現在前列腺癌淋巴結分期可以用PET-CT，生化復發也可以用放療或者新型內分泌治療。那麼，您認為前列腺癌患者有必要做盆腔淋巴結清掃（PLND）嗎？畢竟淋巴結清掃手術也有相應的併發症風險。
Declan Murphy教授：今年，歐洲泌尿外科學會（EAU）關於前列腺癌盆腔淋巴結清掃術的指南發生了重大變化。此前，指南強烈建議，如果患者基於病理標準而懷疑有淋巴結轉移，就應該進行盆腔淋巴結清掃術。
然而，在2024年的指南中，盆腔淋巴結清掃術的重要性顯著降低了。我的看法是，尤其是經過PSMA PET-CT檢查的患者，很少有患者能從盆腔淋巴結清掃術中獲益。如果PSMA PET-CT未顯示淋巴結轉移的證據，那麼淋巴結受累的可能性非常低，這類患者從盆腔淋巴結清掃術中獲益的可能性微乎其微。
這一變化是過去十年中前列腺癌指南中最重大的改變之一。
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.
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《腫瘤瞭望-泌尿時訊》
在臨床實踐中，您會如何決定患者是否需要進行PLND？PSMA-PET檢查是否成為您決定PLND的重要因素？
Declan Murphy教授：PSMA PET-CT在為新診斷的前列腺癌患者進行分期時，最大的優勢之一就是能夠幫助我們決定患者是否適合進行骨盆淋巴結清掃術。
在2023年，《European Urology Oncology》發表了一項新的預測模型研究，首次將PSMA PET-CT的數據納入其中。研究表明，如果前列腺癌患者的PSMA PET-CT掃描未顯示淋巴結轉移的證據，那麼盆腔淋巴結清掃術後發現淋巴結受累以及PSA持續的可能性顯著降低。
這在臨床實踐中意味著什麼？在澳大利亞，我們廣泛使用PSMA PET-CT。如果掃描未顯示淋巴結受累，我們通常不推薦進行盆腔淋巴結清掃術。過去十年，我為患者進行盆腔淋巴結清掃術的比例從超過一半減少到了不到5%。在PSMA PET-CT時代，清掃術幾乎已經從我們的實踐中消失。
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.
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《腫瘤瞭望-泌尿時訊》
現在對應該選擇標準PLND還是擴大PLND（ePLND）的問題也有爭議。您如何看待這個問題？
Declan Murphy教授：2024年末，紀念斯隆-凱特琳癌症中心在《European Urology》上發表了一篇值得注意的論文，該論文介紹了一項隨機試驗，對比了標準（有限）PLND與擴大PLND的療效。標準組僅清掃了外髂淋巴結，而在擴大組還清掃了髂內淋巴結、閉孔淋巴結和下腹淋巴結。
該試驗得出的結論是，在改善生化無復發生存率方面，擴大PLND相較於有限PLND並無獲益（HR 1.05，P=0.03）。然而，該研究還包括了一項回顧性分析，提示擴大PLND可能會降低轉移風險（任何轉移：HR 0.82；遠處轉移：HR 0.75）。但這並非預先規定的終點，且所使用的影像學評估方法也未標準化，因此這一結論的可靠性較低。
在我看來，目前尚無明確證據表明標準PLND或擴大PLND具有明顯優勢。最關鍵的是，任何形式的盆腔淋巴結清掃術是否能帶來切實的好處。如果PSMA PET-CT結果為陰性，則很少有患者可能從中受益，這也是2024年更新後的指南大幅減少對PLND重視的原因。
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.