Value of radical cystectomy in bladder cancer with pelvic node involvement

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.

Lymph node metastasis in bladder cancer

OBJECTIVE

We reviewed the literature on nodal staging in patients with bladder cancer treated with radical cystectomy and lymphadenectomy.

RESULTS

Fractionating the lymph node specimen significantly increases the node count, whereas results are contradictory as to whether that increase improves detection of positive nodes. Pathoanatomic data indicate that extending lymph node dissection to the aortic bifurcation improves nodal staging. That approach might be beneficial, especially in cases of T3/T4a tumours, which more often have lymph node metastases above the iliac bifurcation as compared to less advanced tumours. In node-negative patients, extended lymph node dissection probably removes undetected micrometastases and thereby increases disease-free survival. Four studies suggested that a minimum of 8, 10, 10-14, and 16 nodes must be removed, to improve survival, and in another investigation aortic bifurcation was proposed as the upper limit for dissection. Some patients with positive nodes can be cured by surgery alone, even those with gross adenopathy. There is no evidence that extended lymphadenectomy increases surgery-related morbidity. The TNM classification is apparently insufficient for stratifying node-positive patients because several larger cystectomy series could not verify differences in survival between N groups.

CONCLUSIONS

Fractionating the lymphadenectomy specimen increases the lymph node count. In node-negative patients, more meticulous and extended lymph node dissection (8-16 nodes or to the aortic bifurcation) probably improves disease-free survival by removing undetected micrometastases. Patients with positive lymph nodes should also be offered radical cystectomy.

Extent of pelvic lymphadenectomy and its impact on outcome in patients diagnosed with bladder cancer: analysis of data from the Surveillance, Epidemiology and End Results Program data base

PURPOSE

The benefit of pelvic lymphadenectomy in patients with bladder cancer remains controversial. We analyzed the impact of lymphadenectomy on disease specific survival in a population based sample of patients with bladder cancer who underwent radical cystectomy.

MATERIALS AND METHODS

Analysis included data on 1,923 patients who underwent radical cystectomy for bladder cancer between 1988 and 1996 obtained from the Surveillance, Epidemiology and End Results program cancer registry. We analyzed the impact of the number of lymph nodes examined, number of positive lymph nodes and ratio of positive-to-total number of lymph nodes resected on disease specific and overall survival independent of patient age, gender, stage, race, radiation and chemotherapy.

RESULTS

Median followup in cystectomy cases was 63.5 months (range 0 to 131). Patients with 0 to 3 lymph nodes examined were at significantly higher risk of death from bladder cancer than those with greater than 3 (HR 1 to 1.2 versus 0.41 to 0.58). Patients with stages I/in situ, III and IV disease benefited from more extensive lymphadenectomy. In stage IV cases, while the total number of positive lymph nodes removed did not correlate with increased survival, the proportion of excised lymph nodes positive for metastatic bladder cancer tended to correlate with the risk of death from the disease.

CONCLUSIONS

These results indicate significantly increased survival rates after cystectomy in patients with bladder cancer diagnosed with stages III or IV disease who have relatively more lymph nodes examined, suggesting that even some with higher stage disease may benefit from extended pelvic lymphadenectomy at cystectomy.