前列腺癌盆腔淋巴结清扫“彻底过时了”？--第十四届上海泌尿肿瘤学术大会

第十四届上海泌尿肿瘤学术大会暨中国抗癌协会男性生殖系统肿瘤专委会（CACA-GO）年会2024年12月在上海召开，大会邀请了多位泌尿肿瘤领域的国际知名专家进行学术演讲或手术演示。来自澳大利亚Peter MacCallum癌症中心的Declan Murphy教授带来了题为“Is pelvic lymph node dissection for prostate cancer now dead?”的精彩报告，并在接受采访中进一步分享了他对于前列腺癌盆腔淋巴结清扫手术的看法和经验。

1、现在前列腺癌淋巴结分期可以用PET-CT，生化复发也可以用放疗或者新型内分泌治疗。那么，您认为前列腺癌患者有必要做盆腔淋巴结清扫（PLND）吗？毕竟淋巴结清扫手术也有相应的并发症风险。

Declan Murphy教授：今年，欧洲泌尿外科学会（EAU）关于前列腺癌盆腔淋巴结清扫术的指南发生了重大变化。此前，指南强烈建议，如果患者基于病理标准而怀疑有淋巴结转移，就应该进行盆腔淋巴结清扫术。

然而，在2024年的指南中，盆腔淋巴结清扫术的重要性显著降低了。我的看法是，尤其是经过PSMA PET-CT检查的患者，很少有患者能从盆腔淋巴结清扫术中获益。如果PSMA PET-CT未显示淋巴结转移的证据，那么淋巴结受累的可能性非常低，这类患者从盆腔淋巴结清扫术中获益的可能性微乎其微。

这一变化是过去十年中前列腺癌指南中最重大的改变之一。

Oncology Frontier - Urology Frontier: Nowadays, PET-CT is used for lymph node staging in prostate cancer, and radiotherapy or androgen deprivation therapy are options for biochemical recurrence. Given that lymph node dissection surgery carries certain risks of complications, do you believe it is necessary for prostate cancer patients to undergo pelvic lymph node dissection (PLND)?

Dr. Declan Murphy: This year has seen a very big change in the European Association of Urology (EAU) guidelines on pelvic lymph node dissection for prostate cancer. Previously, there was a strong recommendation that if we suspected patients had lymph node metastases based on pathological criteria, we should offer a lymph node dissection.

However, in 2024, there has been a significant de-emphasis on pelvic lymph node dissection. My view is that very few patients nowadays benefit from pelvic lymph node dissection, especially if they have undergone PSMA PET-CT. If a PSMA PET-CT shows no evidence of lymph node metastases, the predicted likelihood of lymph node involvement is much lower, and those patients are very unlikely to benefit from pelvic lymph node dissection.

This shift represents one of the most substantial changes we‘ve seen in prostate cancer guidelines over the past decade.

2、在临床实践中，您会如何决定患者是否需要进行PLND？PSMA-PET检查是否成为您决定PLND的重要因素？

Declan Murphy教授：PSMA PET-CT在为新诊断的前列腺癌患者进行分期时，最大的优势之一就是能够帮助我们决定患者是否适合进行骨盆淋巴结清扫术。

在2023年，《European Urology Oncology》发表了一项新的预测模型研究，首次将PSMA PET-CT的数据纳入其中。研究表明，如果前列腺癌患者的PSMA PET-CT扫描未显示淋巴结转移的证据，那么盆腔淋巴结清扫术后发现淋巴结受累以及PSA持续的可能性显著降低。

这在临床实践中意味着什么？在澳大利亚，我们广泛使用PSMA PET-CT。如果扫描未显示淋巴结受累，我们通常不推荐进行盆腔淋巴结清扫术。过去十年，我为患者进行盆腔淋巴结清扫术的比例从超过一半减少到了不到5%。在PSMA PET-CT时代，清扫术几乎已经从我们的实践中消失。

Oncology Frontier - Urology Frontier: In clinical practice, how would you determine whether a PLND is necessary? Does PSMA PET-CT play a significant role in your decision-making process regarding PLND?

Dr. Declan Murphy: Absolutely. One of the most important advantages of PSMA PET-CT in staging patients with newly diagnosed prostate cancer is its ability to inform decisions about pelvic lymph node dissection.

In 2023, a new nomogram was published in European Urology Oncology that, for the first time, incorporated data from PSMA PET-CT. This research demonstrated that if these patient has a PSMA PET-CT scan showing no evidence of lymph node metastases, the likelihood of lymph node involvement following PLND is significantly reduced.

What does this mean in clinical practice? In Australia, where PSMA PET-CT is widely utilized, if a scan reveals no lymph node involvement, we do not recommend pelvic lymph node dissection. Over the past decade, the proportion of patients in whom I perform pelvic lymph node dissection has dropped dramatically—from over 50% to now only about 5%. PLND has nearly disappeared from our practice in the PSMA PET-CT era.

3、现在对应该选择标准PLND还是扩大PLND（ePLND）的问题也有争议。您如何看待这个问题？

Declan Murphy教授：2024年末，纪念斯隆-凯特琳癌症中心在《European Urology》上发表了一篇值得注意的论文，该论文介绍了一项随机试验，对比了标准（有限）PLND与扩大PLND的疗效。标准组仅清扫了外髂淋巴结，而在扩大组还清扫了髂内淋巴结、闭孔淋巴结和下腹淋巴结。

该试验得出的结论是，在改善生化无复发生存率方面，扩大PLND相较于有限PLND并无获益（HR 1.05，P=0.03）。然而，该研究还包括了一项回顾性分析，提示扩大PLND可能会降低转移风险（任何转移：HR 0.82；远处转移：HR 0.75）。但这并非预先规定的终点，且所使用的影像学评估方法也未标准化，因此这一结论的可靠性较低。

在我看来，目前尚无明确证据表明标准PLND或扩大PLND具有明显优势。最关键的是，任何形式的盆腔淋巴结清扫术是否能带来切实的好处。如果PSMA PET-CT结果为阴性，则很少有患者可能从中受益，这也是2024年更新后的指南大幅减少对PLND重视的原因。

Oncology Frontier - Urology Frontier: There is ongoing debate regarding the choice between standard PLND and extended PLND. What is your view on this?

Dr. Declan Murphy: A noteworthy paper was published in European Urology in late 2024 by Memorial Sloan Kettering Cancer Center, presenting a randomized trial comparing standard(limited) PLND with extended PLND. In the standard group, only the external iliac lymph nodes were removed, whereas in the extended group, the internal iliac, obturator and hypogastric nodes were also removed.

This trial concluded that there is no benefit of extended PLND over limited PLND in terms of improving biochemical recurrence-free survival(HR 1.05,P=0.03). However, the study also included a retrospective analysis suggesting a potential reduction in metastases(any metastasis: HR 0.82; distant metastasis: HR 0.75) with extended PLND. However, this was not a pre-specified endpoint, and the imaging methods used were not standardized, making this conclusion less reliable.

From my perspective, there is no clear evidence supporting the benefit of either standard or extended pelvic lymph node dissection. The most critical consideration is whether any form of pelvic lymph node dissection offers a tangible benefit. If the PSMA PET-CT is negative, very few patients are likely to benefit, which is why the updated guidelines in 2024 significantly de-emphasize PLND.

Declan Murphy 教授

澳大利亚Peter MacCallum癌症中心

澳大利亚墨尔本Peter MacCallum癌症中心的泌尿科顾问、泌尿生殖系统肿瘤科主任和机器人手术主任，也是墨尔本大学Peter MacCallum肿瘤科的教授级研究员。他曾担任伦敦盖伊和圣托马斯NHS基金会的泌尿科顾问。Declan专攻泌尿生殖系统肿瘤科，尤其是前列腺癌。

原文转自：肿瘤瞭望 泌尿时讯

https://mp.weixin.qq.com/s/gQ2dkEd3ksVwjcUTeA6-WQ