A population‐based assessment of the National Comprehensive Cancer Network practice guideline indications for pelvic lymph node dissection at radical prostatectomy

• Published in: BJU international 2012-04, Vol.109 (8), p.1177-1182
• Main Authors: Abdollah, Firas, Schmitges, Jan, Sun, Maxine, Shariat, Shahrokh F., Briganti, Alberto, Abdo, Al'a, Tian, Zhe, Perrotte, Paul, Montorsi, Francesco, Karakiewicz, Pierre I.
• Format: Article
• Language: English
• Subjects: Adenocarcinoma - epidemiology; Adenocarcinoma - secondary; Adenocarcinoma - surgery; Adult; Aged; Aged, 80 and over; Biological and medical sciences; Biopsy; Dissection; Follow-Up Studies; Guideline Adherence; Hematologic and hematopoietic diseases; Humans; Incidence; Leukemias. Malignant lymphomas. Malignant reticulosis. Myelofibrosis; Lymph Node Excision - methods; lymph node excision/statistics and numerical data; Lymph Nodes - pathology; Lymph Nodes - surgery; Lymphatic Metastasis; lymphatic metastasis/diagnosis; Lymphatic system; Male; Medical sciences; Middle Aged; Nephrology. Urinary tract diseases; Pelvis; Prostatectomy - methods; prostatic neoplasm/pathology; Prostatic Neoplasms - epidemiology; Prostatic Neoplasms - pathology; Prostatic Neoplasms - surgery; Retrospective Studies; Risk Assessment - methods; SEER Program; Survival Rate - trends; Tumors of the urinary system; Urinary tract. Prostate gland
• ISSN: 1464-4096; 1464-410X
• DOI: 10.1111/j.1464-410X.2011.10518.x

Study Type – Therapy (cohort) Level of Evidence  2b What's known on the subject? and What does the study add? The National Comprehensive Cancer Network guidelines recommend pelvic lymph node dissection in patients with a nomogram‐predicted lymph node invasion risk of 2% or more. We set out to examine the validity of this recommendation. OBJECTIVES •  To examine the ability of the threshold recommended by the National Comprehensive Cancer Network (NCCN) in correctly predicting histologically‐confirmed lymph node invasion (LNI). •  The 2010 NCCN practice guidelines for prostate cancer recommend a pelvic lymph node dissection (PLND) at radical prostatectomy in all individuals with a nomogram predicted LNI risk of ≥2%. PATIENTS AND METHODS •  We assessed 20 877 patients who were treated with radical prostatectomy and PLND between 2004 and 2006, within the Surveillance, Epidemiology and End Results database. •  The 2% nomogram threshold, as well as other threshold values (range 1–10%) were tested. •  Finally, we externally validated the NCCN guideline nomogram. RESULTS •  Overall, 2.5% of patients had LNI. •  The use of the 2% threshold would allow the avoidance of 23% of PLNDs, at the cost of missing 1.7% of patients with LNI. Conversely, the use of a 3% threshold would allow the avoidance of 58% of PLNDs, at the cost of missing 15% of patients with LNI vs 72% and 26%, respectively, for the 4% threshold. •  Overall, the accuracy of the NCCN guideline nomogram quantified according to the receiver‐operator characteristics‐derived area under the curve was 82%. CONCLUSIONS •  In a population‐based sample, the NCCN guideline nomogram is highly accurate. •  However, the 2% threshold will permit the avoidance of only 23% of PLNDs, instead of the 48% intended by the NCCN guidelines. •  The use of a 3% threshold may allow a lower rate of PLND overtreatment, although it will miss more patients with LNI.