Role of lymph node dissection in management of bladder cancer

Impact of pelvic lymph node dissection on survival outcomes in non-muscle invasive bladder cancer: a multicenter retrospective study

This multicenter, retrospective study evaluated the impact of pelvic lymph node dissection (PLND) on survival outcomes in non-muscle invasive bladder cancer (NMIBC) patients undergoing radical cystectomy (RC) and identified factors associated with upstaging. A total of 544 NMIBC patients who underwent RC with or without PLND between 2019 and 2024 were analyzed. Survival outcomes, including cancer-specific survival (CSS) and recurrence-free survival (RFS), were compared using Kaplan-Meier analysis and Cox proportional hazards models, while factors associated with upstaging were examined through logistic regression. Of the 544 patients, 509 (93.6%) were staged as cT1, and 412 (75.7%) underwent PLND. Upstaging occurred in 193 patients (35.5%), with pathological stages distributed as pT1 (50.0%), pT2 (20.8%), pT3 (11.2%), and pT4 (3.5%). Among patients who underwent PLND, 29 (7.0%) had positive lymph nodes. PLND was associated with improved RFS (5-year: 84.3% vs. 71.5%; adjusted hazard ratio [HR] = 0.33, 95% confidence interval [CI]: 0.20-0.56, p < 0.001) but did not significantly impact CSS (5-year: 86.5% vs. 81.6%; adjusted HR = 0.57, 95% CI: 0.32-1.02, p = 0.06). Lymph node positivity was linked to the worst prognosis. cT1 tumors, histological subtypes, and PLND were significant predictors of upstaging. In patients with cT1 tumors or histological subtypes, repeat transurethral resection is recommended to obtain more precise staging, which may inform further therapeutic decisions. While PLND is not routinely recommended for all NMIBC patients, it may be considered in those with high-risk features, particularly cT1 tumors or histological subtypes.

Nomogram based on the log odds of negative lymph node/T stage can predict the prognosis of patients with colorectal cancer: a retrospective study based on SEER database and external validation in China

OBJECTIVES

This study investigated the prognostic role of log odds of negative lymph node/T stage (LONT) and established a nomogram based on LONT to predict the prognosis in colorectal cancer (CRC) patients.

DESIGN

A retrospective cohort study.

SETTING AND PARTICIPANTS

We enrolled 80 518 CRC patients from the Surveillance, Epidemiology and End Results database between 2010 and 2015. The dataset was split into a training cohort (56 364 patients) and a validation cohort (24 154 patients) at a ratio of 7:3. Furthermore, 500 CRC patients who underwent surgery in the Tenth Affiliated Hospital of Southern Medical University between 1 January 2017 and 20 December 2018, were recruited as the external validation set.

OUTCOME MEASURES

1-, 3- and 5-year cancer-specific survival (CSS).

METHODS

The univariate and multivariate Cox regression analyses were carried out to identify the significant independent prognostic factors of CSS. A nomogram was established based on LONT to predict the prognosis. The performance of the nomogram was comprehensively assessed via the time-dependent receiver operating characteristic curve, concordance index (C-index), calibration curve and decision curve analysis (DCA) comprehensively. Moreover, Kaplan-Meier curves were performed to assess the CSS of the three risk subgroups.

RESULT

LONT was a significant independent prognostic factor for CSS (LONT1 vs LONT2, HR=0.670, 95% CI 0.642 to 0.698, p<0.001; LONT1 vs LONT3, HR=0.443, 95% CI 0.420 to 0.467, p<0.001). LONT, age, sex, race, subsite, differentiation, histology, tumour size, T stage, N stage, M stage and chemotherapy were included in the nomogram. The 1-, 3- and 5-year survival area under the curve were 0.856, 0.862 and 0.852, respectively. The C-index of the model was 0.809 (95% CI 0.825 to 0.839) in the model. The calibration curve and DCA verified the favourable predictive performance and clinical application of the nomogram.

CONCLUSION

CRC patients with a high LONT had a low incidence of CSS. The nomogram based on LONT could effectively predict the CSS of CRC.

Japanese expert consensus on the standardization of robot-assisted pelvic lymph node dissection in urological surgery: Extent of pelvic lymph node and surgical technique

Pelvic lymph node dissection (PLND) is important for accurate staging and prognosis of prostate and/or bladder cancer. Several guidelines recommend extended PLND for patients with these cancers. However, the therapeutic benefits of extended PLND are unclear. One major reason is that the extent of PLND is not clearly defined. Thus, the working group for standardization of robot-assisted PLND, including nine experienced urologists for PLND in Japan, was launched in January 2023 by the Japanese Society of Endourology and Robotics. This study summarized the discussions to define the individual extent of PLND in urological surgery in a consensus meeting among these experienced urologists. The consensus meeting determined the extent of PLND based on arteries (veins) and anatomical membrane structures rather than a vague concept or approach toward PLND. This concept is expected to allow surgeons to implement the same extent of PLND. Finally, after a total of 10 online web conferences were held, we determined the extent of PLND for the obturator lymph node (LN) area, the internal iliac LN area, the external and common iliac LN area, and the presacral LN area according to the above rules. The extent of PLND suggested here currently does not have a clear therapeutic rationale. Therefore, the extent of our proposed PLND is by no means mandatory. We hope our definition of the extent of PLND will be supported by further evidence of therapeutic benefits for urologic cancers.

Surgical outcomes of a partial or total cystectomy for colorectal cancer invasion of the bladder

BACKGROUND

Although a partial or total cystectomy may be performed for colorectal cancer (CRC) with bladder invasion, the indications for either procedure have not been established. The present study reports the oncological and functional outcomes of CRC in patients who underwent combined resection of the bladder and CRC via either a partial or total cystectomy.

METHODS

This retrospective study was conducted at a single center. A total of 107 consecutive patients with CRC who underwent colorectal surgery combined with partial or total cystectomy between January 2005 and August 2022 were enrolled. The short- and long-term outcomes of the surgery, especially postoperative bladder function, were assessed.

RESULTS

Ninety patients underwent partial resection and 17 patients underwent total resection. Forty-two patients (46.7 %) in the partial cystectomy group and 16 (94.1 %) in the total cystectomy group had histologically confirmed CRC with bladder invasion. The urinary-specific morbidity rate was 18.9 % in the partial cystectomy group and 15.6 % patients in the same group required treatment for dysuria at postoperative month 3. Of the patients who underwent partial cystectomy, five (5.6 %) experienced recurrence stemming from a bladder remnant. The cumulative distant recurrence rates did not differ significantly between patients who underwent partial cystectomy and those who underwent total cystectomy (41.9 % and 57.4 %, respectively).

CONCLUSION

Partial bladder resection contributes to the preservation of bladder function and yields oncologically acceptable outcomes.

Laparoscopic pelvic lymph node dissection in cadaver surgical training from the combined perspectives of urologists, gastroenterologists and gynecologists improves overall knowledge and technique: initial experience of multidisciplinary cadaver surgical training at a single institution in Japan

Surgeons in Japan have recently become more familiar with cadaver surgical training (CST). Extended pelvic lymph node dissection (PLND) considering the vesicohypogastric fascia and ureterohypogastric nerve fascia is gradually being performed not only in urology, but also in gynecology and gastroenterology. We performed CST using a 76-year-old female cadaver who was fixed by the Thiel method, with the aim of confirming the differences in the extent of PLND performed by certified laparoscopic specialists in urology, gastroenterology and gynecology. Even in the common surgeries, there are still several areas where anatomical structures are poorly understood. In recent years, with the spread of robotic surgery, the techniques related to PLND in these three departments have gradually become similar. Through this CST program, we were able to understand the differences in procedures and the extent of PLND in these three departments. By continuing these CSTs, we hope that a standardized PLND procedure will be performed not only within the same department, but also between different departments, and that high-quality PLND will be safely performed.

Methods of Sentinel Lymph Node Detection and Management in Urinary Bladder Cancer—A Narrative Review

Introduction: Detection of lymph node status in bladder cancer significantly impacts clinical decisions regarding its management. There is a wide range of detection modalities for this task, including lymphoscintigraphy, computed tomography, magnetic resonance imaging, single-photon emission computed tomography, positron emission tomography, and fluoroscopy. We aimed to study the pre- and intraoperative detection modalities of sentinel lymph nodes in urinary bladder cancer. Method: This narrative review was performed by searching the PubMed and EMBASE libraries using the following search terms: (“Transitional cell carcinoma of the bladder” OR “urothelial cancer” OR “urinary bladder cancer” OR “bladder cancer”) AND ((“sentinel lymph node”) OR (“lymphatic mapping”) OR (“lymphoscintigraphy”) OR (“lymphangiography”) OR (“lymph node metastases”)). Studies analysing the effectiveness and outcomes of sentinel lymph node detection in bladder cancer were included, while non-English language, duplicates, and non-article studies were excluded. After analysing the libraries and a further manual search of bibliographies, 31 studies were included in this paper. We followed the RAMESES publication standard for narrative reviews to produce this paper. Results: Of the 31 studies included, 7 studies included multiple detection methods; 5 studies included lymphoscintigraphy; 5 studies included computed tomography and/or single-photon emission computed tomography; 5 studies included fluoroscopy; 4 studies included magnetic resonance imaging; and 5 studies included positron emission tomography. Discussion: Anatomical, radioactive, and functional detection modalities have been studied independently and in combination. The consensus is that preoperative detection with imaging helps guide surgical management and intraoperative detection methods help capture any lymph nodes that may have been missed. Each of these types of detection represent their own set of benefits and drawbacks, but there is currently limited evidence to support any change in overall practice to replace conventional staging.

Lymph node dissection for bladder cancer: Current standards and the latest evidence

Lymph node dissection is an indispensable component of radical cystectomy for bladder cancer. Information obtained with lymph node dissection is highly predictive of patient survival, affecting decision-making for adjuvant therapy (diagnostic role). Also, lymph node dissection provides survival benefits in certain patients by removing metastasized nodes (therapeutic role). However, an optimal extent of lymph node dissection has not been established yet. Data from surgical mapping studies showed that approximately 10% of the primary lymphatic landing sites were common iliac nodes, suggesting that lymph node dissection below the common iliac bifurcation is suboptimal. Several retrospective studies have shown a possible survival advantage with more extended lymph node dissection. However, the results of the first prospective randomized controlled trial failed to prove the survival advantage of extended lymph node dissection up to the level of the inferior mesenteric artery, compared with lymph node dissection below the bifurcation of the common iliac artery. Currently, lymph node dissection templates recommended by major guidelines are not consistent with each other. Furthermore, the evidence is limited in the settings of neoadjuvant chemotherapy, robot-assisted surgery and high-risk non-muscle-invasive disease. Physicians need to decide the extent of lymph node dissection for each patient, taking into account the potential survival benefit and possible harms of extended lymph node dissection. Another randomized controlled trial is currently underway and will provide further evidence shortly.

Tetramodal therapy using balloon-occluded arterial infusion of anticancer agents, the Azuma regimen, for lymph node-involved bladder cancer

Overall, >900 patients have been treated at Osaka Medical College (Takatsuki, Osaka, Japan) using the novel approach of balloon-occluded arterial infusion (BOAI) to deliver an extremely high concentration of the anticancer agents cisplatin (CDDP)/gemcitabine to the pelvis (referred to as the OMC-regimen), together with pelvic irradiation. In a previous study, overall survival (OS) rate was significantly higher in this treatment group compared with that in a control group receiving total cystectomy (79.6 vs. 49.6%, respectively, at 10 years). It was speculated that intensive treatment of the pelvic area may aid in preventing metastasis, and thus the present study focused on the effect of this therapy in patients with lymph node metastasis (LN+). A total of 102 patients with advanced LN+ bladder cancer received tetramodal therapy (termed the Azuma regimen), comprising radical transurethral resection of the bladder tumor, systemic chemotherapy, BOAI and pelvic irradiation. Patients who failed to achieve a complete response (CR) underwent secondary BOAI with an increased amount of CDDP and/or gemcitabine with/without hemodialysis. A CR was achieved in 57.8% (59/102) of patients in total, and in 78.8% (41/52) of patients with N1 and Tis-3 disease. Among the complete responders, 81.4% (48/59) of patients retained their bladders with no evidence of recurrence or metastasis within a mean follow-up period of 121 weeks. Stages N2-3 and T4 were determined as significant risk factors for treatment failure in addition to survival. Notably, the 10-year overall survival rates in N1, Tis-3, and N1 and Tis-3 were 67.6% (vs. 33.6% in N2-3; P=0.0003), 61.5% (vs. 37.9% in T4; P=0.0485) and 75.1% (vs. 35.5% in N2-3 or T4; P=0.0002), respectively. No patients suffered from grade IV toxicities. In conclusion, the Azuma regimen may be a feasible option for patients with LN+ disease. The use of intensive treatment in the pelvic area may serve an important role in outcome improvement, and the prevention of metastasis may be its mechanism.

Current role of lymphadenectomy in the upper tract urothelial carcinoma

Introduction

Lymphadenectomy (LND) has recently attracted considerable interest from urological surgeons, as extended lymphadenectomy might have a role in accurate staging or improving patient survival in those patients with urological malignancies.

Upper tract urothelial carcinoma (UTUC) is a relatively rare neoplasm, accounting for about 5% of all urothelial cancers. Up to 30% of patients with muscle-invasive UTUC have metastasis in the regional lymph nodes (LNs), which represents a well-established poor prognostic factor.

Material and methods

A medline search was conducted to identify original articles and review articles addressing the role of lymphadenectomy LND in UTUC. Keywords included lymphadenectomy, lymph node excision, nephroureterectomy, and upper tract urothelial carcinoma.

Results

LND instead of lymphadenectomy has recently attracted considerable interest from urological surgeons and might have a potential role in improving the oncological outcome in patients with urothelial carcinoma. LND ideally improves disease staging; thereby, we need to find the way to identify the patients who could really benefit from adjuvant systemic theraphy. Template-based LND with Radical Nephroureterectomy (RNU) for high risk disease is gaining support based on accumulating retrospective data and supports its utility as a potentially therapeutic maneuver. RNU is still the gold standard treatment for UTUC, but minimal invasive procedures such as laparoscopic RNU and Robot Assisted Nephroureterectomy (RANU) are becoming more employed in recent years and should be used by expert hands.

Conclusions

Therapeutic benefits of LND and nodal status on disease free survival (DFS) and Cancer Free Survival (CSS) remains controversial. Although most of the data comes from retrospective studies, we encourage performing well designed, prospective, and multicentre studies to clarify this in the coming years.

[EFFICACY OF NEOADJUVANT GEMCITABINE AND CISPLATIN IN THE MANAGEMENT OF MUSCLE-INVASIVE UROTHELIAL CARCINOMA OF THE BLADDER]

OBJECTIVE

We investigated the efficacy of neoadjuvant chemotherapy with gemcitabine and cisplatin (GC) in patients with muscle-invasive bladder cancer.

METHOD

This was a retrospective analysis of 14 patients who received neoadjuvant GC before radical cystectomy for clinical stage T2-4N0-3M0 bladder cancer. The primary outcome was pT0 rate and no residual muscle-invasion (≤ pT1) at cystectomy.

RESULTS

Before chemotherapy, clinical stage T2 was in 8 (57%), T3 in 6 (43%) and N + in 3 (21%). Relative dose intensity was 75% for gemcitabine and 91% for cisplatin. At cystectomy, pT0 was observed in 4 (29%) and ≤ pT1 in 10 (71%). Regarding lymph node metastasis, 2 with N1 had pN0 and pN1, respectively, and 1 with N3 did pN1. Grade 3 or 4 anemia, thrombocytopenia, neutropenia, and febrile neutropenia were observed in 3 (21%), 9 (64%), 9 (64%) and 1 (7%), respectively. Three patients died of bladder cancer at median follow-up of 33 months. The 4-year overall survival rate in patients with pT0 was 100% compared to 47% in those with residual diseases (P = 0.153).

CONCLUSIONS

We showed the proportion of pT0 at cystectomy to predict the effect of neoadjuvant GC. The results suggest that neoadjuvant GC is feasible for patients with muscle-invasive bladder cancer.

Prospective mapping of lymph node metastasis in Japanese patients undergoing radical cystectomy for bladder cancer: characteristics of micrometastasis

OBJECTIVE

To investigate node-disease prevalence including micrometastases and its survival impact on bladder cancer patients.

METHODS

A total of 60 patients participated in this study, in which extended lymph node dissection was carried out according to the prospective rule (below aortic bifurcation). Radical cystectomy and extended lymph node dissection were performed by open surgery (n = 23) or laparoscopically (n = 37). Perioperative, pathological and follow-up data were collected. Micrometastasis in lymph nodes was investigated by pan-cytokeratin immunohistochemistry. Recurrence-free survival was estimated with the Kaplan-Meier method.

RESULTS

The median number of lymph nodes removed was 29 (range: 10-103) and there was no significant difference between the two groups (open group: median 30, laparoscopic group: median 29). Routine pathological examination revealed that 10 patients had lymph node metastases. Immunohistochemistry revealed micrometastases in four additional patients (pNmicro+), who had been diagnosed with pN0 on routine pathological examination. After excluding the three patients with pure nonurothelial carcinoma on the final pathology (small cell carcinoma: n = 2, adenocarcinoma: n = 1), 10 out of the 57 urothelial carcinoma patients (17.5%) had node metastasis, and an additional 4 out of the 47 pN0 patients (4/47, 8.5%) had micrometastasis. The 2-year recurrence-free survival rates divided by pN stage were 82.4% for pN0, 66.7% for pNmicro+ and 12.5% for pN+ (three-sample log-rank test, P < 0.0001). Three out of the four patients with pNmicro+ were disease free at the last follow-up.

CONCLUSIONS

We confirmed under extended lymph node dissection that a substantial proportion of the patients had node metastasis (pN+: n = 10 and pNmicro+: n = 4), and the pN stage influenced patient survival. Our observations of micrometastasis yielded additional evidence for the potential survival benefit of extended lymphadenectomy by eliminating microdisease.

Laparoscopic pelvic lymph node dissection system based on preoperative primary tumour stage (T stage) by computed tomography in urothelial bladder cancer: results of a single-institution prospective study

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Bladder cancer (BC) is a public health problem throughout the world, and now radical cystectomy (RC) has been introduced as a standard treatment for BC invading muscle and some BCs not invading muscle. Pelvic lymph node dissection (PLND) is considered an integral part of RC for its prognostic and therapeutic significance, but the extent of the PLND has not been precisely defined. Computed tomography is considered one of the most preferable methods to assess the BC stage preoperatively because of its high sensitivity and specificity. However, there are few articles referring to CT as an aid in deciding the extent of lymphadenectomy during RC. In the present study, we prospectively studied the clinical value of preoperative CT staging of primary tumours in deciding the extent of PLND during laparoscopic RC in the management of BC. The preliminary findings suggested that all patients with higher preoperative CT stage should be given super-extended PLND during RC. For those with lower CT stage, careful and thorough clearance of all lymphatic and adipose tissues within the true pelvis could be more helpful than super-extended PLND.

OBJECTIVE

To study prospectively the clinical value of preoperative spiral computed tomography (CT) staging of primary tumours in deciding the extent of pelvic lymph node dissection (PLND) during laparoscopic radical cystectomy (RC) in the management of bladder cancer (BC).

PATIENTS AND METHODS

Between January 2010 and December 2011, a total of 63 patients with urothelial BC received laparoscopic RC, super-extended PLND and ileac conduit. The super-extended PLND removed all lymphatic tissues in the boundaries at the level of the inferior mesenteric origin from the aorta (cephalad), the pelvic floor (distally), the genitofemoral nerve (laterally) and the sacral promontory (posteriorly). All of the operations were performed by one experienced surgeon, and all harvested lymph nodes were submitted separately. CT was used to evaluate the preoperative CT stage (CTx) of each primary bladder tumour.

RESULTS

All patients were divided into five categories according to their CTx stages: three at CT1, seven at CT2a, 38 at CT2b, seven at CT3b, and eight at CT4a. All 63 procedures were completed successfully without any conversion to open surgery. The mean estimated blood loss was 450 mL, and 14 patients (22.2%) had postoperative lymphatic leakage. Each case was pathologically confirmed as transitional cell carcinoma with negative margins at the urethral and ureteric stumps. None of the patients with a low CTx stage (CT1-CT2a) had positive lymph nodes above the level of the common iliac artery bifurcation. There was no jump lymph node metastasis, and no positive lymph node was detected above the level of aortic bifurcation in all cases.

CONCLUSION

Based on the preoperative CT staging, urological surgeons can determine the boundaries of PLND to reduce intraoperative injury and postoperative complications in patients with BC, especially those at the lower CTx stages (CT1 and CT2a).

Role of lymphadenectomy in the management of urothelial carcinoma of the bladder and the upper urinary tract

The role of lymphadenectomy has been controversial in urological malignancies. Urothelial carcinoma of the bladder and upper urinary tract has a high potential to spread through the lymphatic network compared with other malignancies, including renal cell carcinoma or prostate cancer. In urothelial carcinoma of the bladder, lymphadenectomy of pelvic nodes had been considered as the standard procedure when radical cystectomy was carried out. Recently, many investigators have examined the influence of its extent, and the majority of the studies have supported the beneficial role of extended lymphadenectomy in accurate staging or in improving patient survival. Although randomized controlled trials are required to establish a greater level of evidence, more urological surgeons have already noticed the necessity for extended lymphadenectomy in bladder cancer. In contrast to bladder cancer, there have been far fewer studies on urothelial carcinoma of the upper urinary tract. This might be because of the smaller number of the patients with urothelial carcinoma of the upper urinary tract and the lack of understanding of regional nodes. However, studies of lymph node mapping and the retrospective analyses with respect to the benefit of lymphadenectomy have been carried out in urothelial carcinoma of the upper urinary tract by some investigators, although the results are still controversial. However, the results from multi-institutional studies by high volume centers have supported the beneficial role of lymphadenectomy in urothelial carcinoma of the upper urinary tract, as it has been proposed in bladder cancer. Thus, lymphadenectomy for urothelial carcinoma of the bladder and the upper urinary tract might have a potential role in staging and improving the oncological outcomes.