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Prostate Surgery in Men with Positive Lymph Nodes

Conventional wisdom: Once cancer has escaped the prostate, it can't be cured. Therefore, putting a man with advanced disease through the rigors of surgery is cruel and, more importantly, not helpful.

This belief is why, for years, many physicians have gone to such painstaking lengths to make sure a man has curable disease before performing "curative" treatment -- radical prostatectomy. (Unfortunately, sometimes -- even when cancer seems entirely curable -- it has already spread invisibly, microscopically into the lymph nodes, and this isn't discovered until well after the operation is over.)

This is the whole purpose of lymph node dissection, the procedure-before-the-procedure in which a man's pelvic lymph nodes are checked for the presence of cancer while he lies sedated on the operating table. If cancer is found, many -- but not all -- surgeons simply sew up the incision they just made, genuinely believing it's kinder to spare the patient the rigors of a tough operation. And the poor patient? Having prepared himself for surgery and its complications, hoping for a cure, he wakes up to a terrible psychological blow: He's got an abdominal incision to recover from -- but his prostate and his cancer are still there. Nothing's changed, except perhaps the hopeful part of the picture for him.

Maybe the conventional wisdom is wrong. Results of a new Johns Hopkins study suggest that in stage D1 prostate cancer, radical prostatectomy not only averts many complications and improves quality of life -- a finding Hopkins surgeons have previously published -- but it may prolong life, as well.

For the study, the investigators looked at 168 men with stage D1 disease diagnosed between 1983 and 1995. Of these, 127 had a lymph node dissection and a radical prostatectomy (most of these men turned out to have microscopic lymph node metastases); 41 underwent the lymph node dissection alone (the situation described above). Reviewing the patients in each group, "we found 19 perfectly matched pairs of men," says urology resident Jeffery A. Cadeddu, M.D., who presented these results at the 1997 annual meeting of the American Urological Association. "Men had the exact same age, PSA score, Gleason grade, clinical stage, follow-up and amount of cancer in the lymph nodes. The only difference was that, in each pair, one man had the surgery, one man didn't."

Many complications in advanced prostate cancer arise from the physical presence of the prostate: As the cancer grows, men often develop such problems as urinary retention and obstruction, blood in the urine, kidney and bowel trouble. Men with advanced cancer who have undergone a radical prostatectomy rarely have these problems; from this standpoint, their quality of life is better.

But do they live longer? This study suggests that they may. Ten years later, only 34 percent of the men who had the lymph node dissection were still alive. But 56 percent of the men who had the radical prostatectomy were still alive -- "a big difference in survival," says Cadeddu.

He hastens to add that this is merely the first salvo -- that a much larger study is needed, that there are too few patients here to make a generalization for all men with lymph-node-positive prostate cancer. But: "I would say it's a strong suggestion that there may be a role for radical prostatectomy even in advanced disease."

Further Reading

"Stage D1 (T1-3, N1-3, M0) Prostate Cancer: A Case-Controlled Comparison of Conservative Treatment Versus Radical Prostatectomy," presented at the 1997 annual meeting of the American Urological Association. Jeffery A. Cadeddu, Alan W. Partin, Jonathan I. Epstein, and Patrick C. Walsh.

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