Overtreatment of prostate cancer may be prevented by extended pelvic lymphadenectomy.

OBJECTIVE: Pelvic lymphadenectomy remains the gold standard for providing a diagnosis of lymph node metastasis (N1) in prostate cancer patients who may be candidates for curatively intended radiotherapy (RT). The limited lymphadenectomy technique (L-PLND) provides removal of only a minority of lymph nodes within the expected regions of lymph node drainage of the prostate. We describe our extended lymphadenectomy (e-PLND) and the pathological outcome with a modified template as described by Briganti and compare it with L-PLND. MATERIAL AND METHODS: This was a retrospective study of 44 patients who underwent e-PLND and 36 patients who underwent L-PLND. The lymph node dissection regions were divided into: I the external iliac field, II the obturator field and III the internal iliac field. RESULTS: The mean age was 70.2 years for e-PLND and 68.9 years for L-PLND. There was no significant difference in preoperative prostate-specific antigen (PSA), Gleason score or clinical stage between the two cohorts of patients. The mean operative time was 95 min. (range 75-140 min.) for e-PLND and 82 min. (range 30-145 min.) for L-PLND (p = 0.03). N1 was found in 18 (41%) and six (17%) in e-PLND versus L-PLND, respectively (p = 0.03). Six of the 44 (13.6%) patients who underwent e-PLND had N1 exclusively outside the region related to the limited dissection technique. CONCLUSION: e-PLND is safe and can prevent overtreatment of at least 13.6% of the prostate cancer patients who may be candidates for RT. Positive needle-core biopsies have a direct impact on N1. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Bilateral primary adrenal lymphoma presenting with adrenal insufficiency.

Lymphoma may occasionally involve the adrenal glands, but primary adrenal lymphoma (PAL) is very rare and only few cases have been reported. We present a case of a 60-year-old, otherwise healthy, woman, with bilateral PAL presenting with adrenal insufficiency. The patient responded initially upon administration of large doses of intravenously hydrocortisone with total remission of symptoms. An abdominal computerized tomography scan demonstrated bilateral adrenal lesions but did not demonstrate any other pathology. Since metastatic malignant disease was suspected a positron-emission-tomography scan was performed only showing significant uptake in the adrenal glands. Endocrine evaluation did not reveal abnormal function of any hormonal system and the patient was scheduled for bilateral adrenalectomy. However the clinical condition deteriorated rapidly and the patient was readmitted to hospital before surgery was performed. A new computerized tomography scan showed rapid progression of disease with further enlargement of the adrenal masses and both pulmonary and hepatic metastasis. Needle biopsy was performed but the patient refused further treatment and died before a diagnosis was obtained. The immuneohistochemical diagnosis was large B-cell lymphoma. This case should remind clinicians that PAL may be a cause of bilateral adrenal incidentaloma especially if the patient presents with adrenal insufficiency.