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E U R O P E A N U R O L O G204

Reply from Authors re: R. Jeffrey Karnes. To What ExtentCan We Predict Prostate Cancer Lymph Node Involve-

ment? Eur Urol 2011;60:202–3

Guilherme Godoy a,b, Jonathan A. Coleman a,*

a Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer

Center, New York, NY, USAb Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA

Prostate cancer and its management is an ever-evolving

field, and perhaps this is the motivation and the central

theme of Karnes’ comments [1]. The landscape of patient

evaluation, treatment options, and refinements in treat-

ment technique is always broadening as the joint endeavors

of technology and experience develop apace. This is no less

evident in the approaches to surgical management and,

particularly, the role of lymphadenectomy in the curative

treatment of men with prostate cancer.

Adjunctive lymph node dissection has long been an

established component of surgical management and is part

of the basis of expectation for postoperative oncologic

outcomes. Still, this procedure remains poorly defined with

regard to necessary extent, utility of staging, and therapeu-

tic potential. Perhaps as a result of this ambiguity, among

other factors, there is a trend away from performing

lymphadenectomy during prostatectomy in the United

States, where nearly a third of cases are performed without

node dissection [2]. Concurrently, several groups are

investigating the use of more extended dissection templates

intended to increase the likelihood of detecting occult

positive nodal disease, although they effectively advocate

more invasive and extensive procedures without a defined

biologic end point. It is certainly possible to remove more

lymph nodes, although, taken to its conclusion, this line of

thinking could include a full bilateral template, nerve-

sparing retroperitoneal lymph node dissection. It seems

DOIs of original articles: 10.1016/j.eururo.2011.01.016,10.1016/j.eururo.2011.02.025* Corresponding author. Present address: Department of Surgery,Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York,NY 10065, USA. Tel. +1 646 422 4432; Fax: +1 212 452-3323.E-mail address: colemanj@mskcc.org (J.A. Coleman).

obvious that, like our surgical colleagues in breast cancer

research, the time has come to elucidate the role of this

procedure in routine practice [3].

In designing prospective trials for lymphadenectomy, it

is critical to define several parameters including the

population of at-risk patients needed to appropriately

power the study and the expected incidence of nodal

disease that would be anticipated among those patients.

Predictive instruments such as nomograms and look-up

tables help provide such data, and the more accurate,

standardized, and universal these resources are, the more

utility they provide. Inclusion of additional clinical features,

such as magnetic resonance imaging, has appeal but also

the potential to introduce greater error across institutions.

This updated nomogram offers improved discriminatory

function over its predecessor for dissection of external,

obturator, and hypogastric nodes and was developed to

better estimate patient risk for nodal involvement in these

areas preoperatively.

Conflicts of interest: The authors have nothing to disclose.

References

[1] Karnes RJ. To what extent can we predict prostate cancer lymph node

involvement?. Eur Urol 2011;60:202–3.

[2] Feifer A, Elkin E, Lowrance W, et al. Temporal trends in operative

management of pelvic lymph nodes in patients receiving open or

minimally invasive radical prostatectomy [abstract 128]. J Urol

2010;183:e52.

[3] Giuliano AE, Hunt KK, Ballman KV, et al. Axillary dissection vs no

axillary dissection in women with invasive breast cancer and sentinel

node metastasis: a randomized clinical trial. JAMA 2011;305:569–75.

doi:10.1016/j.eururo.2011.03.048