What is the Correct Treatment Protocol if you Develop Lymph Node Metastasis after Surgery?

Having positive lymph node metastasis (LNM or pN1) after a radical prostatectomy (RP) to treat prostate cancer is a poor prognostic indicator.  Knowing what the next best course of treatment is if you are in this situation remains questionable.  To begin to understand and better answer this problem a group of researchers performed a comparative analysis of three of the current management strategies for men with positive lymph nodes after RP.

They evaluated treatment using (1) just observation, (2) androgen deprivation therapy (ADT), and (3) external beam radiation therapy (XRT) combined with androgen deprivation therapy (ADT).  

Men with LNM following RP were identified using the National Cancer Database (2004-2013). Men were categorized according to the post-operative management strategy they had received. The primary outcome of the study was overall survival (OS).  Sub-analyses also evaluated risk stratification and time to receipt of adjuvant therapy.

The study evaluated 8,074 men who met inclusion criteria. Post-operatively, 4,489 (55.6%) of the men received just observation, 2,065 (25.6%) had ADT, and 1,520 (18.8%) received ADT+XRT. Mean follow-up was 52.3 months.  

The men receiving ADT or ADT+XRT had higher pathologic Gleason scores, T stage, positive surgical margin rates, and nodal burden. 

The statistical analysis showed there was an improved overall survival for men who received ADT+XRT vs. those who only were observed or had ADT alone.  There was no difference in overall survival for men receiving ADT vs. observation.  

These findings were similar when restricting adjuvant cohorts for the timing of adjuvant therapy received. 

There was no difference in overall survival between groups for 2,509 (31.1%) patients lacking any of the following adverse features: pT4, Gleason ≥9, ≥3 positive nodes, or positive surgical margin.

For men with lymph node metastasis following RP, the use of adjuvant ADT+XRT improved OS in the 70% of men who also had the adverse pathologic features. Conversely, adjuvant therapy did not confer significant OS benefit in the 30% of men who did not have the high-risk features.  

If you have had surgery and then present with lymph node metastasis, but you don’t have any additional high-risk factors, you should discuss with your doctor about managing your prostate cancer with observation and forego (or delay) the morbidity associated with immediate ADT or radiation.  On the other hand, if you do have high-risk factors, you should consider the more aggressive approach and add external beam radiation and ADT to your treatment protocol. 


J of Urology  April 2018

Joel T. Nowak, MA, MSW wrote this Post.  Joel is the CEO/Executive Director of Cancer ABCs. He is a Cancer Thriver diagnosed with five primary cancers - Thyroid, Metastatic Prostate, Renal, Melanoma, and the rare cancer Appendiceal cancer.