Stellenwert der pelvinen Lymphadenektomie in der Therapie des Prostata- und Blasenkarzinoms

Zusammenfassung

Die Rationale einer Staging-Lymphadenektomie in der chirurgischen Therapie des Prostata- und Harnblasenkarzinoms mit kurativer Intention besteht in der verlässlichen Diagnose lymphonodulärer Mikrometastasen, um die Sinnhaftigkeit einer möglichen postoperativen adjuvanten Therapie abschätzen zu können. Zielsetzung der vorliegenden Arbeit ist eine kritische Beurteilung der publizierten Daten, um mögliche Standards der LA definieren zu können. Das Ausmaß der pelvinen Lymphadenektomie im Rahmen der radikalen Prostatektomie (RPE) wird kontrovers diskutiert. Die anatomisch adäquate, extendierte pelvine Lymphadenektomie (EPLA) schließt die Lymphknotenstationen der A. iliaca communis bis zur Ureterkreuzung, der A. iliaca externa und interna sowie der Fossa obturatoria ein. Gegenüber der Standard-LA wird die Anzahl dissezierter Lymphknoten signifikant gesteigert, die Frequenz positiver Lymphknoten nahezu verdoppelt. Die Frequenz pathohistologisch detektierter Mikrometastasen ist sowohl beim klinisch lokalisierten als auch beim lokal fortgeschrittenen PCA signifikant höher als durch präoperative Nomogramme vorhergesagt. Auch wenn derzeit keine prospektiv randomisierten klinischen Studien den therapeutischen Benefit der EPLA beweisen, könnten Patienten mit einer minimalen Lymphknotenmetastasierung profitieren. Aus einer Vielzahl von Studien geht hervor, dass das Risiko der PCA-spezifischen Mortalität bei fehlender lymphonodulärer Metastasierung bzw. 1 - 2 befallenen Lymphknoten nicht signifikant voneinander differiert. Da sich die therapieassoziierte Morbidität der EPLA nicht gegenüber der Standard-LA unterscheidet, sollte die EPLA bei allen Patienten im Rahmen der RPE bevorzugt werden. Im Rahmen der radikalen Zystektomie wurde die anatomische Ausdehnung der pelvinen Lymphadenektomie bis dato noch nicht standardisiert, obwohl ein Zusammenhang zwischen Ausmaß der LA und dem progressionsfreien Überleben existiert. Verschiedene retro- und prospektive Mappingstudien zur anatomischen Verteilung lymphonodulärer Mikrometastasen zeigten, dass die Lymphknotendissektion entlang der A. iliaca communis bis zur aortalen Bifurkation, der Aa. Iliaca externa und interna sowie der Fossa obturatoria 80 % aller betroffenen Lymphknotenmetastasen erfasst. Weiter kranial gelegene Filiae sind überwiegend nur bei intrapelviner Metastasierung darstellbar, so dass eine Ausdehnung der LA bis in den Bereich der A. mesenterica inferior nur bei positivem Schnellschnitt indiziert erscheint. Die EPLA beim Harnblasenkarzinom resultiert in der Verbesserung des progressionsfreien Überlebens, nicht jedoch des tumorspezifischen oder Gesamtüberlebens.

Abstract

The rationale for locoregional staging lymphadenectomy in prostate cancer lies in the accurate diagnosis of occult micrometastases in order to stratify patients who might benefit from adjuvant therapeutic measures. In prostate cancer, extended pelvic lymphadenectomy (EPLA) including the lymphatic tissue along the common iliac region with the ureteral crossing as cranial margin, external and internal iliac region and the obturator fossa, has been shown to increase the yield of both total lymph nodes and lymph node metastases significantly. The total number of lymph nodes removed is about 2- to 3-fold higher and the frequency of micrometastatic lymph nodes is approximately 2-fold higher compared to standard lymphadenectomy. Furthermore, the frequency of observed positive lymph nodes in clinically localized and locally advanced prostate cancer is significantly higher than predicted by nomograms such as Partin tables and CART analysis. Although there are no prospective randomized trials demonstrating a survival benefit associated with EPLA, there might be an advantage for those with minimal lymph node involvement. Progression-free survival is significantly improved in patients undergoing EPLA with a 35 % benefit compared to standard lymphadenectomy. Various studies have documented an equal risk of cancer-associated mortality in patients with no or only 1 - 2 positive lymph nodes. Since the surgery-associated morbidity of EPLA is not increased as compared to standard lymphadenectomy, EPLA should be favoured at least for all intermediate and high risk patients undergoing radical prostatectomy; in low risk patients the option of EPLA has to be discussed thoroughly. For the future, ongoing prospective trials have to demonstrate a clear benefit in terms of biochemical-free and cancer-specific survival. With regard to muscle-invasive bladder cancer, it has been shown that lymph node dissection along the external, internal and common iliac artery and obturator fossa achieves accurate data for a valid locoregional staging. Only if frozen section analysis reveals metastatic deposits along these areas an extension of the lymphadenectomy including the aortic bifurcation up to the inferior mesenteric artery seems to be of additional diagnostic value. Various studies have demonstrated that extended pelvic lymphadenectomy results in an improvement of progression-free survival, however no significant benefit with regard to cancer-specific and overall survival has been demonstrated. Nevertheless, pelvic lymphadenectomy remains one of the most significant prognosticators with regard to relapse rates as has been demonstrated recently and, therefore, it should be performed thoroughly and anatomically adequate.

Schlüsselwörter

Prostatakarzinom - muskelinvasives Blasenkarzinom - Staging-lymphadenektomie - lokoregionales Staging - radikale Prostatektomie - tumorfreie Überlebenszeit

Key words

Prostate cancer - muscle invasive bladder cancer - staging lymphadenectomy - locoregional staging - radical prostatectomy - progression-free survival

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