While we see plenty of prostate cancer interventions that significantly lower biochemical recurrence without going so far as to impact distant mets, curiously, the reverse was true in the trial above. This suggests not all biochemical recurrences, even with similar PSA trajectories, are created equal. The authors proceed to revisit the classic postulation that distant mets are often seeded from more aggressive nodal—not less aggressive primary—disease. This would mean specifically eradicating microscopic nodal disease can lower risk of subsequent development of clinically apparent distant disease. “An alternative theory is that presence of tumor cells in the lymph nodes promotes tumor-specific immune tolerance, thereby promoting metastasis.” What’s more, node count in the surgical specimen did not appear to influence outcomes, indicating that dissecting particular anatomic regions (i.e., obturator and hypogastric) is more meaningful than going after as many nodes as you can easily see. | Touijer, Eur Urol 2024
