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Qi W, Zhong M, Jiang N, Zhou Y, Lv G, Li R, Shi B, Chen S. Which lymph node dissection template is optimal for radical cystectomy? A systematic review and Bayesian network meta-analysis. Front Oncol 2022; 12:986150. [PMID: 36505883 PMCID: PMC9732561 DOI: 10.3389/fonc.2022.986150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 11/07/2022] [Indexed: 11/27/2022] Open
Abstract
Objective This study aims to determine the optimal pelvic lymph node dissection (PLND) template for radical cystectomy (RC). Methods A systematic search was conducted using the PubMed, Embase and Cochrane Library database in December 2021. Articles comparing recurrence-free survival (RFS), disease-specific survival (DSS), overall survival (OS), and postoperative complications among patients undergoing limited PLND (lPLND), standard PLND (sPLND), extended PLND (ePLND), or super-extended PLND (sePLND) were included. A Bayesian approach was used for network meta-analysis. Results We included 18 studies in this systematic review, and 17 studies met our criteria for network meta-analysis. We performed meta-analyses and network meta-analyses to investigate the associations between four PLND templates and the RFS, DSS, OS, or postoperative complications. We found that the ePLND group and the sePLND group were associated with better RFS than the sPLND group (Hazard Ratio [HR]: 0.65, 95% Credible Interval [CrI]: 0.56 to 0.78) (HR: 0.67, 95% CrI: 0.56 to 0.83) and the lPLND group (HR: 0.67, 95% CrI: 0.50 to 0.91) (HR: 0.70, 95% CrI: 0.49 to 0.99). For RFS, Analysis of the treatment ranking revealed that ePLND had the highest probabilities to be the best template. There was no significant difference between the four templates in DSS, however, analysis of the treatment ranking indicated that sePLND had the highest probabilities to be the best template. And We found that the sePLND group and the ePLND group were associated with better OS than lPLND (HR: 0.58, 95% CrI: 0.36 to 0.95) (HR: 0.63, 95% CrI: 0.41 to 0.94). For OS, analysis of the treatment ranking revealed that sePLND had the highest probabilities to be the best template. The results of meta-analyses and network meta-analyses showed that postoperative complications rates did not differ significantly between any two templates. Conclusion Patients undergoing sePLND and ePLND had better RFS but not better DSS or OS than those undergoing lPLND or sPLND templates, however, RFS did not differ between patients undergoing sePLND or ePLND. Considering that sePLND involves longer operation time, higher risk, and greater degree of difficulty than ePLND, and performing sePLND may not result in better prognosis, so it seems that there is no need for seLPND. We think that ePLND might be the optimal PLND template for RC. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, identifier CRD42022318475.
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Affiliation(s)
- Wenqiang Qi
- Department of Urology, Qilu Hospital of Shandong University, Jinan, China
| | - Minglei Zhong
- Department of Urology, Qilu Hospital of Shandong University, Jinan, China
| | - Ning Jiang
- Department of Epidemiology, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yongheng Zhou
- Department of Urology, Qilu Hospital of Shandong University, Jinan, China
| | - Guangda Lv
- Department of Urology, Qilu Hospital of Shandong University, Jinan, China
| | - Rongyang Li
- Department of Thoracic Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Benkang Shi
- Department of Urology, Qilu Hospital of Shandong University, Jinan, China
| | - Shouzhen Chen
- Department of Urology, Qilu Hospital of Shandong University, Jinan, China,*Correspondence: Shouzhen Chen,
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Extent of lymph node dissection and impact on survival in radical cystectomy for advanced bladder cancer. Curr Opin Urol 2022; 32:607-613. [PMID: 36101521 DOI: 10.1097/mou.0000000000001035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW In patients with muscle invasive bladder cancer (MIBC) or unresectable non-MIBC, radical cystectomy is routinely combined with bilateral pelvic lymph node dissection (LND) owing to the oncological benefits found in recurrence-free survival (RFS), overall survival (OS) and cancer-specific survival (CSS) compared with radical cystectomy alone. However, the optimal anatomic extent of LND is still unclear. RECENT FINDINGS Retrospective studies were consistent in reporting oncological benefits of extended LND over nonextended LND. A recent RCT (the LEA trial) failed to demonstrate any benefit in terms of RFS, CSS and OS of super-extended LND over standard LND. Several confounding factors hindered the interpretation of the results, leaving the question of the right extent for LND still open. Results of a similar study, the SWOG S1011 are, therefore, highly anticipated. This study differed from the LEA study in several aspects but might also turn out to be a negative study. SUMMARY There are still no firm data on the oncological benefit brought by more extended LND in patients with MIBC. Survival benefits seem limited, at least in the general population. Other factors could influence the impact of LND on survival, including the administration of adjuvant and neoadjuvant chemotherapies.
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Jena R, Shrivastava N, Sharma AP, Choudhary GR, Srivastava A. The Adequacy of Pelvic Lymphadenectomy During Radical Cystectomy for Carcinoma Urinary Bladder: A Narrative Review of Literature. Front Surg 2021; 8:687636. [PMID: 34222323 PMCID: PMC8247657 DOI: 10.3389/fsurg.2021.687636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/19/2021] [Indexed: 11/24/2022] Open
Abstract
An adequate pelvic lymph node dissection (PLND) is an essential part of radical cystectomy for muscle invasive bladder cancer. However, the definition of what constitutes an adequate PLND is often shrouded in controversy. Various authors have defined different anatomic templates of PLND based on levels of pelvic lymph nodes. Some have suggested other surrogate markers of the adequacy of PLND, namely lymph node count and lymph node density. While individual studies have shown the efficacy and reliability of some of the above markers, none of them have been recommended forthright due to the absence of robust prospective data. The use of non-standardized nomenclature while referring to the above variables has made this matter more complex. Most of older data seems to favor use of extended template of PLND over the standard template. On the other hand, one recent randomized controlled trial (RCT) did not show any benefit of one template over the other in terms of survival benefit, but the study design allowed for a large margin of bias. Therefore, we conducted a systematic search of literature using EMBASE, Medline, and PubMed using PRISMA-P checklist for articles in English Language published over last 20 years. Out of 132 relevant articles, 47 articles were included in the final review. We have reviewed existing literature and guidelines and have attempted to provide a few suggestions toward a uniform nomenclature for the various anatomical descriptions and the extent of PLND done while doing a radical cystectomy. The results of another large RCT (SWOG S1011) are awaited and until we have a definitive evidence, we should adhere to these suggestions as much as possible and deal with each patient on a case to case basis.
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Affiliation(s)
- Rahul Jena
- Department of Urology, All India Institute of Medical Sciences, Jodhpur, India
| | - Nikita Shrivastava
- Department of Urology, All India Institute of Medical Sciences, Jodhpur, India
| | - Aditya Prakash Sharma
- Department of Urology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Aneesh Srivastava
- Department of Urology and Renal Transplant, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Wang YC, Wu J, Dai B, Shen YJ, Ma CG, Ye DW, Zhu YP. Extended versus non-extended lymphadenectomy during radical cystectomy for patients with bladder cancer: a meta-analysis of the effect on long-term and short-term outcomes. World J Surg Oncol 2019; 17:225. [PMID: 31864368 PMCID: PMC6925870 DOI: 10.1186/s12957-019-1759-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 11/25/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Pelvic lymphadenectomy (PLND) is an integral part of curative surgery for high-risk non-muscle invasive and muscle-invasive bladder cancer. The therapeutic value of extended PLND is controversial. METHODS We conducted a comprehensive online search in PubMed, EMBASE, and the Cochrane Library databases for relevant literature directly comparing extended PLND (e-PLND) with non-extended PLND (ne-PLND) from database inception to June 2019. We performed the meta-analysis to evaluate the impact of PLND templates on recurrence-free survival (RFS), disease-specific survival (DSS), overall survival (OS), rates of postoperative major complications, and mortality within 90 days of surgery. RESULTS A total of 10 studies involving 3979 patients undergoing either e-PLND or ne-PLND were included. The results showed that e-PLND was significantly associated with better RFS (HR 0.74, 95% CI 0.62-0.90, p = 0.002) and DSS (HR 0.66, 95% CI 0.55-0.79, p < 0.001). However, no correlation was found between e-PLND template and a better OS (HR 0.93, 95% CI 0.55-1.58, p = 0.79). Postoperative major complications were similar between e-PLND group and ne-PLND group, as was mortality within 90 days of surgery. CONCLUSION e-PLND template is correlated with favorable RFS and DSS outcomes for patients with bladder cancer. e-PLND did not have more postoperative major complications than did ne-PLND.
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Affiliation(s)
- Yu-Chen Wang
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong an Road, Shanghai, 200032 People’s Republic of China
| | - Jie Wu
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong an Road, Shanghai, 200032 People’s Republic of China
| | - Bo Dai
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong an Road, Shanghai, 200032 People’s Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People’s Republic of China
| | - Yi-Jun Shen
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong an Road, Shanghai, 200032 People’s Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People’s Republic of China
| | - Chun-Guang Ma
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong an Road, Shanghai, 200032 People’s Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People’s Republic of China
| | - Ding-Wei Ye
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong an Road, Shanghai, 200032 People’s Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People’s Republic of China
| | - Yi-Ping Zhu
- Department of Urology, Fudan University Shanghai Cancer Center, No. 270 Dong an Road, Shanghai, 200032 People’s Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People’s Republic of China
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[Usefulness of frozen section exams during radical cystectomy for urothelial carcinoma]. Prog Urol 2019; 30:51-57. [PMID: 31843294 DOI: 10.1016/j.purol.2019.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/12/2019] [Accepted: 09/28/2019] [Indexed: 11/22/2022]
Abstract
AIM To determine the usefulness of the frozen section exams of lymph nodes dissection, ureteral and urethral section during radical cystectomy for urothelial carcinoma and define the impact on the surgical procedure. METHOD A retrospective, single-center study of data collected from 182 patients who underwent radical cystectomy for an cT=3bN0M0 urothelial bladder cancer between 2016 and 2018. Bladder cancer extension was determined by thoracoabdominal CT with contrast enhancement and urography and an 18-FDG PET scanner. No patient received neoadjuvant chemotherapy. The diagnostic performance of the frozen section exams was related to final examinations. The impact of the result on the initial intervention was determined. RESULTS The frozen section were positive in 29 lymph nodes dissections (15.9 %), 59 (16.6 %) ureteral and 20 (10.9 %) ureteral recessions. With lymph nodes exams, sensitivity, specificity and positive and negative predictive values were 93.5 %, 100 %, 100 %, and 98.7 %, respectively. With ureteral sections exams the same values were 91.5 %, 100 %, 100 %, and 98.4 % respectively. With urethral section exams, all the values were of 100 %. Finally, all the procedure has been modified for all patients with positive frozen section exam except one positive urethral section that did not give rise to radical urethrectomy. CONCLUSION Frozen section exams were useful to the urologist during radical cystectomy for urothelial carcinoma. The performances of the frozen section exams carried out were excellent. The information of the urologist of the positive frozen section leeds to modify its management during the intervention in all the studied cases with the exception of one case.
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Li F, Hong X, Hou L, Lin F, Chen P, Pang S, Du Y, Huang H, Tan W. A greater number of dissected lymph nodes is associated with more favorable outcomes in bladder cancer treated by radical cystectomy: a meta-analysis. Oncotarget 2018; 7:61284-61294. [PMID: 27542252 PMCID: PMC5308651 DOI: 10.18632/oncotarget.11343] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 08/10/2016] [Indexed: 11/25/2022] Open
Abstract
The optimal extent of lymph node dissection (LND) is currently not established, and the debate regarding the association between the number of dissected nodes and the outcomes of bladder cancer treated by radical cystectomy (RC) is still ongoing. Therefore, the present meta-analysis was performed to clarify this potential relationship. Eligible studies were retrieved via an electronic search for studies published up to April 2016, and by manual review of the references. A total of 25 cohort studies involving 41,400 bladder cancer patients who underwent RC were included. The summary relative risk estimates (SRRE) based on the highest compared with the lowest categories of LND were estimated by variance-based meta-analysis. Heterogeneity among the study results was explored through stratified analyses. Overall, bladder cancer patients with the highest category of LND had 28%, 34% and 36% reduced risks, corresponding to overall survival (SRRE = 0.72; 95% CI, 0.64-0.80), cancer-specific survival (SRRE = 0.66; 95% CI, 0.54-0.80) and recurrence-free survival (SRRE = 0.64; 95% CI, 0.50-0.82), respectively, compared with patients with the lowest category of LND. In summary, the patients with a greater number of dissected lymph nodes had statistically significant survival advantages in terms of the outcomes of bladder cancer following RC. The number of dissected lymph nodes could be an independent prognostic factor for bladder cancer. These findings need to be validated in prospective and larger epidemiological studies with a longer follow-up period.
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Affiliation(s)
- Fei Li
- Department of Urology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P. R. China
| | - Xuwei Hong
- Department of Urology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P. R. China
| | - Lina Hou
- Department of Healthy Management, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P. R. China
| | - Fengsheng Lin
- Department of Urology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P. R. China
| | - Pengliang Chen
- Department of Urology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P. R. China
| | - Shiyu Pang
- Department of Urology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P. R. China
| | - Yuejun Du
- Department of Urology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P. R. China
| | - He Huang
- Department of Urology, The Third People's Hospital of Hubei Province, Wuhan, Hubei 430415, P. R. China
| | - Wanlong Tan
- Department of Urology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P. R. China
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Luchey AM, Lin HY, Yue B, Agarwal G, Gilbert SM, Lockhart J, Poch MA, Pow-Sang JM, Spiess PE, Sexton WJ. Implications of Definitive Prostate Cancer Therapy on Soft Tissue Margins and Survival in Patients Undergoing Radical Cystectomy for Bladder Urothelial Cancer. J Urol 2015; 194:1220-5. [DOI: 10.1016/j.juro.2015.05.091] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2015] [Indexed: 01/01/2023]
Affiliation(s)
- Adam M. Luchey
- Departments of Genitourinary Oncology and Biostatistics (HYL, BY), Moffitt Cancer Center, Tampa, Florida
| | - Hui-Yi Lin
- Departments of Genitourinary Oncology and Biostatistics (HYL, BY), Moffitt Cancer Center, Tampa, Florida
| | - Binglin Yue
- Departments of Genitourinary Oncology and Biostatistics (HYL, BY), Moffitt Cancer Center, Tampa, Florida
| | - Gautum Agarwal
- Departments of Genitourinary Oncology and Biostatistics (HYL, BY), Moffitt Cancer Center, Tampa, Florida
| | - Scott M. Gilbert
- Departments of Genitourinary Oncology and Biostatistics (HYL, BY), Moffitt Cancer Center, Tampa, Florida
| | - Jorge Lockhart
- Departments of Genitourinary Oncology and Biostatistics (HYL, BY), Moffitt Cancer Center, Tampa, Florida
| | - Michael A. Poch
- Departments of Genitourinary Oncology and Biostatistics (HYL, BY), Moffitt Cancer Center, Tampa, Florida
| | - Julio M. Pow-Sang
- Departments of Genitourinary Oncology and Biostatistics (HYL, BY), Moffitt Cancer Center, Tampa, Florida
| | - Philippe E. Spiess
- Departments of Genitourinary Oncology and Biostatistics (HYL, BY), Moffitt Cancer Center, Tampa, Florida
| | - Wade J. Sexton
- Departments of Genitourinary Oncology and Biostatistics (HYL, BY), Moffitt Cancer Center, Tampa, Florida
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Gordetsky J, Bivalacqua T, Schoenberg M, Epstein JI. Ureteral and Urethral Frozen Sections During Radical Cystectomy or Cystoprostatectomy: An Analysis of Denudation and Atypia. Urology 2014; 84:619-23. [DOI: 10.1016/j.urology.2014.05.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 05/06/2014] [Accepted: 05/28/2014] [Indexed: 12/01/2022]
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Kim H, Kim M, Kwak C, Kim HH, Ku JH. Prognostic significance of lymphovascular invasion in radical cystectomy on patients with bladder cancer: a systematic review and meta-analysis. PLoS One 2014; 9:e89259. [PMID: 24586637 PMCID: PMC3931717 DOI: 10.1371/journal.pone.0089259] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 01/16/2014] [Indexed: 12/26/2022] Open
Abstract
Purpose The objective of the present study was to conduct a systematic review and meta-analysis of published literature to appraise the prognostic value of lymphovascular invasion (LVI) in radical cystectomy specimens. Materials and Methods Following the PRISMA statement, PubMed, Cochrane Library, and SCOPUS database were searched from the respective dates of inception until June 2013. Results A total of 21 articles met the eligibility criteria for this systematic review, which included a total of 12,527 patients ranging from 57 to 4,257 per study. LVI was detected in 34.6% in radical cystectomy specimens. LVI was associated with higher pathological T stage and tumor grade, as well as lymph node metastasis. The pooled hazard ratio (HR) was statistically significant for recurrence-free survival (pooled HR, 1.61; 95% confidence interval [CI], 1.26–2.06), cancer-specific survival (pooled HR, 1.67; 95% CI, 1.38–2.01), and overall survival (pooled HR, 1.67; 95% CI, 1.38–2.01), despite the heterogeneity among included studies. On sensitivity analysis, the pooled HRs and 95% CIs were not significantly altered when any one study was omitted. The funnel plot for overall survival demonstrated a certain degree of asymmetry, which showed slight publication bias. Conclusions This meta-analysis indicates that LVI is significantly associated with poor outcome in patients with bladder cancer who underwent radical cystectomy. Adequately designed prospective studies are required to provide the precise prognostic significance of LVI in bladder cancer.
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Affiliation(s)
- Hwanik Kim
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
| | - Myong Kim
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
| | - Cheol Kwak
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
| | - Hyeon Hoe Kim
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
| | - Ja Hyeon Ku
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
- * E-mail:
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Neuzillet Y, Soulie M, Larre S, Roupret M, Defortescu G, Murez T, Pignot G, Descazeaud A, Patard JJ, Bigot P, Salomon L, Colin P, Rigaud J, Bastide C, Durand X, Valeri A, Kleinclauss F, Bruyere F, Pfister C. Positive surgical margins and their locations in specimens are adverse prognosis features after radical cystectomy in non-metastatic carcinoma invading bladder muscle: results from a nationwide case-control study. BJU Int 2013; 111:1253-60. [PMID: 23331375 DOI: 10.1111/j.1464-410x.2012.11664.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To compare the prognoses associated with positive surgical margins (PSMs) according to their urethral, ureteric and/or soft tissue locations in patients with pN0 M0 bladder cancer who have not undergone neoadjuvant chemotherapy. PATIENTS AND METHODS A retrospective, case-control study was conducted between 1991 and 2011 using data from 17 academic centres in France. A total of 154 patients (cases) with PSMs met the eligibility criteria and were matched according to centre, pT stage, gender, age and urinary diversion method with a population-based sample of 154 patients (controls) from 3651 patients who had undergone cystectomies. The median follow-up period was 23.9 months. Multivariable Cox regression analysis was used to test the effects of PSMs on local recurrence (LR)-free survival, metastatic recurrence (MR)-free survival and cancer-specific survival (CSS). RESULTS The 5-year LR-free survival and CSS rates of patients with urethral and soft tissue PSMs were lower than those in the control group. A significant decrease in CSS was associated with soft tissue PSMs (P = 0.003, odds ratio = 0.425, 95% confidence interval 0.283-0.647). The prognosis was not affected in cases of ureteric PSMs. CONCLUSIONS Soft tissue PSMs were associated with poor CSS rates in patients with pN0 M0 bladder cancer. A correlation between urethrectomy and a reduction of the risk of LR in a urethral PSM setting was observed.
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Affiliation(s)
- Yann Neuzillet
- Department of Urology, Hopital Foch, Universite De Versailles - Saint-Quentin En Yvelines, Suresnes, France.
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Shariat SF, Ehdaie B, Rink M, Cha EK, Svatek RS, Chromecki TF, Fajkovic H, Novara G, David SG, Daneshmand S, Fradet Y, Lotan Y, Sagalowsky AI, Clozel T, Bastian PJ, Kassouf W, Fritsche HM, Burger M, Izawa JI, Tilki D, Abdollah F, Chun FK, Sonpavde G, Karakiewicz PI, Scherr DS, Gonen M. Clinical nodal staging scores for bladder cancer: a proposal for preoperative risk assessment. Eur Urol 2011; 61:237-42. [PMID: 22033174 DOI: 10.1016/j.eururo.2011.10.011] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Accepted: 10/12/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND Radical cystectomy (RC) with pelvic lymph node dissection (LND) is the standard of care for refractory non-muscle-invasive and muscle-invasive bladder cancer. Although consensus exists on the need for LND, its extent is still debated. OBJECTIVE To develop a model that allows preoperative determination of the minimum number of lymph nodes (LNs) needed to be removed at RC to ensure true nodal status. DESIGN, SETTING, AND PARTICIPANTS We analyzed data from 4335 patients treated with RC and pelvic LND without neoadjuvant chemotherapy at 12 academic centers located in the United States, Canada, and Europe. MEASUREMENTS We estimated the sensitivity of pathologic nodal staging using a beta-binomial model and developed clinical (preoperative) nodal staging scores (cNSS), which represent the probability that a patient has LN metastasis as a function of the number of examined nodes. RESULTS AND LIMITATIONS The probability of missing a positive LN decreased with an increasing number of nodes examined (52% if 3 nodes were examined, 40% if 5 were examined, and 26% if 10 were examined). A cNSS of 90% was achieved by examining 6 nodes for clinical Ta-Tis tumors, 9 nodes for cT1 tumors, and 25 nodes for cT2 tumors. In contrast, examination of 25 nodes provided only 77% cNSS for cT3-T4 tumors. The study is limited due to its retrospective design, its multicenter nature, and a lack of preoperative staging parameters. CONCLUSIONS Every patient treated with RC for bladder cancer needs an LND to ensure accurate nodal staging. The minimum number of examined LNs for adequate staging depends preoperatively on the clinical T stage. Predictive tools can give a preoperative estimation of the likelihood of nodal metastasis and thereby allow tailored decision-making regarding the extent of LND at RC.
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Affiliation(s)
- Shahrokh F Shariat
- Brady Urologic Health Center, Weill Cornell Medical College, 525 East 68th St., Box 94, Starr 900, New York, NY 10065, USA.
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Prediction of prognosis after radical cystectomy for pathologic node-negative bladder cancer. Int Urol Nephrol 2011; 43:1059-65. [PMID: 21626133 DOI: 10.1007/s11255-011-9920-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 02/10/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To evaluate risk factors related to bladder cancer recurrence in patients with pathologically negative pelvic lymph nodes. METHODS We reviewed 192 patients who underwent radical cystectomy for muscle invasive bladder cancer between 1999 and 2009. Patients with pathologically positive pelvic lymph nodes and <6-month follow-up were excluded. Clinicopathological parameters including grade, stage, lymphadenectomy type (standard vs. extended), number of nodes removed, margin status, lymphovascular invasion, perineural invasion, presence of carcinoma in situ, ureteral invasion, prostatic urethral invasion, and longest tumor dimension were evaluated. Kaplan-Meier and multivariate Cox analyses were used to evaluate these parameters for 5-year recurrence-free survival (5RFS) and 5-year overall survival (5OS). RESULTS One hundred and fifty-five patients were included in this study. Mean follow-up duration was 36.6 months (12-141 months). Nuclear grade according to 2004 WHO classification (P = 0.006, P = 0.001), perineural invasion (P = 0.041, P = 0.048), lymphovascular invasion (P = 0.005, P = 0.027), and number of nodes removed (P < 0.001, P < 0.001) demonstrated differences in 5RFS and 5OS, respectively. In multivariate analysis, 5RFS was related to perineural invasion (P = 0.008; HR: 10.951; 95% CI: 1.891-63.407) and the number of nodes removed (P = 0.038; HR: 1.087; 95% CI: 1.004-1.176), and 5OS was correlated with lymphovascular invasion (P = 0.035; HR: 6.694; 95% CI: 1.143-39.217). CONCLUSIONS Perineural invasion and the number of nodes removed were independent risk factors for 5RFS, and lymphovascular invasion was for 5OS in patients with node-negative bladder cancer.
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