Lymph Node–Positive Bladder Cancer Treated With Radical Cystectomy and Lymphadenectomy: Effect of the Level of Node Positivity

• Published in: European urology Vol. 61; no. 5; pp. 1025 - 1030
• Main Authors: Tarin, Tatum V, Power, Nicholas E, Ehdaie, Behfar, Sfakianos, John P, Silberstein, Jonathan L, Savage, Caroline J, Sjoberg, Daniel, Dalbagni, Guido, Bochner, Bernard H
• Format: Journal Article
• Language: English
• Published: Kidlington Elsevier B.V 01.05.2012; Elsevier
• Subjects: Aged; Biological and medical sciences; Bladder cancer; Carcinoma - mortality; Carcinoma - pathology; Carcinoma - surgery; Cystectomy - methods; Disease-Free Survival; Female; Follow-Up Studies; Hematologic and hematopoietic diseases; Humans; Leukemias. Malignant lymphomas. Malignant reticulosis. Myelofibrosis; Lymph Node Excision - methods; Lymph Nodes - surgery; Lymphatic Metastasis; Male; Medical sciences; Middle Aged; Neoplasm Grading; Nephrology. Urinary tract diseases; Pelvic lymphadenectomy; Prognosis; Prospective Studies; TNM staging system; Treatment Outcome; Tumors of the urinary system; Urinary Bladder Neoplasms - mortality; Urinary Bladder Neoplasms - pathology; Urinary Bladder Neoplasms - surgery; Urinary tract. Prostate gland; Urology; TNM staging system; Pelvic lymphadenectomy; Bladder cancer; Nephrology; Urinary system disease; Node; Positivity; Malignant lymphadenopathy; Malignant hemopathy; Urinary tract disease; Malignant tumor; TNM-System; Urology; Lymph node metastasis; Lymphadenectomy; Cystectomy; Treatment; Pelvic cavity; Surgery; Classification; Bladder disease; Cancer
• ISSN: 0302-2838; 1873-7560
• DOI: 10.1016/j.eururo.2012.01.049

Abstract Background The extent of lymphadenectomy needed to optimize oncologic outcomes after radical cystectomy (RC) for patients with regionally advanced bladder cancer (BCa) is unclear. Objective Evaluate the effect of the location of lymph node metastasis on recurrence-free survival (RFS) and cancer-specific survival (CSS) for patients undergoing RC with a mapping pelvic lymph node dissection (PLND). Design, setting, and participants A study of 591 patients undergoing RC with mapping PLND was completed between 2000 and 2010. Median follow-up was 30 mo. Intervention RC with mapping PLND. Measurements We evaluated the impact of lymph node involvement by location on disease outcomes using the 2010 TNM staging system. Survival estimates were described using Kaplan-Meier methods. Gender, age, pathologic stage, histology, number of positive nodes, location of positive nodes, node density, use of perioperative chemotherapy, and grade were evaluated as predictors of RFS and CSS using multivariate Cox proportional hazard regression. Results and limitations Overall, 114 patients (19%) had lymph node involvement, and 42 patients (7%) had pN3 disease. On multivariate analysis, the number of positive lymph nodes (one or two or more) was significantly associated with increased risk of cancer-specific death (hazard ratio [HR]: 1.9 [95% confidence interval (CI), 1.04–3.46], p = 0.036; versus HR: 4.3 [95% CI, 2.25–8.34], p < 0.0005). Positive lymph node location was not an independent predictor of RFS or CSS. Five-year RFS for pN3 patients undergoing RC with PLND was 25% (95% CI, 10–42). This finding was not statistically different from our pN1 and pN2 patients (38% [95% CI, 22–54] and 35% [95% CI, 11–60], respectively). This study is limited by the lack of prospective randomization and a control group. Conclusions The outcome for patients with involved common iliac lymph nodes was similar to the outcome for patients with primary nodal basin disease. These data support inclusion of the common iliac lymph nodes (pN3) in the nodal staging system for BCa. Lymph node location was not an independent predictor of outcome, whereas the number of positive lymph nodes was an independent predictor of worse oncologic outcome (pN1, pN2). Further refinements of the TNM system to provide improved prognostication are warranted.