Incidence, extent and location of unsuspected pelvic lymph node metastasis in patients undergoing radical cystectomy for bladder cancer

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.

Lymph Node Dissection for Advanced Bladder Cancer: Is There a Role?

The role of a thorough pelvic lymph node dissection at radical cystectomy for high risk bladder cancer is an important component for quality surgical care. Selected patients with advanced disease involving the retroperitoneal lymph nodes (limited nodal disease, significant response to systemic therapy, and the ability to resect all sites of prior involvement) may benefit from surgical resection.

Lower tract neoplasm: Update of imaging evaluation

Cancers of the lower urinary tract can arise from the bladder, urachus or urethra. Urothelial carcinoma of the bladder (UCB) is the most common of these. The presentation of bladder, urachal and urethral cancers can differ but many result in hematuria as an initial indication. The diagnosis and staging of these cancers often necessitate radiologic imaging often in the form of cross-section CT urography or MR urography. The following article reviews the specific nature of lower tract cancers and their imaging.

Radical transurethral resection alone, robotic or partial cystectomy, or extended lymphadenectomy: can we select patients with muscle invasion for less or more surgery?

Improvements in the accuracy of clinical staging and refinements in patient selection may allow for improved outcomes of bladder-preservation strategies for muscle-invasive bladder cancer incorporating radical transurethral resection (TUR) and partial cystectomy (PC). Retrospective studies of patients treated with radical cystectomy and pelvic lymph node dissection have reported an association between greater extent of lymphadenectomy and improved clinical outcomes. However, there is no consensus regarding the optimal extent of lymphadenectomy, as there are currently no reports from prospective, randomized trials to address this issue in regards to cancer-specific and overall survival. Future advances in the understanding of the appropriate extent of lymphadenectomy requires well-designed prospective clinical trials that directly compare varying extents of surgery with their ability to provide local and distant disease control and disease-specific survival.

Clinical outcome after cystectomy in patients with lymph node-positive bladder cancer

Whereas radical cystectomy is the standard of care in high-grade, invasive bladder tumors, the extent of lymphadenectomy and its diagnostic and/or therapeutic potential is controversial. Independent predictors for lymph node involvement are T-stage, histological grading and lymphovascular invasion. Preoperative assessment, including 3D magnetic resonance imaging and sentinel node detection, are promising concepts for the future. The extension of lymphadenectomy is not yet defined, although prospective data regarding the absence of skipped lesions in the case of pelvic lymphadenectomy and the damage of autonomic nerves in the case of extensive lymphadenectomy are arguments for a limited or stepwise approach. Outcome of N1 patients appears to be nearly equivalent to N0 patients in organ-confined tumors, whereas the outcome of N3 patients is poor in all studies presented to date. Therefore, it has been suggested that a meticulous lymphadenectomy in N1 patients, with positive lymph nodes almost exclusively localized within the endopelvic region, has a long-term therapeutic impact in terms of an improvement in the patient's clinical prognosis. For N2 patients, a long-term survival benefit from extensive lymphadenectomy remains to be demonstrated. Recognizing the inevitably poor clinical prognosis in cases with gross nodal involvement (N3), the clinical value of an extended lymph node dissection in these patients is very questionable.

The importance of an extended lymphadenectomy in the management of high-grade invasive bladder cancer

The role of a regional lymphadenectomy in the surgical management of high-grade invasive bladder cancer has evolved over the last several decades. A growing body of evidence suggests that an extended lymph node dissection may provide, not only improved prognostic information, but also a clinically significant therapeutic benefit for both lymph node-positive and -negative patients undergoing radical cystectomy. The extent of the primary bladder tumor, number of lymph nodes removed and the lymph node tumor burden are important prognostic variables in patients undergoing cystectomy. In addition, the concept of lymph node density may further improve stratification of lymph node-positive patients. The historical development and contemporary rationale for an extended pelvic lymphadenectomy in patients undergoing radical cystectomy are reviewed.

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.

Pattern of lymph node metastasis correlates with tumor location in bladder cancer

Purpose

Resection of a large number of lymph nodes (LNs) increases survival in patients with LN-positive disease; however, morbidity also increases. Here, we investigated the correlation between tumor location and LN metastasis in bladder cancer.

Materials and Methods

Thirty-six patients with pathological N1 or higher bladder cancer, who underwent radical cystectomy with extended lymphadenectomy, were reviewed retrospectively. The tumor location was classified as right, left, front, posterior, or whole bladder. The LN metastasis pattern was classified as right, left, or bilateral. The correlation between tumor location and LN metastasis was determined by chi-square test. Survival rates were compared by Kaplan-Meier analysis.

Results

The numbers of patients with a tumor on the right (group 1), left (group 2), posterior (group 3), or whole (group 4) bladder were 16 (44.4%), 16 (44.4%), 2 (5.6%), and 2 (5.6%), respectively. In group 1, 14 patients (87.5%) had right-sided ipsilateral LNs, and 2 patients (12.5%) had left-sided contralateral LNs. In group 2, 4 patients (25%) had right-sided contralateral LNs, and 12 patients (75%) had left-sided ipsilateral LNs. In group 3, both patients (100%) had right-sided posterior LNs. In group 4, both patients (100%) had positive LNs on both sides. Tumor location and LN metastasis were significantly correlated (p<0.05). Moreover, the survival rate was significantly higher in patients with no LN metastasis than in patients with ipsilateral or contralateral LN-positive bladder cancer.

Conclusions

The location of the bladder tumor and direction of metastatic spread were significantly correlated. Mandatory bilateral lymphadenectomy during radical cystectomy should be questioned.

Does extended lymphadenectomy preclude laparoscopic or robot-assisted radical cystectomy in advanced bladder cancer?

PURPOSE OF REVIEW

Open radical cystectomy with an appropriate bilateral lymph node dissection (LND) is currently the standard treatment for patients with muscle-invasive bladder cancer. Approximately 25% of patients with stages T1-T4 N0 M0 harbour metastatic lymph nodes at the time of radical cystectomy. Results from open high volume radical cystectomy series suggest that a more extended LND provides the best survival outcomes and the lowest local recurrence rates. Currently, there is controversy whether laparoscopic or robot-assisted extended LND at radical cystectomy is technically feasible and whether it can provide oncological control equivalent to open LND series at the time of radical cystectomy.

RECENT FINDINGS

Laparoscopic LND is technically demanding and requires prolonged operation time. Most studies to date indicate that fewer nodes are removed than with an open approach, putting a question mark to this surgical approach from an oncological point of view. Limited data on lymph node yield using a robot-assisted approach are available; however, several series found similar results as in open series.

SUMMARY

At present, there is no conclusive evidence showing that laparoscopic LND gives similar results than open LND. Robot-assisted LND is still in its learning curve and more patient series are needed.

Prospective study of [18F]fluorodeoxyglucose positron emission tomography/computed tomography for staging of muscle-invasive bladder carcinoma

PURPOSE

Novel imaging modalities are needed to detect occult metastatic disease in bladder carcinoma. Patients with regional lymphatic spread could be targeted for neoadjuvant chemotherapy, and patients with distant metastatic disease could be spared the unnecessary morbidity of radical cystectomy. Herein, we report a prospective study of positron emission tomography/computed tomography (PET/CT) with [(18)F]fluorodeoxyglucose (FDG) in patients undergoing radical cystectomy for cT2-3N0M0 urothelial carcinoma of the bladder.

METHODS

Forty-three chemotherapy-naïve patients underwent FDG-PET/CT before planned cystectomy. All had negative conventional CT and bone scintigraphy before enrollment. Positive FDG-PET/CT was confirmed by percutaneous biopsy or open surgical exploration, whereas negative FDG-PET/CT was confirmed by complete lymphadenectomy. Recurrence-free survival (RFS), disease-specific survival (DSS), and overall survival (OS) were described using the Kaplan-Meier method and compared using log-rank test.

RESULTS

Median follow-up was 14.9 months (range, 0.4 to 46.1 months). One patient who did not undergo lymphadenectomy was excluded from the pathology data analysis (n = 42), whereas another patient who failed to return for follow-up was excluded from survival analysis (n = 42). FDG-PET/CT demonstrated a positive predictive value of 78% (seven of nine), a negative predictive value of 91% (30 of 33), sensitivity of 70% (seven of 10), and specificity of 94% (30 of 32). RFS, DSS, and OS were all significantly poorer in the patients with positive FDG-PET/CT than in those with negative FDG-PET/CT.

CONCLUSION

FDG-PET/CT detected occult metastatic disease in seven of 42 patients with negative conventional preoperative evaluations. PET findings were strongly correlated with survival. As such, FDG-PET/CT may help in making treatment decisions before radical cystectomy.

Optimizing the approach for lymph node dissection during laparoscopic radical cystectomy

BACKGROUND

Lymph node dissection (LND) for muscle-invasive bladder cancer is one of the integral steps of radical cystectomy. In addition to staging, adequate LND has been found to alter both the prognosis for and the course of the disease after radical cystectomy.

OBJECTIVE

To point out several essential steps that provide optimal exposure for LND during laparoscopic radical cystectomy for muscle-invasive bladder cancer.

DESIGN, SETTING AND PARTICIPANTS

From August 2006 to September 2008, we performed 10 laparoscopic cystectomies with an extended LND using this approach at our institution. Patient and tumor characteristics, the anatomic extent of the LND, the number of lymph nodes examined, and the postoperative complications encountered were evaluated.

SURGICAL PROCEDURE

Essential steps include (1) a modified five-trocar arrangement; (2) use of a 30 degrees telescope during LND; (3) prior complete mobilization of the sigmoid colon, allowing its retraction using an umbilical tape; (4) accomplishment of most of the bilateral LND from the right side; and (5) performance of LND after removal of the specimen.

MEASUREMENTS

The primary end points were adequate intraoperative exposure of the template and number of lymph nodes retrieved. The secondary end point was evaluation of postoperative lymph node recurrence as an assessment of a complete LND.

RESULTS AND LIMITATIONS

Mean total operative time was 512.5 min (range: 420-660), with a mean operative time of 143 min (range: 115-165) for the extended LND. Adequate exposure was successful in all 10 patients. The average number of lymph nodes examined was 25.5 (range: 19-32), with 4 nodes positive for metastasis. No patients had pelvic or lymph node metastasis at a mean follow-up of 14.8 mo (range: 4-30). Limitations included an analysis of a small series of patients.

CONCLUSIONS

This new approach provides optimal exposure for an adequate laparoscopic LND during radical cystectomy, without any compromise.

Pelvic lymphadenectomy during radical cystectomy: a review of the literature

Currently, radical cystectomy associated with pelvic lymph node dissection is the gold standard surgical treatment for muscle invasive bladder cancer. However, although there is consensus on the need for pelvic lymph node dissection, controversies still exist regarding its extent and exact role. Evidence from the literature is based on retrospective data from high volume, often multicentre studies. Different series report very different templates of lymphadenectomy, thereby complicating data analysis. Furthermore, morbidity related to lymphadenectomy does not seem to be influenced by the extent of the procedure. The role of the pathologist and the modality of node retrieval have a pivotal role in the quality of node assessment. Different prognostic factors regarding node status (number of nodes retrieved, lymphovascular invasion, lymph node density, extracapsular extension, gross node involvement, and extent of primary bladder tumour related to positive nodes) have been introduced and analysed, although the impact on staging and survival are still under investigation. The correct use and assessment of these prognostic factors should help to provide an accurate staging in order to identify those patients who need adjuvant therapy. Future studies should, therefore, be prospective and include all information achievable from a lymphadenectomy.

The association between extent of lymphadenectomy and survival among patients with lymph node metastases undergoing radical cystectomy

BACKGROUND

Long-term survival in patients with lymph node-positive bladder cancer who undergo cystectomy suggests a therapeutic role for lymphadenectomy. The objective of this study was to describe the association between extent of lymphadenectomy and survival in lymph node-positive patients who underwent radical cystectomy.

METHODS

The cohort consisted of patients from the Surveillance, Epidemiology, and End Results registry with transitional cell carcinoma who underwent cystectomy with lymphadenectomy and had at least 1 positive lymph node and no distant metastases. The Kaplan-Meier method and multivariate Cox proportional-hazards regression analyses were used to estimate differences in survival among different lymphadenectomy variables.

RESULTS

In total, 1260 patients had at least 1 positive lymph node. A median of 9 lymph nodes were removed (range, 1-48 lymph nodes) with a median of 2 positive lymph nodes (range, 1-18 positive lymph nodes), and the median lymph node density was 22%. In multivariate analysis controlling for patient demographics, tumor classification, and year of diagnosis, the number of positive and total lymph nodes removed remained independent predictors of survival. There was an inverse association between the number of lymph nodes removed and the risk of death for all quartiles. Removal of > 10 lymph nodes was associated with increased overall survival (hazard ratio, 0.52; 95% confidence interval, 0.43-0.64). In addition, with a lymph node density from 0.1% to 12.5% as the referent group, each higher quartile experienced worse survival.

CONCLUSIONS

An increased number of lymph nodes removed at the time of cystectomy was associated with improved survival in patients with lymph node-positive bladder cancer. Improved survival was observed at a lower lymph node density threshold than previously reported. The current findings support performing a more extensive lymphadenectomy at the time of cystectomy.

Lymphadenectomy in bladder cancer: a review

BACKGROUND

Radical cystectomy is the standard treatment for muscle invasive bladder cancer, however the role and appropriate extent of an associated lymphadenectomy continues to change.

METHODS

We performed a detailed review of the medical literature pertaining to the development and rationale for an extended lymphadenectomy in patients undergoing radical cystectomy.

RESULTS

A perspective of lymphadenectomy and an anatomic account of bladder lymphatic drainage are presented. The technique of an extended lymphadenectomy is also highlighted. Autoptic contemporary clinical data are presented to suggest that a more extensive lymphadenectomy has both prognostic and therapeutic utility. Furthermore, the stage of the primary bladder tumor, total number of lymph nodes removed, and the lymph node tumor burden are shown to be important prognostic variables in patients undergoing cystectomy with pathologic evidence of lymph node metastasis.

CONCLUSIONS

Radical cystectomy provides excellent local cancer control with the Lowe's pelvic recurrence rates and the best long-term survival. Radical cystectomy with an appropriate extended lymphadenectomy, while surgically more challenging, does not significantly increase the morbidity or mortality of the procedure. The limits of lymph node dissection are still subject to debate and there is growing evidence that an extended lymphadenectomy provides further diagnostic and therapeutic benefit.

Radical cystectomy and extended pelvic lymphadenectomy: survival of patients with lymph node metastasis above the bifurcation of the common iliac vessels treated with surgery only

PURPOSE

We assessed the clinical outcome in patients with invasive bladder cancer and lymph node metastasis above the bifurcation of the common iliac vessels treated with radical cystectomy including extended pelvic lymph node dissection without adjunct therapy.

MATERIALS AND METHODS

Between 1993 and June 2005 a total of 336 consecutive patients underwent radical cystectomy and extended pelvic lymphadenectomy without preoperative or postoperative chemotherapy by 1 surgeon. A total of 263 patients (78.3%) had orthotopic bladder reconstruction. The pelvic lymph node dissection began at the distal aorta including the common and external iliac lymph nodes, and the periaortic, presacral and obturator fossa nodes. The lymphatic tissue removed above and below the bifurcation of the common iliac vessels was submitted separately for histopathological analysis. Data were prospectively entered into a database that forms the basis of this cohort study.

RESULTS

The 5-year overall and recurrence-free survival rates in the entire study population of 336 patients were 68% and 69%, respectively. Overall 64 patients (19%) had lymph node metastases of whom 22 (34.4%) had lymph node involvement above the bifurcation of the common iliac vessels outside the template of the standard lymph node dissection. The median number of retrieved lymph nodes was 27 (range 7 to 78) and in those with lymph node metastases 27 (range 11 to 49) included 8 (range 0 to 17) above the bifurcation and 18 (range 8 to 41) below the bifurcation of the common iliac vessels in the true pelvis. Lymph node involvement proved a significant adverse prognostic factor with a 5-year probability of survival of 39% vs 76%. The overall 5-year survival rates was similar in patients with lymph node involvement above the bifurcation of the common iliac vessels (37%) compared to the entire population with lymph node metastasis (41%) and to those with lymphatic metastases in the true pelvis below the bifurcation of the common iliac vessels (42%). The survival rate was significantly higher in patients with 5 or less involved lymph nodes (50% vs 13%, p <0.002) and in those with a lymph node density (number of lymph nodes involved/total number of lymph nodes removed) less than 20% (25% vs 47%, p <0.05), but it did not relate to the total number of retrieved lymph nodes.

CONCLUSIONS

Overall 34% of our patients with lymph node metastases had nodal involvement in the common iliac, periaortic and presacral regions after radical cystectomy for bladder cancer. Survival was similar in this group of patients with lymphatic metastasis outside the boundaries of the standard pelvic lymph node dissection template compared to the entire population with lymph node metastasis. This finding underscores the contention that extended dissection not only provides the most accurate staging but also offers the patient the best chance of survival. Following radical cystectomy patients can be stratified into risk groups according to tumor stage, lymph node involvement, number of metastatic nodes and lymph node density. Our results support the idea that the benchmark for radical cystectomy should include extensive pelvic lymph node dissection with anatomical boundaries including the common iliac and presacral nodes.

Radical cystectomy and lymphadenectomy for invasive bladder cancer: towards the evolution of an optimal surgical standard

The surgical management of invasive bladder cancer has undergone a significant evolution in technique since its initial introduction. Changes in the extent of surgery have largely reflected a better understanding of the natural history of bladder cancer and the recognized pathways of progression. Incorporation of contemporary surgical techniques that target the perivesical soft tissues, regional lymph nodes, and adjacent organs appear to enhance oncologic outcomes. A growing body of evidence indicates that the quality of radical cystectomy (RC) directly affects patient outcome. Recently, quality of life and functional considerations have led to surgical modifications such as nerve-, prostate-, vaginal wall-, and urethra-sparing approaches. While some modifications in appropriate candidates appear not to decrease cancer control, further studies will be needed to establish their role and safety. This ongoing evolution in the technique of RC and pelvic lymph node dissection (PLND) may help define a new surgical standard that provides optimal benefit in patients with invasive bladder cancer.

RADICAL CYSTECTOMY FOR PRIMARY BLADDER MALIGNANCY: A 10 YEAR REVIEW

BACKGROUND

Radical cystectomy is universally accepted as the definitive treatment for muscle invasive bladder cancer and preventing stage progression in high-risk groups. There are few recent reviews outside of major international centres. We compared our institution's results with published literature.

METHODS

Records of 50 consecutive patients treated with radical cystectomy for biopsy-proven bladder carcinoma between 1995 and 2005 were reviewed.

RESULTS

The mean age was 70 years and 76% were male. Median follow up was 38 months (1-111 months). Twenty-three patients (46%) had known history of superficial transitional cell carcinoma and 12 patients (24%) had undergone previously intravesical therapy. Transitional cell carcinomas accounted for 94% of cases and most (76%) were poorly differentiated. Twenty-four (48%) had disease at pT3 stage or higher. Regional lymph nodes were involved in 35%. Twenty-three patients (46%) developed recurrence and over half (12 patients) recurred within 12 months. Both lymph node involvement and recurrence were associated with higher pT stage (P < 0.001). All patients with recurrent disease were dead within a year (median 103 days). Median hospital stay was 19 days and there was one postoperative death (2%). Five-year disease-free and overall survival were 42 and 34% respectively.

CONCLUSION

Survival following curative resection for primary bladder malignancy is at best modest. Our overall proportion of higher stage disease contributed to earlier recurrence and lower survival rates. Our postoperative morbidity and mortality rates as well as length of stay are acceptable compared with major international units.

The prognostic and staging value of lymph node dissection in the treatment of invasive bladder cancer

Regional lymph node dissection (LND) at the time of radical cystectomy is an essential component of the surgical management of invasive bladder cancer and might provide diagnostic and therapeutic benefits for both node-negative and node-positive patients. The benefits obtained in pathologically node-negative patients might result from more complete resection of undetected micrometastases or from a more meticulous surgical technique. Advanced nodal disease also seems to be amenable to thorough surgical resection in a subpopulation of patients with bladder cancer. Despite the growing body of evidence to support the role of a more extended LND, no guidelines regarding the optimal boundaries of LND have been established. An increased number of resected nodes and wider LND boundaries have been associated with improved local disease control and prolonged survival. Additionally, mapping series indicate that the common iliac and presacral nodal regions are more frequently involved with tumor metastases than previously recognized. Efforts to limit any unnecessary dissection in patients at low risk for metastases--a tailored approach--has been proposed, but remains unproven. From the available evidence, the most reliable diagnostic and therapeutic approach to LND includes the routine extended LND in all patients undergoing cystectomy with curative intent.

Relevance of extracapsular extension of pelvic lymph node metastasis in patients with bladder cancer treated in the contemporary era

BACKGROUND

Previous reports have suggested that extracapsular extension (ECE) is a prognostic factor in patients with urothelial carcinoma who have positive lymph nodes at the time of radical cystectomy. In the current study, the relevance of ECE in patients treated in the contemporary era was evaluated.

METHODS

A database search from 1993 to 2003 revealed 150 patients with pN+M0 disease detected after radical cystectomy; of these, 108 patients did not receive neoadjuvant chemotherapy and form the basis of the current report. Overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) data were analyzed by the Kaplan-Meier method, with log-rank tests used to evaluate associations between survival and variables studied.

RESULTS

Five-year OS, DSS, and RFS rates were 30.9%, 45.5%, and 29.7%, respectively. Adjuvant chemotherapy was administered to 70% of patients. On multivariate analysis, adjuvant chemotherapy was significantly associated with prolonged OS, DSS, and RFS (P </= .01). For patients overall and when stratified by pN status, the presence of ECE of lymph node metastasis was not found to be significantly associated with OS (P = .52), DSS (P = .43), or RFS (P = .83). CONCLUSIONS.: The current study suggests that ECE is not an independent prognostic factor in a contemporary series of patients with positive lymph nodes at radical cystectomy. This might be reflective of a paradigm shift that encompasses the adoption of multimodal therapy.

A fourteen-year review of radical cystectomy for transitional cell carcinoma demonstrating the usefulness of the concept of lymph node density

OBJECTIVE

We studied the long-term outcome of radical cystectomy for transitional cell carcinoma and evaluated prognostic factors for disease specific survival.

MATERIALS AND METHODS

A retrospective review was carried out for all cystectomies performed for transitional cell carcinoma between 1989 and 2002. Disease specific survival was correlated to patient, pathological and operative factors as well as to adjuvant therapy.

RESULTS

Of the 133 cystectomies included, 100 were male and 33 were female patients. The median age was 69 years (range 43 to 86). The median follow up was 20 months (range 0 to 158). With univariate analysis, pT stage, N stage, lymph node density, carcinoma in-situ, surgical margin and post-operative radiotherapy to distant metastasis were predictive of disease specific survival. On the other hand, with multivariate analysis, only pT stage, lymph node density and post-operative radiotherapy to distant metastasis were predictive of disease specific survival. Within the group of node positive disease, lymph node density also predicted disease specific survival with both univariate and multivariate analyses. Patients with lymph node density 20% or below showed better disease specific survival.

CONCLUSIONS

pT stage and lymph node density were found to be the most important predictive factors for disease specific survival after cystectomy in the Asian population.

Evaluation of the relevance of lymph node density in a contemporary series of patients undergoing radical cystectomy

PURPOSE

Lymph node density, that is the ratio of positive nodes to the total number of nodes excised, has been suggested to better stratify patients with bladder cancer who have nodal metastasis. We evaluated its relevance in a contemporary series of patients treated with radical cystectomy and in the context of adjuvant chemotherapy.

MATERIALS AND METHODS

From 1993 to 2003, 150 patients had pN+M0 disease at cystectomy, of whom 108 who did not receive neoadjuvant chemotherapy form the basis of this report. Statistical analyses were performed using standard methodology.

RESULTS

Five-year overall, disease specific and recurrence-free survival rates were 30.9%, 45.5% and 29.7%, respectively. The median number of lymph nodes removed was 12 and the median number of positive nodes was 2. Of the patients 70% received adjuvant chemotherapy. Patients with a lymph node density of 25% or less had 5-year overall and recurrence-free survival rates of 37.3% and 38.1% compared with 18.7% and 10.6%, respectively in those with a lymph node density of greater than 25% (p = 0.02). In the context of adjuvant chemotherapy, which was associated with prolonged overall, disease specific and recurrence-free survival (p < or =0.01), lymph node density still remained prognostic for recurrence-free survival (HR 1.69, p = 0.047). The total number of nodes removed and the number of positive nodes were not prognostic.

CONCLUSIONS

Our results support the relevance of lymph node density in a contemporary series of patients with bladder cancer treated with radical cystectomy. Lymph node density remains a significant prognostic factor for recurrence-free survival even when adjuvant chemotherapy is used.

Lymphadenectomy in bladder cancer: How high is “high enough”?

PURPOSE

The role of a regional lymphadenectomy in the surgical treatment of high-grade, invasive transitional cell carcinoma of the bladder has evolved over the last several decades. Although the application of a lymphadenectomy for bladder cancer is not significantly debated, the absolute extent or level of proximal dissection of the lymphadenectomy remains a controversial issue.

MATERIAL AND METHODS

A review of the literature should help elucidate the rationale and extent of an appropriate lymphadenectomy in patients undergoing radical cystectomy for bladder cancer. Various surgical issues of lymphadenectomy as well as prognostic factors in patients undergoing radical cystectomy for bladder cancer are examined.

RESULTS

A growing body of evidence, spanning from early autopsy and cadaveric studies to recent retrospective series and multicenter prospective trials, suggests that an extended lymph node dissection (cephalad extent to include the common iliac arteries) may provide not only prognostic information but also provide a therapeutic benefit for both patients with lymph node-positive and lymph node-negative disease undergoing radical cystectomy for bladder cancer. Although the absolute boundaries of the lymphadenectomy remain a subject of controversy, historical reports confirmed by recent lymphatic mapping studies suggest the inclusion of the common iliac as well as possibly presacral nodes in the routine lymphadenectomy for transitional cell carcinoma of the bladder. The need to extend the dissection higher to include the distal para-aortic and paracaval lymph nodes may be important in select individuals but remains more controversial. The extent of the primary bladder tumor (p-stage), number of lymph nodes removed, the lymph node tumor burden (tumor volume), and lymph node density (number of lymph nodes involved/number of lymph nodes removed) are all important prognostic variables in patients undergoing cystectomy with pathologic evidence of lymph node metastases. Systemic adjuvant chemotherapy remains a mainstay of treatment of patients with lymph node metastases.

CONCLUSIONS

Radical cystectomy with an appropriately performed lymphadenectomy provides the best survival outcomes and lowest local recurrence rates. Although the absolute limits of the lymph node dissection remain to be determined, evidence supports a more extended lymphadenectomy to include the common iliac vessels and presacral lymph nodes at cystectomy in patients who are appropriate surgical candidates. When feasible, adjuvant chemotherapy is warranted in patients with positive nodal metastasis.

Current status of establishing standards for lymphadenectomy in the treatment of bladder cancer

PURPOSE

Pelvic lymph node dissection at the time of radical cystectomy is a crucial component of the surgical management of invasive bladder cancer. No established therapeutic or diagnostic guidelines regarding pelvic lymph node dissection are, however, currently available. We reviewed the past and contemporary literature to clarify the current role of pelvic lymph node dissection both as a staging modality as well as potential therapeutic intervention.

RECENT FINDINGS

The role of pelvic lymph node dissection has evolved over the past 60 years. Although the added benefits of radical cystectomy over simple cystectomy alone are accepted, an optimal template for pelvic lymph node dissection has not been established. Increasing evidence suggesting therapeutic and diagnostic benefits by extending the boundaries of lymphadenectomy or by increasing the number of nodes excised has been reported. Much of the recent literature, however, is based on retrospective studies, and is influenced by factors such as node count variability, inconsistencies in the quality of the surgery, and the biases in patient selection. Currently, the optimal boundaries of pelvic lymph node dissection and the minimum number of nodes to be pathologically examined remain undetermined.

SUMMARY

The diagnostic and therapeutic benefits obtained by extending the limits of lymphadenectomy are compelling but inconclusive. Establishing standards for pelvic lymph node dissection will not only increase the consistency of staging and improve the design and interpretation of clinical trials in invasive bladder cancer but also help to identify and optimize the therapeutic benefits of lymphadenectomy. Prospective, randomized trials will be needed to properly establish the extent of lymphadenectomy required to obtain such benefits.

A prognostic index (bladder prognostic index) for bilharzial-related invasive bladder cancer

PURPOSE

Bladder cancer is still the most common solid tumor among adult males in Egypt because of the prevalence of bilharzial infestation, especially in the countryside. In this prospective study, we have recorded the prognostic factors for 180 patients with invasive bladder cancer for whom standard radical cystectomy had been performed to develop a prognostic index (bladder prognostic index) that defines high risk patients who are more vulnerable to disease relapse after surgery and who may benefit from additional therapy.

PATIENTS AND METHODS

The study was performed between January 1997 and December 1999, in which 180 patients with histopathologically proved invasive bladder cancer associated with bilharziasis underwent radical cystectomy or anterior pelvic exenteration. After surgery, patients were regularly followed for a minimum of 2 years.

RESULTS

Our patients included 141 males and 39 females. Squamous cell carcinoma was the most common type (53.3%), and most of the tumors were grade II (61.1%). A total of 173 patients had their tumors operable, while 7 were inoperable. We had 5 (2.8%) operative related mortalities. At 5 years postoperatively, free and overall survival rates for the whole group of patients were 31.44%+/-5.9% and 32.5%+/-6.8%, respectively. Tumor pathologic stage, grade, and nodal affection were the only significant factors with impact on survival (P=0.008, 0.051, and 0.004, respectively). These 3 prognostic indexes were used to design a model to predict an individual patient's risk factor for recurrence. Patients were then assigned to one of the 4 risk groups according to the score achieved in this prognostic index (0=low risk, 1=intermediate risk, and 2 or 3=higher risk). These 4 risk groups had distinctly different rates of disease-free survival, i.e., 91.7%, 53%, 13%, and 7% for low, intermediate, and higher risk groups, respectively.

CONCLUSION

Although this prognostic index appears to be of a significant clinical relevance, it needs to be more validated on a larger number of patients, and it could be a surrogate variable for biologic factors responsible for the heterogeneity of bladder cancer.

The Role of Lymphadenectomy in High-grade Invasive Bladder Cancer

Radical cystectomy with bilateral pelvic iliac lymphadenectomy is a standard treatment for high-grade, invasive bladder cancer. Cystectomy arguably provides the best survival outcomes and the lowest local recurrence rates. Although the extent or absolute limits of the lymph node dissection are unknown and remain to be better defined, an ever-growing body of data supports a more extended lymphadenectomy at the time of cystectomy in all patients who are appropriate surgical candidates. An extended lymph node dissection should include the distal para-aortic and paracaval lymph nodes as well as the pre-sacral nodes, known anatomic sites of lymph node drainage from the bladder and potential sites of lymph node metastases in patients with bladder cancer. An extended dissection may provide a survival advantage in patients with node-positive and node-negative tumors without significantly increasing the morbidity or mortality of the surgery. The extent of the primary bladder tumor (p stage), the number of lymph nodes removed, and the lymph node tumor burden are important prognostic variables in patients undergoing cystectomy with pathologic evidence of lymph node metastases. Lymph node density may become an even more useful prognostic variable in these high-risk, node-positive patients with bladder cancer. This concept simultaneously incorporates the lymph node tumor burden (number of lymph nodes involved) and the number of lymph nodes removed (extent of the lymphadenectomy), improving the stratification of lymph node-positive patients following radical cystectomy. This notion may also be useful in future staging systems. Adjuvant therapies and clinical trials should consider applying these concepts, because they may help reduce bias and incorporate the extent of the lymphadenectomy, which currently is not standardized.

Prognostic implications of extracapsular extension of pelvic lymph node metastases in urothelial carcinoma of the bladder

To determine whether extracapsular extension of pelvic lymph node metastases from urothelial carcinoma of the bladder is of prognostic significance. From a consecutive series of 507 patients with urothelial carcinoma of the bladder preoperatively staged N0M0, 101 of 124 patients with lymph node metastases detected on histologic examination fulfilled the inclusion criteria for this study and were evaluated. All underwent radical cystectomy between 1985 and 2000 with standardized extended bilateral pelvic lymphadenectomy in curative intent and were prospectively followed for recurrence-free (RFS) and overall (OS) survival. Staging was done according to UICC 2002. A total of 2375 lymph nodes were examined. The median number of nodes examined per patient was 22 (range, 10-43). The median number of positive nodes was 2 (range, 1-24). Median RFS and OS were 17 and 21 months (range for both, 1-191), respectively. The 5-year RFS and OS rates were 32% and 30%, respectively. There were 59 patients (58%) with extracapsular extension of lymph node metastases. They had a significantly decreased RFS (median, 12 vs. 60 months, P=0.0003) and OS (median, 16 vs. 60 months, P <0.0001) compared with those with intranodal metastases. There were no significant differences in survival between pN1 and pN2 categories with extracapsular extension of the lymph node metastases (RFS, P=0.70; OS, P=0.65) or those without extension (RFS, P=0.47; OS, P=0.34). On a multivariate analysis, extracapsular extension of lymph node metastases was the strongest negative predictor for RFS. Meticulous lymph node resection and subsequent thorough histologic examination in patients undergoing radical cystectomy for bladder cancer reveals a high incidence of lymph node-positive disease (24%) despite negative preoperative staging. Lymph node metastases with extracapsular extension in pN1 and pN2 stages carry a very poor prognosis. Therefore, this feature should be used to designate a separate pN category in the staging system. The discrimination of pN1/pN2 in the UICC 2002 classification seems to be arbitrary and of no significant prognostic relevance.

Lymph node involvement in patients with bladder cancer treated with radical cystectomy: a patho-anatomical study--a single center experience

PURPOSE

To our knowledge the extent of lymphadenectomy with cystectomy, the number of lymph nodes to be retrieved and the anatomical groups to be dissected are still undetermined. This study was done to clarify these issues.

MATERIALS AND METHODS

A total of 200 patients underwent radical cystectomy and extended lymphadenectomy up to the level of origin of the inferior mesenteric artery. Removed tissues were labeled according to anatomical location and sent separately for pathological evaluation. In each group the number and status of lymph nodes were determined. The number of positive nodes was correlated with the number of retrieved nodes. Cases with a single positive node were identified and the anatomical location was defined.

RESULTS

The mean number of retrieved nodes per patient +/- SE was 50.6 +/- 14.4 and 48 (24%) patients had nodal disease. The mean number of positive nodes per involved case was 8.08 +/- 13.2. There was a weak correlation between the number of positive nodes and the number of harvested nodes. Bilateral disease was noted in 39.6% of cases. Single node involvement was observed in 22 cases, of which all except 1 were in the endopelvic region.

CONCLUSIONS

There is a sentinel region, which is the endopelvic region (that is the internal iliac and obturator groups of lymph nodes). There are no skipped lesions. Negative nodes in the endopelvic region indicate that more proximal dissection is not necessary. Bilateral endopelvic dissection is mandatory.

PROSPECTIVELY PACKAGED LYMPH NODE DISSECTIONS WITH RADICAL CYSTECTOMY: EVALUATION OF NODE COUNT VARIABILITY AND NODE MAPPING

PURPOSE

Accumulating evidence supports the relationship between an increased number of lymph nodes (LNs) reported following radical cystectomy (RC) and overall outcome. We prospectively evaluated RC cases with transitional cell carcinoma of the bladder to determine which factors may contribute to the variability in the number of reported LNs.

MATERIALS AND METHODS

We conducted a prospective evaluation in which 144 patients undergoing RC and pelvic lymph node dissection (PLND) between June 2001 and April 2003 were included. Lymph nodes were processed as individual packets. A standard method of evaluating nodal submissions was used. A mixed statistical model was used with neoadjuvant chemotherapy, node status, pathological stage, bacillus Calmette-Guerin exposure, age and number of days from transurethral resection as the fixed effects. Surgeon and pathologist were treated as random effects.

RESULTS

The extended PLND group had a significantly greater lymph node yield (median 22.5 nodes) compared to standard PLND (median 8), however, no staging advantage was observed in the extended dissection group. Only the type of PLND performed was associated with node yield (p <0.001). Subset analysis of patients with unexpected microscopic nodal involvement revealed that 33% had involvement of the common iliac nodes.

CONCLUSIONS

In our series only the extent of the lymph node dissection was found to influence node yield significantly after radical cystectomy. Additionally, the observed risk of involvement of the common iliac chain in microscopically node positive cases suggests a need to include this region as part of the PLND for bladder cancer for cases without grossly involved LNs.

Nodal involvement in bladder cancer cases treated with radical cystectomy: incidence and prognosis

PURPOSE

We studied the factors that promote the incidence of nodal metastasis and characterized survival predictions in cases treated with radical cystectomy.

MATERIALS AND METHODS

We retrospectively studied 418 bladder cancer cases treated with radical cystectomy and bilateral endopelvic lymphadenectomy. The incidence of nodal involvement was correlated with several patient and tumor characteristics. The number of involved nodes was also correlated with the number of retrieved nodes. Finally, survival in node positive cases was correlated with some select pathological features.

RESULTS

Of the 418 cases nodal involvement was reported in 110 (26.3%). The mean number of harvested nodes per patient +/- SE was 17.9 +/- 6.7. The mean number of positive nodes per involved case was 4.1 +/- 5.4. A weak correlation between the number of retrieved nodes and number of positive nodes was noted (r = 0.4). Tumor pT stage and grade, and lymphovascular invasion were independent factors promoting the incidence of nodal involvement. Three-year disease-free survival in node positive cases was 37.8% +/- 4.8%. Two factors had an independent impact on survival in node positive cases, namely pT stage and the number of positive nodes.

CONCLUSIONS

Tumor pT stage and grade, and lymphovascular invasion independently influence the incidence of lymph node involvement. There was a weak correlation between the number of retrieved nodes and number of positive nodes. The survival probability in pT N+ cases depended on pT stage and the number of involved nodes. A prospective study with anatomical mapping of retrieved nodes is necessary to define the optimal extent of lymphadenectomy with cystectomy.

Clinical outcome of a large-scale multi-institutional retrospective study for locally advanced bladder cancer: a survey including 1131 patients treated during 1990-2000 in Japan

OBJECTIVE

We conducted a multi-institutional analysis to establish the contemporary clinical outcome of invasive bladder cancer treated with radical cystectomy in Japan.

METHODS

A total of 1131 consecutive patients who underwent radical cystectomy for invasive bladder cancer between January 1990 and December 2000 at 32 hospitals were retrospectively analyzed.

RESULTS

Histopathological analysis demonstrated that 1042 patients (92.1%) harbored transitional cell carcinomas (TCCs), whereas 89 patients (7.9%) presented non-TCCs, including squamous cell carcinoma and adenocarcinoma. Pelvic lymphadenectomy was performed in 1013 patients in total, and pathologically confirmed lymph node metastases were found in 162 (16.0%). The overall survival at 5 years was 68.0% and most deaths (79.0%) occurred within 3 years. Multivariate analysis demonstrated that gender, clinical stage, pathological stage, lymph node involvement and lymph node dissection were the independent predictive factors for survival, whereas histological type, sex and grade had no significant impact on survival.

CONCLUSIONS

These clinical results demonstrate that radical cystectomy with lymph node dissection results in good survival for invasive bladder cancer, providing standard data with which other forms of therapy can be compared.

The evolving role of pelvic lymphadenectomy in the treatment of bladder cancer

Regional lymphadenectomy is integral to the surgical management of high-grade invasive bladder cancer. A growing body of evidence suggests that a lymph node dissection may provide not only improved prognostic information, but also a clinically significant therapeutic benefit for both lymph node positive and negative patients undergoing radical cystectomy. While the inclusion of lymph node resection in conjunction with radical cystectomy for patients with clinically negative nodes is well accepted, the extent of the nodal dissection remains highly contentious. Similarly, the benefit of node dissection for patients with advanced disease and gross adenopathy or for those with superficial disease (Ta, T1 or TIS) remains a topic of heated debate. This review describes the historical evolution of lymphadenectomy in the surgical treatment of bladder cancer and provides a comprehensive review of the current literature addressing the role of lymph node dissection in the treatment of bladder cancer.

Extended Radical Lymphadenectomy in Patients With Urothelial Bladder Cancer:: Results of a Prospective Multicenter Study

PURPOSE

Previous studies demonstrate a positive correlation between postoperative survival and the extent of pelvic lymphadenectomies in patients with bladder cancer. However, the distribution of nodal metastases has not been examined in sufficient detail. Therefore, we conducted a comprehensive prospective analysis of lymph node metastases to obtain precise knowledge about the pattern of lymphatic tumor spread.

MATERIALS AND METHODS

Between 1999 and 2002 we performed 290 radical cystectomies and extended lymphadenectomies. Cranial border of the lymphadenectomy was the level of the inferior mesenteric artery, lateral border was the genitofemoral nerve and caudal border was the pelvic floor. We made every effort to excise and examine microscopically all lymph nodes from 12 well-defined anatomical locations.

RESULTS

Mean total number and standard deviation of lymph nodes removed was 43.1 +/- 16.1. Nodal metastases were present in 27.9% of patients. The percentage of metastases at different sites ranged from 14.1% (right obturator nodes) to 2.9% (right paracaval nodes above the aortic bifurcation). By studying cases of unilateral primary tumors or with only 1 metastasis we observed a preferred pattern of metastatic spread. However, there were many exceptions to the rule and we did not identify a well-defined sentinel lymph node.

CONCLUSIONS

We strongly recommend extended radical lymphadenectomy to all patients undergoing radical cystectomy for bladder cancer to remove all metastatic tumor deposits completely. The operation can be conducted in routine clinical practice and our data may serve as a guideline for future standardization and quality control of the procedure.

Nodal Involvement in Bladder Cancer

There are many controversies about the actual meaning of nodal involvement in bladder cancer and, subsequently, about the real benefit of pelvic lymph node dissection (PLND) in patients with positive nodes at the time of cystectomy.

In this article we reviewed the literature about the role of nodal involvement and the impact of positive nodes on the prognosis.

The finding of positive nodes after radical cystectomy and PLND makes generally consider bladder cancer as a systemic disease and it is associated with poor prognosis. Therefore many urologists don't perform radical surgery in patients with positive nodes at time of cystectomy.

P category, N category, and distant metastases are the most important factors in determining the outcome of patients with bladder cancer with nodal involvment. PLND is necessary for accurate staging in bladder cancer and appears to benefit patients with limited nodal involvement.

PLND should be considered as a standard procedure that should be performed in every patient with indication of surgical treatment for TCC of the bladder.

The Prognostic Significance of Metastatic Perivesical Lymph Nodes Identified in Radical Cystectomy Specimens for Transitional Cell Carcinoma of the Bladder

PURPOSE

We determined the prognostic significance of metastatic perivesical lymph nodes (PVLN) in transitional cell carcinoma of the bladder (TCC).

MATERIALS AND METHODS

A retrospective review of 198 consecutive patients who underwent radical cystectomy for clinically organ confined TCC identified 32 patients with PVLN in pathology specimens. Patient characteristics were compared. Overall survival, disease-specific survival (DSS) and disease-free survival were estimated using Kaplan-Meier actuarial methodology. The log-rank test was used to compare the differences between patients with and without metastatic TCC to PVLN. Cox multivariate regression analysis was used to determine whether the effect of metastatic PVLN on survival was independent of pathological stage.

RESULTS

Metastatic TCC was found in the PVLN of 14 patients. Median followup and age were 13.5 months and 66.5 years, respectively. Patients with and without metastatic PVLN had similar characteristics and pathological disease staging. The overall survival, DSS and disease-free survival were significantly less for patients with metastatic TCC in PVLN (p = 0.002, p = 0.013 and p <0.001, respectively), and involvement of PVLN and pelvic nodes (p = 0.001, p = 0.010 and p = 0.041, respectively). Metastatic PVLN was an independent predictor of OS and DSS (p = 0.016 and p = 0.025, respectively).

CONCLUSIONS

Metastases to PVLN appear to confer a significantly worse prognosis for patients undergoing radical cystectomy. Patients with identifiable metastatic PVLN may benefit from early adjuvant therapies.

Transitional cell carcinoma of the urinary bladder with regional lymph node involvement treated by cystectomy: clinicopathologic features associated with outcome

BACKGROUND

Patients with transitional cell carcinoma (TCC) of the urinary bladder metastatic to regional lymph nodes (LN) typically have a poor prognosis. However, some patients are cured by radical cystectomy alone. The goal of this study was to identify predictors of survival in this cohort.

METHODS

The authors identified 154 patients with TCC metastatic to regional LNs treated by cystectomy between 1970 and 1998. Clinical characteristics collected included age, gender, and preoperative computed tomographic or magnetic resonance image scan findings, as well as neoadjuvant and adjuvant therapy. Pathologic features evaluated included multifocality, size, pathologic stage, grade, and margin status of the primary tumor, as well as the number, location, and bilaterality of the positive LNs. Capsular penetration, greatest linear extent, and surface area of the largest metastatic LN deposit were also recorded. The Kaplan-Meier method was used to evaluate survival rates. Cox proportional hazards models were used to identify predictors of outcome.

RESULTS

The mean follow-up was 4.5 years (range, 0.1-13.9 years). In a multivariate setting, only adjuvant chemotherapy and the number of positive LNs were associated significantly with death from TCC. Patients treated adjuvantly with chemotherapy were 2.1 times less likely to die of their disease (P = 0.005). Each increase in one positive LN increased the risk of death from TCC by 20% (P < 0.001). Recursive partitioning indicated that the optimal cutoff point to predict death from TCC was five or more positive LNs.

CONCLUSIONS

Adjuvant chemotherapy and the number of positive LNs were associated significantly with death from TCC.