Impact of the number of lymph nodes retrieved on outcome in patients with muscle invasive bladder cancer

Departments of Urology (Genitourinary Oncology Service), Medicine and Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York, USA.
The Journal of Urology (Impact Factor: 4.47). 04/2002; 167(3):1295-8. DOI: 10.1016/S0022-5347(05)65284-6
Source: PubMed


We postulate that the number of lymph nodes examined in cystectomy specimens can have an impact on the outcome of patients with bladder cancer.
We analyzed data on 322 patients with muscle invasive bladder cancer who underwent radical cystectomy and bilateral pelvic lymphadenectomy. We evaluated the associations of the number of lymph nodes identified by the pathologist in the surgical specimen with the local recurrence rate and survival outcome.
Patients were divided into groups by lymph node status and the distribution of the number of lymph nodes examined. In stages pN0 and pN+ cases improved survival was associated with a greater number of lymph nodes examined. We determined that at least 9 lymph nodes should be studied to define lymph node status accurately.
These results indicate that surgical resection and pathological assessment of an adequate number of lymph nodes in cystectomy specimens increases the likelihood of proper staging and impacts patient outcome. Such information is important not only for the therapy and prognosis of individuals, but also for identifying those who may benefit from adjuvant chemotherapy.

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    • "Without doubt, PLND is performed near to delicate anatomic structures and is time consuming. On the other hand, a meticulous PLND helps to identify pelvic structures, facilitates cystectomy, and offers better vascular control35 without increasing perioperative morbidity.27,36 It is difficult to estimate the impact of surgical education/experience, institutional philosophy, and possible economic considerations (reimbursement) on the extent and thoroughness of PLND. "
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    ABSTRACT: Pelvic lymph node dissection (PLND) in patients with bladder cancer varies widely in extent, technique employed, and pathological workup of specimens. The present paper provides an overview of the existing evidence regarding the effectiveness of PLND and elucidates the interactions between patient, surgeon, pathologist, and treating institution as well as their cumulative impact on the final postoperative lymph node (LN) staging. Bladder cancer patients undergoing radical cystectomy with extended PLND appear to have better oncologic outcomes compared to patients undergoing radical cystectomy and limited PLND. Attempts have been made to define and assess the quality of PLND according to the number of lymph nodes identified. However, lymph node counts depend on multiple factors such as patient characteristics, surgical template, pathological workup, and institutional policies; hence, meticulous PLND within a defined and uniformly applied extended template appears to be a better assurance of quality than absolute lymph node counts. Nevertheless, the prognosis of the patients can be partially predicted with findings from the histopathological evaluation of the PLND specimen, such as the number of positive lymph nodes, extracapsular extension, and size of the largest LN metastases. Therefore, particular prognostic parameters should be addressed within the pathological report to guide the urologist in terms of patient counseling.
    Research and Reports in Urology 08/2013; 5(1):121-128. DOI:10.2147/RRU.S32333
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    • "The metastatic lymph node ratio (LNR) is defined as the ratio of metastatic lymph nodes to the number of total lymph nodes pathologically examined. This figure seems to be superior to the absolute number of metastatic lymph nodes in predicting the prognosis and to be useful in reducing stage migration in types of solid cancers such as cancers of the stomach [8-10], breast [11], bladder [12], pancreas [13], and lung [14]. Many clinical studies on colorectal cancer patients have been performed to investigate the significance of the LNR as a prognostic factor [13, 15-20]. "
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    ABSTRACT: Lymph-node metastasis is the most important predictor of survival in stage III rectal cancer. The number of metastatic lymph nodes may vary depending on the level of specimen dissection and the total number of lymph nodes harvested. The aim of this study was to evaluate whether the lymph node ratio (LNR) is a prognostic parameter for patients with rectal cancer. A retrospective review of a database of rectal cancer patients was performed to determine the effect of the LNR on the disease-free survival (DFS) and the overall survival. Of the total 228 patients with rectal cancer, 55 patients with stage III cancer were eligible for analysis. Survival curves were estimated using the Kaplan-Meier method. Cox regression analyses, after adjustments for potential confounders, were used to evaluate the relationship between the LNR and survival. According to the cutoff point 0.15 (15%), the 2-year DFS was 95.2% among patients with a LNR < 0.15 compared with 67.6% for those with LNR ≥ 0.15 (P = 0.02). In stratified and multivariate analyses adjusted for age, gender, histology and tumor status, a higher LNR was independently associated with worse DFS. This study showed the prognostic significance of ratio-based staging for rectal cancer and may help in developing better staging systems. LNR 0.15 (15%) was shown to be a cutoff point for determining survival and prognosis in rectal cancer cases.
    Annals of Coloproctology 06/2013; 29(3):100-5. DOI:10.3393/ac.2013.29.3.100
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    • "Radical cystectomy is the gold standard for treatment of muscle-invasive bladder cancer and noninvasive bladder cancer refractory to intravesical therapy [1,2]. Despite these improvements of surgical techniques, radical cystectomy remains a high-risk procedure with complication rates ranging from 30% to over 50% [3,4]. "
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    ABSTRACT: To report our technique for and experience with robot-assisted laparoscopic radical cystectomy (RARC) with orthotopic neobladder (ON) formation in a cohort of bladder cancer patients. Between December 2007 and December 2011, a total of 35 patients underwent RARC. The patients' mean age was 63.3 years and their mean body mass index was 23.7 kg/m(2). Thirty patients had a clinical stage of T2 or higher. Postoperative mean follow-up duration was 25.5 months. In 5 patients, a 4-cm midline infraumbilical skin incision was made for an ileal conduit (IC) and the stoma formation was similar to the open procedure. In 30 patients undergoing the ON procedure, the skin for specimen removal and extracorporeal enterocystoplasty was incised infraumbilically in the early 5 cases with redocking (ON-I) and suprapubically in the latter 25 cases without redocking (ON-S). The mean operative times of the IC, ON-I, and ON-S groups were 442.5, 646.0, and 531.3 minutes, respectively (p=0.001). Mean console and lymph node dissection time were not significantly different between the groups. Mean urinary diversion times in each group were 68.8, 125.0, and 118.8 minutes, respectively (p=0.001). In the comparison between the ON-I and ON-S group, only operative time was significant. Four patients required a blood transfusion. We had no cases of intraabdominal organ injury or open conversion. Thiry-three patients (94.2%) had a pathologic stage of T2 or higher. Two patients (5.7%) had lymph node-positive disease. Postoperative complications included ileus (n=4), stricture in the uretero-ileal junction (n=2), and vesicovaginal fistula (n=1). Our robotic neobladder-suprapubic incision without redocking procedure is easier and more rapid than that of infraumbilical incision with redocking.
    Korean journal of urology 11/2012; 53(11):766-73. DOI:10.4111/kju.2012.53.11.766
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