Investig Clin Urol.  2017 Nov;58(6):416-422. 10.4111/icu.2017.58.6.416.

Lymph node yield in node-negative patients predicts cancer specific survival following radical cystectomy for transitional cell carcinoma

• Crozier J
• Papa N
• Perera M
• Stewart M
• Goad J
• Sengupta S
• Bolton D
• Lawrentschuk N

• KMID: 2414768
• DOI: http://doi.org/10.4111/icu.2017.58.6.416

Abstract

PURPOSE
To determine the oncological implications of increased nodal dissection in node-negative bladder cancer during radical cystectomy in a contemporary Australian series.
MATERIALS AND METHODS
We performed a multicenter retrospective study, including more than 40 surgeons across 5 sites over a 10-year period. We identified 353 patients with primary bladder cancer undergoing radical cystectomy. Extent of lymphadenectomy was defined as follows; limited pelvic lymph node dissection (PLND) (perivesical, pelvic, and obturator), standard PLND (internal and external iliac) and extended PLND (common iliac). Multivariable cox proportional hazards and logistic regression models were used to determine LNY effect on cancer-specific survival.
RESULTS
Over the study period, the extent of dissection and lymph node yield increased considerably. In node-negative patients, lymph node yield (LNY) conferred a significantly improved cancer-specific survival. Compared to cases where LNY of 1 to 5 nodes were taken, the hazard ratio (HR) for 6 to 15 nodes harvested was 0.78 (95% confidence interval [CI], 0.43-1.39) and for greater than 15 nodes the HR was 0.31 (95% CI, 0.17-0.57), adjusted for age, sex, T stage, margin status, and year of surgery. The predicted probability of cancer-specific death within 2 years of cystectomy was 16% (95% CI, 13%-19%) with 10 nodes harvested, falling to 5.5% (95% CI, 0%-12%) with 30 nodes taken. Increasing harvest in all PLND templates conferred a survival benefit.
CONCLUSIONS
The findings of the current study highlight the improved oncological outcomes with increased LNY, irrespective of the dissection template. Further prospective research is needed to aid LND data interpretation.

Keyword

Lymph node excision; Neoplasm staging; Survival; Urinary bladder neoplasms

MeSH Terms

Accidental Falls
Carcinoma, Transitional Cell*
Cystectomy*
Humans
Logistic Models
Lymph Node Excision
Lymph Nodes*
Neoplasm Staging
Prospective Studies
Retrospective Studies
Surgeons
Urinary Bladder Neoplasms

Figure

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  Fig. 1 Definitions of pelvic lymph node dissection templates. Limited pelvic lymph node dissection (PLND) (A), standard PLND (B), extended PLND (C), and superextended PLND (D).

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  Fig. 2 Populations of highest dissection level over time.

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  Fig. 3 Populations of number of nodes taken over time.

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  Fig. 4 Kaplan-Meier plots of bladder cancer specific survival grouped by number of nodes harvested with log-rank test.

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  Fig. 5 Predicted probability (red line) of bladder cancer death within 2 years of cystectomy and 95% confidence interval. Black dots are patients who died of bladder cancer and blue dots are patients alive at 2. One patient alive at 2 years with 68 nodes harvested not shown.

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  Fig. 6 Predicted probability of bladder cancer death within 2 years of cystectomy versus number of nodes taken at each dissection level.

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