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Management van lymfekliergemetastaseerd prostaatcarcinoom: rol voor chirurgie?

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Samenvatting

De rol van chirurgie bij de behandeling van patiënten met lymfogeen- gemetastaseerd prostaatcarcinoom is controversieel. Chirurgie zal bij deze patiënten waarschijnlijk geen genezing brengen. Ook met een uitgebreide lymfeklierdissectie is de kans op biochemische progressie zeer groot. Een belangrijke vraag is of het ziektebeloop wordt beïnvloed door resectie van de prostaat, ook als deze resectie niet curatief is. Uit de beschikbare literatuur kan worden afgeleid dat deze invloed er waarschijnlijk wél is, ondanks dat prostaatresectie niet gerandomiseerd is onderzocht. In dit artikel wordt de literatuur over de effecten van radicale prostatectomie bij lymfeklier-gemetastaseerd prostaatcarcinoom op een rij gezet.

Het onderzoek is uitgevoerd als systematische review met studies naar de rol van radicale prostatectomie bij lymfogeen- gemetastaseerd prostaatcarcinoom; daarnaast zijn de studies beoordeeld die sinds 1973 zijn verschenen naar de

Er zijn geen gerandomiseerde studies gevonden die de rol van radicale chirurgie bij het lymfogeen-gemetastaseerd prostaatcarcinoom onderbouwen. De literatuur laat zien dat (1) patiënten met < 2 lymfekliermetastasen een langdurige overleving hebben, (2) patiënten met lymfekliermetastasen na radicale prostatectomie een langere levensverwachting hebben dan patiënten die geen lokale behandeling hebben ondergaan en dat (3) een tijdig ingestelde hormonale behandeling een significante levensverlenging bewerkstelligt, mits de primaire tumor is bestraald of operatief is verwijderd.

Van een radicale prostatectomie kan geen genezing worden verwacht in geval van lymfekliermetastasen. De literatuur suggereert wel een aanzienlijke overlevingswinst, die met name ook wordt behaald door vroegtijdige hormonale therapie aan te bieden na lokale behandeling. Niet alleen na radicale prostatectomie, maar ook na lokale radiotherapie wordt gezien dat langdurige hormonale therapie tot een betere overleving leidt. Tegenover de overlevingswinst die van deze intensieve behandeling mag worden verwacht, staan de bijwerkingen van de ingreep en hormonale therapie. Een keuze voor een bepaalde behandelvorm blijft moeilijk en kan alleen worden bepaald in overleg met een goed geïnformeerde patiënt.

Summary

Management of lymph node metastatic prostate cancer: role for surgery?

The role of surgery in lymph node metastastic prostate cancer is controversial. In the N+ patient surgery cannot be expected to bring a cure. Also following an extended lymph node dissection, biochemical progression will occur in almost all patients. An important question is whether the course of the disease will be influenced by surgical resection of the prostate. There are no randomized studies that have addressed this issue. However, literature suggests this is probably the case. In this article the literature regarding the effects of surgery in lymph node metastatic prostate cancer will be reviewed.

This study includes a systematic review describing studies on the role of radical prostatectomy in lymph node metastatic disease. In addition, review of randomized studies addressing the role of hormonal therapy (castration or LHRH analogs) in various stages of prostate cancer.

There are no randomized studies addressing the effects of radical surgery in lymph node metastatic disease. Literature suggests the following: 1) patients with < 2 positive lymph nodes have a long survival; 2) patients with lymph node metastases who underwent a radical prostatectomy show a longer survival than those in whom no prostatectomy was performed and 3) immediate hormonal therapy impacts on survival provided the primary tumour has been irradiated or surgically removed.

A radical prostatectomy will not lead to cure in the N+ patient. Literature suggests an important survival benefit, which is achieved when a local therapy is combined with immediate hormonal therapy. Both radical prostatectomy and local irradiation are associated with improved survival following immediate hormonal therapy. This intensive treatment has important side-effects, therefore a decision on the type of treatment can only be reached in discussion with an informed patient.

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Authors and Affiliations

  1. uroloog, afdeling Urologie, Erasmus Medisch Centrum, Rotterdam, The Netherlands

    P. C. M. S. Verhagen,  L. Collette &  C. H. Bangma

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  1. P. C. M. S. Verhagen
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  2. L. Collette
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  3. C. H. Bangma
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Verhagen, P.C.M.S., Collette, L. & Bangma, C.H. Management van lymfekliergemetastaseerd prostaatcarcinoom: rol voor chirurgie?. Tijdschrift voor Urologie 2, 29–37 (2012). https://doi.org/10.1007/s13629-012-0008-2

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