Effect of a minimum lymph node policy in radical cystectomy and pelvic lymphadenectomy on lymph node yields, lymph node positivity rates, lymph node density, and survivorship in patients with bladder cancer.
ABSTRACT Extended pelvic lymphadenectomy (PLND) during radical cystectomy (RC) reportedly improves bladder cancer-specific survival. Lymph node counts are often a proxy for the extensiveness of a dissection. In the current study, the impact of an institutional policy requiring a minimum number of lymph nodes was assessed.
Patients undergoing RC and PLND for invasive bladder cancer between March 2000 and February 2008 were retrospectively reviewed at the study institution. Beginning March 1, 2004, a policy was established that at least 16 lymph nodes had to be examined. Specimens with <16 lymph nodes were resubmitted (including any fat) to detect additional lymph nodes. Lymph node yields, lymph node positivity, lymph node density (LND), and survivorship before and after policy implementation were compared.
A total of 147 patients underwent surgery 4 years before policy implementation and 202 underwent surgery 4 years after. The median number of lymph nodes increased from 15 to 20. Percentage of cases with >or=16 lymph nodes increased from 42.9% to 69.3% (P <.01). The lymph node positivity rates did not change significantly, but the proportion of patients with LND <20% increased from 43.9% to 65.5% (P = .04). Overall survival increased from 41.5% to 72.3% (P <.01). Univariate and multivariate regression demonstrated that policy implementation, and subsequent increase in median lymph node yield, decreased mortality risk by 30% (hazards ratio [HR], 0.70; P = .04) and 48% (HR, 0.52; P = .01), respectively.
Thorough evaluation of PLND specimens obtained at RC can be influenced by an institutional policy mandating a minimum number of lymph nodes. This could lead to greater confidence in pathologic staging and reliability of LND as a predictor of prognosis. Survival can improve due to increased awareness to perform a more thorough PLND.
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ABSTRACT: ● To analyze the long term outcome of lymph node (LN) positive bladder cancer patients following radical cystectomy (RC) and extended pelvic lymph node dissection (ePLND) who did not receive any adjuvant therapy PATIENTS AND METHODS: ● Retrospective, combined cohort analysis based on the two prospectively maintained cystectomy databases from the University of Southern California and the University of Bern ● Eligible patients underwent RC with ePLND for cN0M0 disease but turned out to be LN-positive ● None had neo-adjuvant therapy, all negative surgical margins ● Kaplan-Meier plots were used to estimate recurrence-free (RFS) and overall survival (OS), subgroup comparisons were performed with Log-rank tests, and multivariable analysis based on Cox proportional hazard models RESULTS: ● Of 521 LN-positive patients, 251 (48%) never received adjuvant therapy ● While pathological stage distribution was comparable, they were older and had both fewer total and positive LNs identified compared to those who underwent adjuvant therapy ● Median RFS for patients with surgery alone was 1.6y ● Recurrences mainly occurred within 2 years following RC resulting in 5- and 10-year RFS rates of 32% and 26%, respectively ● Pathological T-stage, total number of LNs and number of positive LNs identified were independent predictors of survival for RFS and OS CONCLUSIONS: ● 25% of patients with documented LN metastases not receiving adjuvant therapy were cured with RC and ePLND ● However, a few relapses may occur also later than three years ● redictors of survival are pathological T-stage, number of total LNs, and number of positive LNs identified.BJU International 10/2013; · 3.05 Impact Factor
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ABSTRACT: The presence of lymphatic metastasis is associated with markedly worse prognosis in patients with bladder cancer, although surgical resection and chemotherapy can still provide long-term survival for selected patients. The prognostic stratification of patients with positive lymph nodes has been broadly discussed in the current literature and a more extensive pelvic lymph node dissection and thorough pathologic assessment has been advocated. It is clear that stratification using the tumor node metastasis staging system is insufficient to adequately discriminate prognosis between patients with different lymph node involvement. Lymph node density and extranodal extension have been extensively investigated and appear to influence the prognosis of these patients. Molecular markers have been developed to improve the diagnosis of micrometastatic disease, and new targeted therapies have shown promising preclinical results and are now being tested in different clinical scenarios.Expert Review of Anti-infective Therapy 10/2013; · 2.07 Impact Factor
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ABSTRACT: ● To compare extended versus non-extended PLND and their influence on recurrence-free survival (RFS) in patient undergoing radical cystectomy for bladder cancer. ● Through a comprehensive searching of PubMed, Embase, and the Cochrane Library databases in September 2012, we performed a systematic review and cumulative meta-analysis of all comparative studies assessing the extent of PLND and its influence on RFS. ● Six studies including 2824 patients were identified. ● On overall analysis, a significantly better RFS was observed in extended PLND (e-PLND) compared with non e-PLND (HR: 0.65; p ＜0.001). ● On subgroup analysis, compared with non e-PLND, e-PLND was associated with better RFS for both lymph node negative (LN-) (HR: 0.68; p = 0.007) and positive (LN+) (HR: 0.58; p＜0.001) patients. When stratified by pathologic T stage, e-PLND could provide additional RFS benefits for pT3-4 patients (HR: 0.61; p＜0.001), but not for ≤pT2 patients (HR: 0.95; p = 0.81). ● The results of this meta-analysis indicate that e-PLND provides more RFS benefit compared with non e-PLND. On subgroup analysis, e-PLND provides better RFS for not only LN+ patients, pT3-4 patients, but also LN- patients. ● Two RCTs are awaited to provide more clinically meaningful results for this topic.BJU International 07/2013; · 3.05 Impact Factor