Patterns of lymph node failure after dose-escalated radiotherapy: Implications for extended pelvic lymph node coverage Journal Article


Authors: Spratt, D. E.; Vargas, H. A.; Zumsteg, Z. S.; Golia Pernicka, J. S.; Osborne, J. R.; Pei, X.; Zelefsky, M. J.
Article Title: Patterns of lymph node failure after dose-escalated radiotherapy: Implications for extended pelvic lymph node coverage
Abstract: Background Clinical trials evaluating the benefit of pelvic radiotherapy (PRT) in the radiotherapeutic management of patients with higher-risk prostate cancer have limited the superior field border to the S1/S2 or L5/S1 interspace. However, imaging and surgical series have demonstrated a high frequency of prostatic lymph node (LN) drainage beyond these landmarks. Objective To determine the patterns of radiographically defined abdominopelvic LN failures and their potential implications for PRT field design. Design, setting, and participants During 1992–2008, 2694 patients with localized prostate cancer were treated with prostate/seminal vesicle–only radiotherapy without PRT. Some 156 patients had their first failure within the abdominopelvic LNs, of whom 60 had isolated failures within the pelvic LNs. Outcome measurements and statistical analysis A radiologist reviewed all imaging and mapped each LN failure to a template consisting of 34 abdominopelvic LN stations. Results and limitations The median follow-up was 8.9 yr. Of patients who experienced first recurrence in the pelvic LNs (n = 60), the common iliac station was involved in 55% (n = 33) of patients, including 10% (n = 6) who had isolated common iliac failures. Use of a PRT field superior border of L5/S1 would fully cover only 42% of the first recurrences among these patients. Extending the field to cover the common iliac stations would increase coverage to 93% of recurrences. The presence of T3/T4 disease and omission of androgen-deprivation therapy both independently conferred an approximate fivefold increase in the likelihood of having a common iliac LN failure. Use of imaging as a surrogate for LN involvement is the primary study limitation. Conclusions Pelvic LN failures frequently occur superior to the commonly used L5/S1 landmark for PRT coverage, and use of ADT may be protective of more superior LN failures. The current RTOG 0924 trial is evaluating the benefit of PRT with extended superior coverage to L4/5 when possible, which, according to our data, should significantly improve the coverage of potential sites of failure. Patient summary We looked at lymph node recurrence patterns after external beam radiotherapy of the prostate in men who did not have their lymph nodes treated. We found that there was a high incidence of pelvic lymph node recurrences above the internal and external iliac lymph node regions. Therefore, the current field recommendation for pelvic lymph nodes that stops at the superior border of the internal and external iliac vessels provides inadequate coverage of common sites of cancer recurrence, namely the common iliac lymph nodes. © 2016 European Association of Urology
Keywords: radiotherapy; prostate cancer; metastatic pattern; pelvic lymph nodes
Journal Title: European Urology
Volume: 71
Issue: 1
ISSN: 0302-2838
Publisher: Elsevier Science, Inc.  
Date Published: 2017-01-01
Start Page: 37
End Page: 43
Language: English
DOI: 10.1016/j.eururo.2016.07.043
PROVIDER: scopus
PUBMED: 27523595
PMCID: PMC5571898
DOI/URL:
Notes: Article -- Export Date: 3 January 2017 -- Source: Scopus
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MSK Authors
  1. Joseph R Osborne
    56 Osborne
  2. Michael J Zelefsky
    610 Zelefsky
  3. Zachary Stephan Zumsteg
    34 Zumsteg
  4. Daniel Eidelberg Spratt
    83 Spratt
  5. Xin Pei
    98 Pei