate cancer patients. Oncotarget 2017; 8: 84180-84192 DOI: 10.18632/oncotarget.21118.
• 15 Knipper S, Tilki D, Mansholt J. et al. Metastases-yield and Prostate-specific Antigen Kinetics Following Salvage Lymph Node Dissection for Prostate Cancer: A Comparison Between Conventional Surgical Approach and Prostate-specific Membrane Antigen-radioguided Surgery. Eur Urol Focus 2019; 5: 50-53 DOI: 10.1016/j.euf.2018.09.014.
• 16 Steuber T, Jilg C, Tennstedt P. et al. Standard of Care Versus Metastases-directed Therapy for PET-detected Nodal Oligorecurrent Prostate Cancer Following Multimodality Treatment: A Multi-institutional Case-control Study. Eur Urol Focus 2019; 5: 1007-1013 DOI: 10.1016/j.euf.2018.02.015.