title: A population-based assessment of the National Comprehensive Cancer Network practice guideline indications for pelvic lymph node dissection at radical prostatectomy.
abstract: OBJECTIVE
  To examine the ability of the threshold recommended by the National Comprehensive Cancer Network (NCCN) in correctly predicting histologically-confirmed lymph node invasion (LNI). The 2010 NCCN practice guidelines for prostate cancer recommend a pelvic lymph node dissection (PLND) at radical prostatectomy in all individuals with a nomogram predicted LNI risk of ≥2%.
  
  
  METHODS
  We assessed 20,877 patients who were treated with radical prostatectomy and PLND between 2004 and 2006, within the Surveillance, Epidemiology and End Results database. The 2% nomogram threshold, as well as other threshold values (range 1-10%) were tested. Finally, we externally validated the NCCN guideline nomogram.
  
  
  RESULTS
  Overall, 2.5% of patients had LNI. The use of the 2% threshold would allow the avoidance of 23% of PLNDs, at the cost of missing 1.7% of patients with LNI. Conversely, the use of a 3% threshold would allow the avoidance of 58% of PLNDs, at the cost of missing 15% of patients with LNI vs 72% and 26%, respectively, for the 4% threshold. Overall, the accuracy of the NCCN guideline nomogram quantified according to the receiver-operator characteristics-derived area under the curve was 82%.
  
  
  CONCLUSIONS
  In a population-based sample, the NCCN guideline nomogram is highly accurate. However, the 2% threshold will permit the avoidance of only 23% of PLNDs, instead of the 48% intended by the NCCN guidelines. The use of a 3% threshold may allow a lower rate of PLND overtreatment, although it will miss more patients with LNI.
authors: Cancer Prognostics and Health Outcomes Unit, Department of Urology, Vita Salute San Raffaele University, Milan, Italy. firas.abdollah@gmail.com
authors: Firas
authors: F
authors: Abdollah
authors: Jan
authors: J
authors: Schmitges
authors: Maxine
authors: M
authors: Sun
authors: Shahrokh F
authors: SF
authors: Shariat
authors: Alberto
authors: A
authors: Briganti
authors: Al'a
authors: A
authors: Abdo
authors: Zhe
authors: Z
authors: Tian
authors: Paul
authors: P
authors: Perrotte
authors: Francesco
authors: F
authors: Montorsi
authors: Pierre I
authors: PI
authors: Karakiewicz
mesh_terms: D000230:Adenocarcinoma / Q000453:epidemiology / Q000556:secondary* / Q000601:surgery; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005500:Follow-Up Studies; D019983:Guideline Adherence; D006801:Humans; D015994:Incidence; D008197:Lymph Node Excision / Q000379:methods*; D008198:Lymph Nodes / Q000473:pathology / Q000601:surgery; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D010388:Pelvis; D011468:Prostatectomy / Q000379:methods*; D011471:Prostatic Neoplasms / Q000453:epidemiology / Q000473:pathology* / Q000601:surgery; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D018426:SEER Program; D015996:Survival Rate / Q000639:trends