Korean J Urol.  2015 May;56(5):357-364. 10.4111/kju.2015.56.5.357.

Does skip metastasis or other lymph node parameters have additional effects on survival of patients undergoing radical cystectomy for bladder cancer?

• Ugurlu O
• Baltaci S
• Aslan G
• Can C
• Cal C
• Elhan A
• Turkeri L
• Mungan A

• KMID: 2155315
• DOI: http://doi.org/10.4111/kju.2015.56.5.357

Abstract

PURPOSE
To investigate the effects of lymph node metastasis, skip metastasis, and other factors related to lymph node status on survival in patients who underwent radical cystectomy (RC) and extended lymph node dissection (eLND).
MATERIALS AND METHODS
RC and eLND were performed in 85 patients with a diagnosis of bladder cancer. Disease-free survival (DFS) and overall survival (OS) were determined by using a Cox proportional hazards model that included the number of excised lymph nodes, the presence of pathological lymph node metastasis, the anatomical level of positive nodes, the number of positive lymph nodes, lymph node density, and the presence of skip metastasis.
RESULTS
The mean number of lymph nodes removed per patient was 29.4+/-9.3. Lymph node positivity was detected in 85 patients (34.1%). The mean follow-up duration was 44.9+/-27.4 months (2-93 months). Five-year estimated OS and DFS for the 85 patients were 62.6% and 57%, respectively. Three of 29 lymph node-positive patients (10.3%) had skip metastasis. Only lymph node positivity had a significant effect on 5-year OS and DFS (p<0.001). No difference in OS and DFS was found between the three patients with skip metastasis and other lymph node-positive patients. Other factors related to lymph node status had no significant effect on 5-year OS and DFS.
CONCLUSIONS
No factors related to lymph node status predict DFS and OS, except for lymph node positivity. OS and DFS were comparable between patients with skip metastasis and other lymph node-positive patients.

Keyword

Lymph node excision; Treatment outcome; Urinary bladder neoplasms

MeSH Terms

Adult
Aged
Cystectomy
Female
Humans
Lymph Node Excision
Lymph Nodes/*pathology
Lymphatic Metastasis
Male
Middle Aged
Prognosis
Survival Analysis
Treatment Outcome
Urinary Bladder/*pathology
Urinary Bladder Neoplasms/*pathology/*surgery

Figure

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  Fig. 1 Anatomical regions of extended lymphadenectomy.

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  Fig. 2 Lymphadenectomy levels.

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  Fig. 3 Overall survival of patients with and without lymph node positivity.

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  Fig. 4 Disease-free survival of patients with and without lymph node positivity.

Reference

1. Karl A, Carroll PR, Gschwend JE, Knuchel R, Montorsi F, Stief CG, et al. The impact of lymphadenectomy and lymph node metastasis on the outcomes of radical cystectomy for bladder cancer. Eur Urol. 2009; 55:826–835. PMID: 19150582.

2. Dhar NB, Klein EA, Reuther AM, Thalmann GN, Madersbacher S, Studer UE. Outcome after radical cystectomy with limited or extended pelvic lymph node dissection. J Urol. 2008; 179:873–878. PMID: 18221953.

3. Zehnder P, Studer UE, Skinner EC, Dorin RP, Cai J, Roth B, et al. Super extended versus extended pelvic lymph node dissection in patients undergoing radical cystectomy for bladder cancer: a comparative study. J Urol. 2011; 186:1261–1268. PMID: 21849183.

4. Abol-Enein H, Tilki D, Mosbah A, El-Baz M, Shokeir A, Nabeeh A, et al. Does the extent of lymphadenectomy in radical cystectomy for bladder cancer influence disease-free survival? A prospective single-center study. Eur Urol. 2011; 60:572–577. PMID: 21684070.

5. Herr HW, Bochner BH, Dalbagni G, Donat SM, Reuter VE, Bajorin DF. Impact of the number of lymph nodes retrieved on outcome in patients with muscle invasive bladder cancer. J Urol. 2002; 167:1295–1298. PMID: 11832716.

6. Leissner J, Ghoneim MA, Abol-Enein H, Thuroff JW, Franzaring L, Fisch M, et al. Extended radical lymphadenectomy in patients with urothelial bladder cancer: results of a prospective multicenter study. J Urol. 2004; 171:139–144. PMID: 14665862.

7. Vazina A, Dugi D, Shariat SF, Evans J, Link R, Lerner SP. Stage specific lymph node metastasis mapping in radical cystectomy specimens. J Urol. 2004; 171:1830–1834. PMID: 15076287.

8. Baltaci S, Adsan O, Ugurlu O, Aslan G, Can C, Gunaydin G, et al. Reliability of frozen section examination of obturator lymph nodes and impact on lymph node dissection borders during radical cystectomy: results of a prospective multicentre study by the Turkish Society of Urooncology. BJU Int. 2011; 107:547–553. PMID: 20633004.

9. Stein JP, Lieskovsky G, Cote R, Groshen S, Feng AC, Boyd S, et al. Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1,054 patients. J Clin Oncol. 2001; 19:666–675. PMID: 11157016.

10. Jensen JB, Ulhoi BP, Jensen KM. Evaluation of different lymph node (LN) variables as prognostic markers in patients undergoing radical cystectomy and extended LN dissection to the level of the inferior mesenteric artery. BJU Int. 2012; 109:388–393. PMID: 21851538.

11. Hautmann RE, Gschwend JE, de Petriconi RC, Kron M, Volkmer BG. Cystectomy for transitional cell carcinoma of the bladder: results of a surgery only series in the neobladder era. J Urol. 2006; 176:486–492. PMID: 16813874.

12. Bassi P, Ferrante GD, Piazza N, Spinadin R, Carando R, Pappagallo G, et al. Prognostic factors of outcome after radical cystectomy for bladder cancer: a retrospective study of a homogeneous patient cohort. J Urol. 1999; 161:1494–1497. PMID: 10210380.

13. Zehnder P, Studer UE, Daneshmand S, Birkhauser FD, Skinner EC, Roth B, et al. Outcomes of radical cystectomy with extended lymphadenectomy alone in patients with lymph node-positive bladder cancer who are unfit for or who decline adjuvant chemotherapy. BJU Int. 2014; 113:554–560. PMID: 24131453.

14. Svatek R, Zehnder P. Role and extent of lymphadenectomy during radical cystectomy for invasive bladder cancer. Curr Urol Rep. 2012; 13:115–121. PMID: 22328190.

15. Jensen JB, Ulhoi BP, Jensen KM. Lymph node mapping in patients with bladder cancer undergoing radical cystectomy and lymph node dissection to the level of the inferior mesenteric artery. BJU Int. 2010; 106:199–205. PMID: 20002670.

16. Steven K, Poulsen AL. 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. J Urol. 2007; 178(4 Pt 1):1218–1223. PMID: 17698113.

17. Herr HW, Donat SM. Outcome of patients with grossly node positive bladder cancer after pelvic lymph node dissection and radical cystectomy. J Urol. 2001; 165:62–64. PMID: 11125364.

18. Zehnder P, Studer UE, Skinner EC, Thalmann GN, Miranda G, Roth B, et al. Unaltered oncological outcomes of radical cystectomy with extended lymphadenectomy over three decades. BJU Int. 2013; 112:E51–E58. PMID: 23795798.

19. Madersbacher S, Hochreiter W, Burkhard F, Thalmann GN, Danuser H, Markwalder R, et al. Radical cystectomy for bladder cancer today--a homogeneous series without neoadjuvant therapy. J Clin Oncol. 2003; 21:690–696. PMID: 12586807.

20. Fleischmann A, Thalmann GN, Markwalder R, Studer UE. Extracapsular extension of pelvic lymph node metastases from urothelial carcinoma of the bladder is an independent prognostic factor. J Clin Oncol. 2005; 23:2358–2365. PMID: 15800327.

21. Leissner J, Hohenfellner R, Thuroff JW, Wolf HK. Lymphadenectomy in patients with transitional cell carcinoma of the urinary bladder; significance for staging and prognosis. BJU Int. 2000; 85:817–823. PMID: 10792159.

22. Dorin RP, Daneshmand S, Eisenberg MS, Chandrasoma S, Cai J, Miranda G, et al. Lymph node dissection technique is more important than lymph node count in identifying nodal metastases in radical cystectomy patients: a comparative mapping study. Eur Urol. 2011; 60:946–952. PMID: 21802833.

23. Davies JD, Simons CM, Ruhotina N, Barocas DA, Clark PE, Morgan TM. Anatomic basis for lymph node counts as measure of lymph node dissection extent: a cadaveric study. Urology. 2013; 81:358–363. PMID: 23374802.

24. Herr HW. The concept of lymph node density--is it ready for clinical practice? J Urol. 2007; 177:1273–1275. PMID: 17382708.

25. Herr HW. Superiority of ratio based lymph node staging for bladder cancer. J Urol. 2003; 169:943–945. PMID: 12576818.

26. Kassouf W, Agarwal PK, Herr HW, Munsell MF, Spiess PE, Brown GA, et al. Lymph node density is superior to TNM nodal status in predicting disease-specific survival after radical cystectomy for bladder cancer: analysis of pooled data from MDACC and MSKCC. J Clin Oncol. 2008; 26:121–126. PMID: 18165646.

27. Wiesner C, Salzer A, Thomas C, Gellermann-Schultes C, Gillitzer R, Hampel C, et al. Cancer-specific survival after radical cystectomy and standardized extended lymphadenectomy for node-positive bladder cancer: prediction by lymph node positivity and density. BJU Int. 2009; 104:331–335. PMID: 19220265.

28. May M, Herrmann E, Bolenz C, Tiemann A, Brookman-May S, Fritsche HM, et al. Lymph node density affects cancer-specific survival in patients with lymph node-positive urothelial bladder cancer following radical cystectomy. Eur Urol. 2011; 59:712–718. PMID: 21296488.

29. Abol-Enein H, El-Baz M, Abd El-Hameed MA, Abdel-Latif M, Ghoneim MA. Lymph node involvement in patients with bladder cancer treated with radical cystectomy: a patho-anatomical study--a single center experience. J Urol. 2004; 172(5 Pt 1):1818–1821. PMID: 15540728.

30. Mills RD, Turner WH, Fleischmann A, Markwalder R, Thalmann GN, Studer UE. Pelvic lymph node metastases from bladder cancer: outcome in 83 patients after radical cystectomy and pelvic lymphadenectomy. J Urol. 2001; 166:19–23. PMID: 11435814.