Extended versus limited lymph node dissection in radical cystectomy: Impact on recurrence pattern and survival

DaBlaCa-17: nationwide observational study in Denmark on survival before and after implementation of neoadjuvant chemotherapy prior to cystectomy for muscle-invasive bladder cancer

OBJECTIVE

To investigate the impact of neoadjuvant chemotherapy implementation with gemcitabine-cisplatin on survival outcomes for patients with muscle-invasive bladder cancer in Denmark.

MATERIALS AND METHODS

Data were collected on all patients in Denmark undergoing radical cystectomy who were potential candidates for neoadjuvant chemotherapy from 2010 to 2015 (n = 851). A cohort before the implementation of neoadjuvant chemotherapy (Cohort 2010-12) was compared with a cohort after implementation (Cohort 2013-15). Patients in Cohort 2013-15 receiving neoadjuvant chemotherapy (+NAC, n = 213) were compared with patients in Cohort 2013-15 not receiving neoadjuvant chemotherapy (-NAC, n = 139). Pathological results after radical cystectomy and oncological outcomes were compared between the study cohorts. Overall survival, disease-free survival, and disease-specific survival were compared with Kaplan-Meier plots and with univariable and multivariable Cox regression. Kaplan-Meier estimates of overall survival were also performed separately for treating hospital and for pathological stage.

RESULTS

Pathological T0 (pT0) was more frequent in patients who received neoadjuvant chemotherapy: 34% versus 18% when comparing Cohort 2013-15 with Cohort 2010-12 (p < 0.001), and 46% versus 16% in +NAC compared with -NAC (p < 0.001). Overall survival, disease-free survival, and disease-specific survival at 5 years after cystectomy were not improved in Cohort 2013-15 compared with Cohort 2010-12 with adjusted hazard ratios of 1.11 (95% confidence interval [CI]: 0.87-1.43), 1.02 (95% CI: 0.81-1.29), and 1.06 (95% CI: 0.80-1.41), respectively.

CONCLUSIONS

This observational study found no improved survival in a national cohort of patients with muscle-invasive bladder cancer undergoing radical cystectomy after implementation of NAC. However, reservations should be made regarding the study design and the true effect of NAC on survival outcomes.

Bladder Cancer: Immunotherapy and Pelvic Lymph Node Dissection

Bladder cancer, a common malignancy of the urinary system, is routinely treated with radiation, chemotherapy, and surgical excision. However, these strategies have inherent limitations and may also result in various side effects. Immunotherapy has garnered considerable attention in recent years as a novel therapeutic approach. It harnesses and activates the patient's immune system to recognize and eliminate cancer cells, which not only prolongs therapeutic efficacy but also minimizes the toxic side effects. Several immune checkpoint inhibitors and cancer vaccines have been developed for the treatment of bladder cancer. Whereas blocking immune checkpoints on the surface of tumor cells augments the effect of immune cells, immunization with tumor-specific antigens can elicit the production of anti-tumor immune effector cells. However, there are several challenges in applying immunotherapy against bladder cancer. For instance, the efficacy of immunotherapy varies considerably across individual patients, and only a small percentage of cancer patients are responsive. Therefore, it is crucial to identify biomarkers that can predict the efficacy of immunotherapy. Pelvic lymph nodes are routinely dissected from bladder cancer patients during surgical intervention in order to remove any metastatic tumor cells. However, some studies indicate that pelvic lymph node dissection may reduce the efficacy of immunotherapy by damaging the immune cells. Therefore, the decision to undertake pelvic lymph node removal should be incumbent on the clinical characteristics of individual patients. Thus, although immunotherapy has the advantages of lower toxic side effects and long-lasting efficacy, its application in bladder cancer still faces challenges, such as the lack of predictive biomarkers and the effects of pelvic lymph node dissection. Further research is needed to explore these issues in order to improve the efficacy of immunotherapy for bladder cancer.

Pelvic lymphadenectomy: Evaluating nodal stage migration and will rogers effect in bladder cancer

INTRODUCTION

Pelvic lymphadenectomy (PLND) alongside radical cystectomy (RC), provides crucial diagnostic and therapeutic value in patients with bladder cancer. With the advent of neoadjuvant chemotherapy and prospective data supporting standard PLND, controversy remains regarding the optimal PLND extent and patient selection. Nearly 40% of patients may not receive adequate PLND, even though 25% of patients have positive lymph nodes (LN) at time of RC. We hypothesized that PLND still remains an important facet of bladder cancer treatment. To clarify the prognostic importance of nodal yield, we performed a retrospective investigation of a heterogenous population (pTanyNx/0M0) of patients undergoing RC.

METHODS

From the Surveillance, Epidemiology, and End Results (SEER) program, we identified pTanyNx/0M0 bladder cancer patients undergoing RC from 2004 to 2015. Kaplan Meier curves and Cox proportional hazards models assessed cancer-specific survival. Patients were analyzed with PLND performed as the primary covariate. Survival analysis then stratified patients undergoing PLND by LN yield, both as a continuous and categorial variable (≤10, 11-20, 21-30, and >30), and T stage.

RESULTS

The final cohort included pTanyNx/0M0 patients with urothelial bladder cancer (n = 12,096); median follow up was 39 (IQR: 17-77) months. PLND was performed in 81.45% of patients with a median LN yield of 14 (IQR: 7-23). Most commonly, patients had T2 disease (44.68%). After controlling for age and T stage, patients receiving PLND had improved CSS (HR = 0.56, [95% CI: 0.51-0.62]) compared to those that did not receive PLND. When grouping patients by LN yield, survival improved in a "dose dependent" manner (>30 LN: HR = 0.76, [95% CI: 0.66-0.87]). We noted similar results when stratifying patients into non-muscle-invasive (NMIBC) and muscle-invasive bladder cancer (MIBC).

CONCLUSIONS

In a large contemporary series of pTanyNx/0M0 bladder cancer patients, we found a significant oncologic benefit to PLND. Higher LN yield correlated to improved CSS in non-muscle-invasive and muscle-invasive disease. Our data support the possibility of occult micrometastasis even in non-muscle-invasive disease. Additionally, in light of recent advances in adjuvant immunotherapy, our results emphasize the importance of adequate nodal yield for accurate staging and optimal treatment.

Extended pelvic lymph node dissection in muscle invasive bladder cancer

PURPOSE OF REVIEW

Bilateral pelvic lymph node dissection (PLND) at the time of radical cystectomy (RC) provides important staging information and oncologic benefit in patients with bladder cancer. The optimal extent of the PLND remains controversial. Our aim is to highlight nodal mapping studies and the data that guides optimization of both staging and oncologic outcomes. We then review contemporary randomized trials studying the extent of PLND.

RECENT FINDINGS

A recent randomized trial (RCT) powered for a 15% improvement in recurrence-free survival (RFS) of extended (e) over limited (l)PLND was completed but failed to identify this large difference in outcome. Concerns over study design limit the ability to interpret the oncologic results. Importantly, ePLND minimally changed surgical morbidity. An ongoing, similar RCT (SWOG S1011) powered to detect a 10% difference in RFS has completed accrual, but no published outcomes are available.

SUMMARY

RC and ePLND can provide cure in 33% of LN positive bladder cancer patients. Current data support a 5% improvement in RFS if ePLND is routinely used in MIBC patients. Two randomized trials powered to identify much larger (15 and 10%) improvements in RFS are unlikely to identify such an ambitious benefit by extending the PLND.

Comprehensive Analysis of the Prognostic Value of Circulating MMP-7 Levels in Urothelial Carcinoma: A Combined Cohort Analysis, Systematic Review, and Meta-Analysis

Lymph node (LN) status is the most significant prognostic factor for invasive urothelial bladder cancer (UBC); however, the optimal extent of LN dissection (LND) is debated. We assessed circulating matrix metalloproteinase-7 (MMP-7) as a prognostic factor and decision-making marker for the extent of LND. Preoperative serum MMP-7 levels were determined in two independent UBC cohorts (n = 188; n = 68) and in one control cohort (n = 97) by using the ELISA method. A systematic review and meta-analysis on the prognostic role of circulating pretreatment MMP-7 levels were performed. Serum MMP-7 levels were higher in patients compared to controls (p < 0.001) with the highest levels in LN-positive cases. Half of LN-positive UBC patients had low MMP-7 levels, whereas the survival of LN-negative patients with high serum MMP-7 findings was poor. MMP-7 levels were independently associated with poor survival in both cohorts (p = 0.006, p < 0.001). Accordingly, our systematic review of six eligible publications revealed a 2.5-fold higher mortality risk in patients with high MMP-7 levels. In conclusion, preoperative MMP-7 level is a validated and independent prognostic factor in urothelial cancer. It cannot be used to decide between regional or extended LND but may be useful in identifying LN-negative high-risk patients with potentially undetected metastases.

Which lymph node dissection template is optimal for radical cystectomy? A systematic review and Bayesian network meta-analysis

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.

Extent of lymph node dissection and impact on survival in radical cystectomy for advanced bladder cancer

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.

Multicenter external validation of the radical cystectomy pentafecta in a European cohort of patients undergoing robot-assisted radical cystectomy with intracorporeal urinary diversion for bladder cancer

Objective

To perform an external validation of this RC-pentafecta.

Method

Between January 2014 and December 2019, 104 consecutive patients who underwent RARC with ICUD within 6 urological centers were analyzed retrospectively. Patients who simultaneously demonstrated negative soft tissue surgical margins (STSMs), a lymph node (LN) yield ≥ 16, absence of major (Clavien–Dindo grade III–V) 90-day postoperative complications, absence of UD-related long-term sequelae, and absence of 12-month clinical recurrence were considered to have achieved RC-pentafecta. A multivariable logistic regression model was used to measure predictors for achieving RC-pentafecta. We analyzed the influence of this RC-pentafecta on survival, and the impact ofthe surgical experience.

Results

Since 2014, 104 patients who had completed at least 12 months of follow-up were included. Over a mean follow-up of 18 months, a LN yield ≥ 16, negative STSMs, absence of major complications at 90 days, and absence of UD-related surgical sequelae and clinical recurrence at ≤ 12 months were observed in 56%, 96%, 85%, 81%, and 91% of patients, respectively, resulting in a RC-pentafecta rate of 39.4%. Multivariate analysis showed that age was an independent predictor of pentafecta achievement (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.90. 0.99; p = 0.04). The surgeon experience had an impact on the validation of the criteria.

Conclusion

This study confirmed that the RC-pentafecta is reproducible and could be externally used for the outcome assessment after RARC with ICUD. Therefore, the RC-pentafecta could be a useful tool to assess surgical success and its impact on different outcomes.

The Prognosis and the Role of Adjuvant Chemotherapy for Node-Positive Bladder Cancer Treated with Neoadjuvant Chemotherapy Followed by Surgery

Purpose

This study aims to evaluate the prognosis of pathologically node-positive bladder cancer after neoadjuvant chemotherapy, the role of adjuvant chemotherapy in these patients, and the value of preoperative clinical evaluation for lymph node metastases.

Materials and Methods

Patients who received neoadjuvant chemotherapy followed by partial/radical cystectomy and had pathologically confirmed lymph node metastases between January 2007 and December 2019 were identified and analyzed.

Results

A total of 53 patients were included in the study. The median age was 61 years (range, 34 to 81 years) with males comprising 86.8%. Among the 52 patients with post-neoadjuvant/pre-operative computed tomography results, only 33 patients (63.5%) were considered positive for lymph node metastasis. Sixteen patients (30.2%) received adjuvant chemotherapy (AC group), and 37 patients did not (no AC group). With the median follow-up duration of 67.7 months, the median recurrence-free survival (RFS) and the median overall survival (OS) was 8.5 months and 16.2 months, respectively. The 2-year RFS and OS rates were 23.3% and 34.6%, respectively. RFS and OS did not differ between the AC group and no AC group (median RFS, 8.8 months vs. 6.8 months, p=0.772; median OS, 16.1 months vs. 16.3 months, p=0.479). Thirty-eight patients (71.7%) experienced recurrence. Distant metastases were the dominant pattern of failure in both the AC group (91.7%) and no AC group (76.9%).

Conclusion

Patients with lymph node-positive disease after neoadjuvant chemotherapy followed by surgery showed high recurrence rates with limited survival outcomes. Little benefit was observed with the addition of adjuvant chemotherapy.

The Usefulness of Lymphadenectomy in Bladder Cancer-Current Status

The purpose of this review is to present the current status of lymph node dissection (LND) during radical cystectomy in patients with bladder cancer (BCa). Despite the growing body of evidence of LND utility at the time of radical cystectomy (RC) in high-risk nonmuscle-invasive and muscle-invasive BCa (MIBC), therapeutic and prognostic value and optimal extent of LND remain unsolved issues. Recently published results of the first prospective, a randomized trial assessing the therapeutic benefit of extended versus limited LND during RC, failed to demonstrate survival improvement with the extended template. Although LND is the most accurate staging procedure, the direct therapeutic effect is still not evident from the current literature, limiting the possibility of establishing clear recommendations. This indicates the need for robust and adequately powered clinical trials.

Surgery for Bladder and Upper Tract Urothelial Cancer

The cornerstone for diagnosis and treatment of bladder and upper tract urothelial carcinoma involves surgery. Transurethral resection of bladder tumors forms the basis of further management. Radical cystectomy for invasive bladder carcinoma provides good oncologic outcomes. However, it can be a morbid procedure, and advances such as minimally invasive surgery and early recovery after surgery need to be incorporated into routine practice. Diagnostic ureteroscopy for upper tract carcinoma is needed in cases of doubt after cytology and imaging studies. Low-risk cancers can be managed with conservative endoscopic surgery without compromising oncological outcomes; however, high-risk disease necessitates radical nephroureterectomy.

Is there an oncological benefit to extended lymphadenectomy for muscle-invasive bladder cancer?

The full optimal extent of a pelvic lymph node dissection (PLND) at time of radical cystectomy (RC) has not yet been determined. The diagnostic role of LND is clear and is extremely important for identifying those who may benefit from adjuvant therapy. While retrospective analyses have demonstrated improved survival when the number of lymph nodes is increased and extended LNDs (eLNDs) are performed, these results have yet to be borne out in prospective randomized phase III trials. The recently published LEA AUO AB 25/02 trial is a promising attempt to determine the efficacy of eLND, but unfortunately falls short because of its limited design and therefore, did not demonstrate an improvement in recurrence-free survival (RFS). In an era of increased utilization of neoadjuvant chemotherapy (NAC) providing survival benefit, the ability to demonstrate improved survival with eLND is even more challenging. Currently, we are awaiting the results of SWOG S1011, expectations of achieving a positive trial with improved RFS remains unlikely.

[Adjuvant radiotherapy after radical cystectomy for muscle-invasive bladder cancer]

OBJECTIVES

Locoregional relapse (LRR) after cystectomy is a common early event associated with poor prognosis. The role of radiotherapy as an adjunct to radical cystectomy is not well-defined. The aim of this critical literature review is to provide an overview of the elements in favor of adjuvant radiation for patients treated for muscle-invasive bladder cancer.

MATERIAL AND METHODS

An exhaustive review of the literature was carried out using the Pubmed search tool with the following keywords: "radiotherapy" [Mesh], "adjuvant" [Mesh], "local recurrence" [Mesh], "Bladder cancer" [Mesh].

RESULTS

Several recent publications have led to the development of a nomogram that predicts the risk of LRR, in order to identify patients for which adjuvant radiotherapy could be beneficial. Several randomized trials seem to suggest a benefit of radiotherapy, in particular when combined with chemotherapy, in terms of reducing LRR, and may even improve overall survival, with good safety profile. However, there are many biases and the interest of adjuvant radiotherapy in urothelial carcinomas remains debated.

CONCLUSION

Prospective trials evaluating adjuvant radiotherapy with current techniques should be undertaken.

The evolving role of lymphadenectomy for bladder cancer: why, when, and how

Radical cystectomy (RC) represents a standard treatment for non-metastatic muscle-invasive and select high-risk non-muscle invasive bladder cancer. Lymphadenectomy performed at time of RC identifies nodal metastases in up to 25% of patients despite normal imaging. There has been an increasing utilization of pelvic lymph node dissection (PLND) with RC since 1950, and in fact lymph node dissection is now recommended in contemporary National Comprehensive Cancer Network (NCCN) guidelines. Benefits of removing of nodal disease include improved staging, guidance for adjuvant treatment, and potentially improved oncologic outcomes. Advantages of dissection have been suggested among both node-negative and node-positive patients. Numerous studies have attempted to define the optimal dissection characteristics of lymphadenectomy with regard to nodal yield and anatomic boundaries of dissection. The ideal extent of lymphadenectomy remains uncertain due to the retrospective and non-randomized nature of the majority of existing reports, which are thereby limited by significant confounding and selection bias. Two randomized controlled trials have investigated this issue, one of which LEA AUO AB 25/02 recently reported its outcomes, demonstrating no significant improvement in 5-year outcomes with an extended dissection. Meanwhile, the Southwest Oncology Group 1011 trial has completed enrollment and data are maturing. While current data preclude definitive recommendations, herein we review the why, when, and how to perform a PLND for bladder cancer.

Lymph node dissection for bladder cancer: Current standards and the latest evidence

Lymph node dissection is an indispensable component of radical cystectomy for bladder cancer. Information obtained with lymph node dissection is highly predictive of patient survival, affecting decision-making for adjuvant therapy (diagnostic role). Also, lymph node dissection provides survival benefits in certain patients by removing metastasized nodes (therapeutic role). However, an optimal extent of lymph node dissection has not been established yet. Data from surgical mapping studies showed that approximately 10% of the primary lymphatic landing sites were common iliac nodes, suggesting that lymph node dissection below the common iliac bifurcation is suboptimal. Several retrospective studies have shown a possible survival advantage with more extended lymph node dissection. However, the results of the first prospective randomized controlled trial failed to prove the survival advantage of extended lymph node dissection up to the level of the inferior mesenteric artery, compared with lymph node dissection below the bifurcation of the common iliac artery. Currently, lymph node dissection templates recommended by major guidelines are not consistent with each other. Furthermore, the evidence is limited in the settings of neoadjuvant chemotherapy, robot-assisted surgery and high-risk non-muscle-invasive disease. Physicians need to decide the extent of lymph node dissection for each patient, taking into account the potential survival benefit and possible harms of extended lymph node dissection. Another randomized controlled trial is currently underway and will provide further evidence shortly.

An Epithelial-Mesenchymal Transition (EMT) Preoperative Nomogram for Prediction of Lymph Node Metastasis in Bladder Cancer (BLCA)

Lymph node (LN) metastasis is a lethal independent risk factor for patients with bladder cancer (BLCA). Accurate evaluation of LN metastasis is of vital importance for disease staging, treatment selection, and prognosis prediction. Several histopathologic parameters are available to predict LN metastasis postoperatively. To date, medical imaging techniques have made a great contribution to preoperatively diagnosis of LN metastasis, but it also exhibits substantial false positives. Therefore, a reliable and robust method to preoperatively predict LN metastasis is urgently needed. Here, we selected 19 candidate genes related to epithelial-mesenchymal transition (EMT) across the LN metastasis samples, which was previously reported to be responsible for the subtype transition and correlation with malignancy and prognosis of BLCA, to establish an EMT-LN signature through LASSO logistic regression analysis. The EMT-LN signature could significantly predict LN metastasis with high accuracy in the TCGA-BLCA cohort, as well as several independent cohorts. As integrating with C3orf70 mutation, we developed an individualized prediction nomogram based on the EMT-LN signature. The nomogram exhibited good discrimination on LN metastasis status, with AUC of 71.7% and 75.9% in training and testing datasets of the TCGA-BLCA cohort. Moreover, the EMT-LN nomogram displayed good calibration with p > 0.05 in the Hosmer-Lemeshow goodness of fit test. Decision curve analysis (DCA) revealed that the EMT-LN nomogram was of high potential for clinical utility. In summary, we established an EMT-LN nomogram integrating an EMT-LN signature and C3orf70 mutation status, which acted as an easy-to-use tool to facilitate preoperative prediction of LN metastasis in BLCA individuals.

The role of extended lymph node dissection in patients undergoing radical cystectomy

Radical cystectomy (RC) with a pelvic lymph node dissection (LND) is the gold standard for the treatment of muscle invasive bladder cancer (MIBC) as well as for some high-risk non-muscle invasive bladder cancers. The therapeutic advantage of LND, in terms of cancer-specific survival (CSS), still divides opinion and, certainly, the question of the extent of LND at the time of cystectomy is still debated. In this article, we have reviewed the evidence supporting the practice of extending LND in order to help clinicians determine what is appropriate in their practice. There still remains a lack of prospective randomized studies addressing whether extended LND provides a survival benefit in patients undergoing RC for BC. However, there is large body of evidence that suggests there is a positive impact on the oncological outcomes in these patients without an apparent cost of unacceptable adverse events.

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

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.

Pelvic lymph node dissection during radical cystectomy for muscle-invasive bladder cancer

Radical cystectomy is the gold-standard treatment option for muscle-invasive and metastatic bladder cancer. At the time of cystectomy, up to 25% of patients harbour metastatic lymph node deposits. These deposits most frequently occur in the obturator fossa, but can be as proximal as the interaortocaval region. Thus, the use of concurrent pelvic lymph node dissection (PLND) with cystectomy has been increasingly reported. Data from studies including many patients suggest substantial oncological benefit in PLND cohorts versus non-PLND cohorts, irrespective of pathological nodal status. Additionally, PLND provides useful prognostic information, including disease burden, lymph node density, and extracapsular extension of metastatic lymph nodes. Accordingly, the National Comprehensive Cancer Network guidelines advocate the use of PLND during radical cystectomy for muscle-invasive bladder cancer. Despite this recommendation, a lack of consensus exists regarding the optimal PLND template. Comparative series suggest that extended PLND provides improved recurrence-free survival and cancer-specific survival compared with more limited PLND templates. More extensive templates (such as super-extended PLND) provide no additional survival benefit at the potential cost of increased operative time and patient morbidity. In addition to extended PLND templates, increased nodal harvest confers an oncological benefit in patients with node-positive disease or in patients with node-negative disease. Accordingly, recommendations for a minimum nodal yield have been proposed. Despite the growing body of evidence, formal recommendations by oncological and urological authoritative bodies have been limited owing to the lack of randomized data and level I evidence.

Association of super-extended lymphadenectomy at radical cystectomy with perioperative complications and re-hospitalization

Purpose

We performed a retrospective analysis of patients treated with radical cystectomy and lymphadenectomy (LAD) for bladder cancer to assess the differential association of the extent of LAD with perioperative complications and re-hospitalization.

Materials and methods

LAD templates were defined as limited (lLAD = external, internal iliac and obturator), extended (eLAD = up to crossing of ureter and presacral lymph nodes), and super-extended (sLAD = up to the inferior mesenteric artery). Logistic regression models investigated the association of LAD templates with intraoperative, 30- and 30–90-day postoperative complications, as well as re-hospitalizations within 30 and 30–90 days.

Results

A total of 284 patients were available for analysis. sLAD led to a higher lymph-node yield (median 39 vs 13 for lLAD and 31 for eLAD, p < 0.05) and N2/N3 status compared to lLAD and eLAD (p = 0.04). sLAD was associated with a blood loss of > 500 ml (OR 1.3, 95% CI 1.08–1.49, p = 0.003) but not with intraoperative transfusion, operation time, or length of hospital stay (p > 0.05). Overall, 11 (4%) patients were readmitted within 30 days and 50 (17.6%) within 30–90 days. The 30- and 30–90-day mortality rates were 2.8% and 1.4%, respectively. On logistic regression, LAD template was not associated with postoperative complications or re-hospitalization rates.

Conclusions

sLAD leads to higher lymph-node yield and N2/N3 rate but not to higher complication rate compared to lLAD and eLAD. With the advent of novel adjuvant systemic therapies, precise nodal staging will have a crucial role in patients counseling and clinical decision making.

Electronic supplementary material

The online version of this article (10.1007/s00345-019-02769-9) contains supplementary material, which is available to authorized users.

Sentinel lymph node imaging in urologic oncology

Lymph node (LN) metastases in urological malignancies correlate with poor oncological outcomes. Accurate LN staging is of great importance since patients can benefit from an optimal staging, accordingly aligned therapy and more radical treatments. Current conventional cross-sectional imaging modalities [e.g., computed tomography (CT) and magnetic resonance imaging (MRI)] are not accurate enough to reliably detect early LN metastases as they rely on size criteria. Radical lymphadenectomy, the surgical removal of regional LNs, is the gold standard of invasive LN staging. The LN dissection is guided by anatomic considerations of lymphatic drainage pathways of the primary tumor. Selection of patients for lymphadenectomy heavily relies on preoperative risk stratification and nomograms and, as a result a considerable number of patients unnecessarily undergo invasive staging with associated morbidity. On the other hand, due to individual variability in lymphatic drainage, LN metastases can occur outside of standard lymphadenectomy templates leading to potential understaging and undertreatment. In theory, metastases from the primary tumor need to pass through the chain of LNs, where the initial node is defined as the sentinel LN. In theory, identifying and removing this LN could lead to accurate assessment of metastatic status. Radiotracers and more recently fluorescent dyes and superparamagnetic iron oxide nanoparticles (SPION) are injected into the primary tumor or peritumoral and the sentinel LNs are identified intraoperatively by a gamma probe, fluorescent camera or a handheld magnetometer. Preoperative imaging [e.g., single-photon emission computed tomography (SPECT)/CT or MRI] after tracer injection can further improve preoperative planning of LN dissection. While sentinel LN biopsy is an accepted and widely used approach in melanoma and breast cancer staging, its use in urological malignancies is still limited. Most data published so far is in penile cancer staging since this cancer has a typical echelon-based lymphatic metastasizing pattern. More recent data is encouraging with low false-negative rates, but its use is limited to centers with high expertise. Current guidelines recommend sentinel LN biopsy as an accepted alternative to modified inguinal lymphadenectomy in patients with pT1G2 disease and non-palpable inguinal LNs. In prostate cancer, a high diagnostic accuracy could be demonstrated for the sentinel approach. Nevertheless, due to lack of data or high false-negative rates in other urological malignancies, sentinel LN biopsy is still considered experimental in other urological malignancies. More high-level evidence and longitudinal data is needed to determine its final value in those malignancies. In this manuscript, we will review sentinel node imaging for urologic malignancies.

Risk factors for loco-regional recurrence after radical cystectomy of muscle-invasive bladder cancer: A systematic-review and framework for adjuvant radiotherapy

BACKGROUND

Radical cystectomy (RC) associated with pelvic lymph node dissection (PLND) is the most common local therapy in the management of non-metastatic muscle invasive bladder cancer (MIBC). Loco-regional recurrence (LRR), however, remains a common and important therapeutic challenge associated with poor oncologic outcomes. We aimed to systematically review evidence regarding factors associated with LRR and to propose a framework for adjuvant radiotherapy (RT) in patients with MIBC.

METHODS

We performed this systematic review in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. We searched the PubMed database for articles related to MIBC and associated treatments, published between January 1980 and June 2015. Articles identified by searching references from candidate articles were also included. We retrieved 1383 publications from PubMed and 34 from other sources. After an initial screening, a review of titles and abstracts, and a final comprehensive full text analysis of papers assessed for eligibility, a final consensus on 32 studies was obtained.

RESULTS

LRR is associated with specific patient-, tumor-, center- or treatment-related variables. LRR varies widely, occurring in as many as 43% of the cases and is strongly related to survival outcomes. While perioperative treatment does not impact on LRR, pathological factors such as pT, pN, positive margins status, extent of PLND, number of lymph nodes removed and/or invaded are correlated with LRR. Patients with pT3-T4a and/or positive lymph-nodes and/or limited pelvic lymph-node dissection and/or positive surgical margins have been distributed in LRR risk groups with accuracy.

CONCLUSIONS

LRR patterns are well-known and for selected patients, adjuvant treatments could target this event. Intrinsic tumor subtype may guide future criteria to define a personalized treatment strategy. Prospective trials evaluating safety and efficacy of adjuvant RT are ongoing in several countries.

Lymphadenectomy for Muscle-Invasive Bladder Cancer and Upper Tract Urothelial Cell Carcinoma

There are currently no reported randomized trials that characterize the staging or therapeutic benefit of performing a lymph node dissection in either bladder cancer or upper tract urothelial carcinoma. Several unanswered questions remain in this domain focused on the indications and patient selection for pelvic lymph node dissection, extent of dissection, its impact on outcome, and potential risks. However, the results of observational studies suggest that the burden of metastasis is high in both diseases when muscle invasive and performing a lymphadenectomy can provide prognostic information and yield therapeutic benefit.

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

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.

The anatomical limits and oncological benefit of lymphadenectomy in muscle invasive bladder cancer

BACKGROUND

Lymphadenectomy is part of standard treatment for muscle invasive bladder cancer. The objective of this review is to provide an up-to-date review on the available scientific evidence in this field.

ACQUISITION OF EVIDENCE

We conducted a literature review in PubMed of relevant articles up to the present (2016). We found a systematic review published in 2014 that included the comparative studies published up to that year, and we updated the review with new relevant publications since that date.

SYNTHESIS OF THE EVIDENCE

The number of lymph nodes is not the best indicator for determining the quality of the lymphadenectomy given that the number can vary depending on numerous factors that depend not only on the surgeon but also on the patient and on the pathologist. The definition of standard anatomical territories and a meticulous extraction of the lymph nodes in these territories are more reproducible than the numbers of nodes removed. The optimal extension of lymphadenectomy is a topic of debate. The evidence published to date indicates that any extension of lymphadenectomy is better than not performing it, although it appears that limited lymphadenectomy is insufficient for the oncological control of the disease and that superextended lymphadenectomy provides no oncological benefit versus extended lymphadenectomy.

CONCLUSIONS

Despite a certain amount of controversy in terms of the optimal extension of lymphadenectomy, performing lymphadenectomy in all cases appears to be recommendable according to the available evidence. Extended lymphadenectomy provides greater oncological benefit than more limited dissections, while more extensive lymphadenectomies are not recommended.

Adjuvant radiotherapy after radical cystectomy for muscle-invasive bladder cancer: A retrospective multicenter study

Objectives

Radical cystectomy (RC) and pelvic lymph-node dissection (LND) is standard treatment for non-metastatic muscle-invasive urothelial bladder cancer (MIBC). However, loco-regional recurrence (LRR) is a common early event associated with poor prognosis. We evaluate 3-year LRR-free (LRRFS), metastasis-free (MFS) and overall survivals (OS) after adjuvant radiotherapy (RT) for pathological high-risk MIBC.

Material and methods

We retrospectively reviewed data from patients in 3 institutions. Inclusion criteria were MIBC, histologically-proven urothelial carcinoma treated by RC and adjuvant RT. Patients with conservative surgery were excluded. Outcomes were evaluated by Kaplan-Meier method. Acute toxicities were recorded according to CTCAE V4.0 scale.

Results

Between 2000 and 2013, 57 patients [median age 66.3 years (45–84)] were included. Post-operative pathological staging was ≤pT2, pT3 and pT4 in 16%, 44%, and 39%, respectively. PLND revealed 28% pN0, 26% pN1 and 42% pN2. Median number of lymph-nodes retrieved was 10 (2–33). Forty-eight patients (84%) received platin-based chemotherapy. For RT, clinical target volume 1 (CTV 1) encompassed pelvic lymph nodes for all patients. CTV 1 also included cystectomy bed for 37 patients (65%). CTV 1 median dose was 45 Gy (4–50). A boost of 16 Gy (5–22), corresponding to CTV 2, was administered for 30 patients, depending on pathological features. One third of patients received intensity-modulated RT. With median follow-up of 40.4 months, 8 patients (14%) had LRR. Three-year LRRFS, MFS and OS were 45% (95%CI 30–60), 37% (95%CI 24–51) and 49% (95%CI 33–63), respectively. Five (9%) patients had acute grade ≥3 toxicities (gastro-intestinal, genito-urinary and biological parameters). One patient died with intestinal fistula in a septic context.

Conclusions

Because of poor prognosis, an effective post-operative standard of care is needed for pathological high-risk MIBC. Adjuvant RT is feasible and may have oncological benefits. Prospective trials evaluating this approach with current RT techniques should be undertaken.

A preliminary oncologic outcome and postoperative complications in patients undergoing robot-assisted radical cystectomy: Initial experience

PURPOSE

Robot-assisted radical cystectomy (RARC) was originally intended to replace open radical cystectomy (ORC) as a minimally invasive surgery for patients with invasive bladder cancer. The purpose of this study was to evaluate the advantages of robotic surgery, comparing perioperative and oncologic outcomes between RARC and ORC.

MATERIALS AND METHODS

Between June 2012 and August 2016, 49 bladder cancer patients were given a radical cystectomy, 21 robotically and 28 by open procedure. We compared the clinical variables between the RARC and ORC groups.

RESULTS

In the RARC group, the median estimated blood loss (EBL) during cystectomy, total EBL, operative time during cystectomy, and total operative time were 0 mL, 457.5 mL, 199 minutes, and 561 minutes, respectively. EBL during cystectomy (p<0.001), total EBL (p<0.001), and operative time during cystectomy (p=0.003) in the RARC group were significantly lower compared with the ORC group. Time to resumption of a regular diet (p<0.001) and length of stay (p=0.017) were also significantly shorter compared with the ORC group. However, total operative time in the RARC group (median, 561 minutes) was significantly longer compared with the ORC group (median, 492.5 minutes; p=0.015).

CONCLUSIONS

This Japanese study presented evidence that RARC yields benefits in terms of BL and time to regular diet, while consuming greater total operative time. RARC may be a minimally invasive surgical alternative to ORC with less EBL and shorter length of stay.

Beyond penile cancer, is there a role for sentinel node biopsy in urological malignancies?

This review aims to discuss the current state-of-the-art of sentinel node (SN) mapping in urological malignancies. The principles and methodological aspects of lymphatic mapping and SN biopsy in urological malignancies are reviewed. Literature search was restricted to English language. The references of the retrieved articles were examined to identify additional articles. The review also includes meta-analyses published in the past 5 years. SN biopsy for penile cancer is recommended by the European Association of Urology as the preferred staging tool for clinically node-negative patients with at least T1G2 tumours (level of evidence 2a, Grade B). The feasibility of SN biopsy in prostate cancer has been repeatedly demonstrated and its potential value is increasingly being recognised. However, conclusive prospective clinical data as well as consensus on methodology and patient selection are still lacking. For bladder, renal and testicular cancer, only few studies have been published, and concerns around high false-negative rates remain. Throughout the years, the uro-oncological field has portrayed a pivotal role in the development of the SN concept. Recent advances such as hybrid tracers and novel intraoperative detection tools such as fluorescence and portable gamma imaging will hopefully encourage prospectively designed clinical trials which can further substantiate the potential of the SN approach in becoming an integral part of staging in urological malignancies beyond penile cancer.

Extraperitoneal versus transperitoneal laparoscopic radical cystectomy for selected elderly bladder cancer patients: a single center experience

OBJECTIVE

This study reports the initial experience of extraperitoneal laparoscopic radical cystectomy (ELRC) and compared with transperitoneal laparoscopic radical cystectomy (TLRC) in the treatment of selected elderly bladder cancer patients.

PATIENTS AND METHODS

A total of forty male bladder cancer patients who underwent ELRC (n=19) or TLRC (n=21) with ureterocutaneostomy were investigated. Demographic parameters, perioperative variables, oncological outcomes and follow-up data were retrospectively analyzed.

RESULTS

A significantly shorter time to exsufflation (1.5±0.7 vs 2.1±1.1 d; p=0.026) and liquid intake (1.8±0.9 vs 2.8±1.9 d; p=0.035) were observed in the ELRC group compared with the TLRC group. The incidence of postoperative ileus in the ELRC group was lower than the TLRC group (0 vs 9.5%). However, the difference had no statistical significance (p>0.05). The removed lymph node number in the ELRC group was significantly lower than the TLRC group (p<0.001). No significant differences were observed between the two groups in the overall and cancer-free survival rates (p>0.05).

CONCLUSIONS

ELRC seems to be a safe and feasible surgical strategy for the selected elderly bladder cancer patients with ≤T2 disease. The surgical and oncological efficacy of the ELRC is similar to that of the TLRC, but with faster intestinal function recovery. Further studies with a large series including different urinary diversions are needed to confirm our results and to better evaluate the benefit of ELRC in bladder cancer patients.

Balancing risk and benefit of extended pelvic lymph node dissection in patients undergoing radical cystectomy

PURPOSE

The optimal extent of pelvic lymph node dissection (PLND) during radical cystectomy (RC) in patients with urothelial carcinoma of the bladder (UCB) is the subject of ongoing debate. In this study, we compared local recurrence-free and overall survival, in addition to complication rates, after extended PLND (ePLND) compared to standard PLND (sPLND).

METHODS

We reviewed the charts of 314 patients who underwent RC for UCB between 2008 and 2013. ePLND was performed in 105 patients, and 105 matched patients who underwent standard PLND (sPLND) were selected based on clinical parameters. Local recurrence-free and overall survival rates were assessed using Kaplan-Meier survival analysis, and Cox proportional hazards models were used to assess potential determinants of these outcomes. Complications were assessed at 30 and 90 days using the Clavien-Dindo reporting system.

RESULTS

More lymph nodes were removed by ePLND (median 21) compared to sPLND (median 9; P < 0.001), but the rate of nodal involvement was not different. In multivariable analysis, ePLND was associated with a better local recurrence-free survival (HR = 0.63, P = 0.005), but was not an independent predictor of overall survival (HR = 1.06, P = 0.84). Estimated blood loss was greater with ePLND (1047.3 vs. 584.5 ml P < 0.001), but there was no significant difference in complications.

CONCLUSIONS

Extended PLND appears to reduce the risk of local recurrence, but was not an independent predictor of overall survival in this cohort. ePLND was associated with greater blood loss compared to sPLND, but not with other perioperative complications.

Treatment and management of high-grade T1 bladder cancer: what should we do after second TUR?

Most T1 bladder cancers are high grade and have the potential to progress to muscle invasion and extravesical dissemination. Many studies reported that ∼50% of patients displayed residual tumors when a second transurethral resection was performed 2-6 weeks after the initial resection for patients who were diagnosed with T1 bladder cancer. Furthermore, muscle-invasive disease was detected by the second transurethral resection in 10-25% of those patients. Therefore, a second transurethral resection is strongly recommended for patients newly diagnosed with high-grade T1 bladder cancer in various guidelines. T1 bladder cancers are heterogeneous in terms of progression and prognosis after the second transurethral resection. Optimal management and treatment should be considered for patients with T1 bladder cancer based on the pathological findings for the second transurethral resection specimen. If the second transurethral resection reveals residual tumors, aggressive treatments based on the pathological findings should be performed. Conversely, overtreatment with respect to the tumor status should be avoided. Since the evidence of pathological diagnosis at the second transurethral resection is insufficient and many retrospective studies were carried out before the second transurethral resection era, prospective randomized studies should be conducted.

Lymphadenectomy with radical cystectomy at an Australian tertiary referral institution: time trends and impact on oncological outcomes

BACKGROUND

Lymph node dissection (LND) with radical cystectomy (RC) for surgical treatment of invasive urothelial carcinoma of the bladder can improve staging and has possible therapeutic benefit. The aim of this study was to assess utilization and extent of LND with RC at our institution and determine its impact on oncological outcomes.

METHODS

Using surgical databases and hospital coding, clinical and histopathological characteristics of 87 patients who underwent RC at Austin Health between 2004 and 2011 were retrospectively analysed. Associations of predictor variables with LND use and lymph node (LN) status were analysed using logistic regression. Survival analyses were undertaken using Cox proportional hazard models.

RESULTS

Fifty-eight (65.9%) patients underwent LND, with a clear trend over time in the proportion of patients undergoing LND (three of seven in 2004 up to 10 of 10 in 2011, P < 0.001) and the median (range) of LN yield from five (2-19) in 2004 to 18 (7-35) in 2011 (P < 0.001). Year of treatment was the only significant predictor (univariately and multivariately) of a patient undergoing LND. Multivariately, a significant association with nodal metastases was found for cN stage and planned extent of LND preoperatively, and pT stage postoperatively. LN status was associated significantly with recurrence-free survival with best outcomes in patients who were node-negative on a pelvic LND. A similar trend was seen for cancer-specific survival (P = 0.053).

CONCLUSIONS

Over the study period, there was an increase in the use of pelvic LND and LN numbers retrieved during RC. LN status appears to impact on recurrence-free survival, and possibly cancer-specific survival.

Regional differences in practice patterns and outcomes in patients treated with radical cystectomy in a universal healthcare system

INTRODUCTION

Our objective is to assess differences in practice patterns and outcomes across 3 regions in bladder cancer patients treated with radical cystectomy under a universal healthcare system.

METHODS

In total, we included 2287 patients treated with radical cystectomy at 8 Canadian centres from 1998 to 2008. Variables included various clinico-pathologic parameters, recurrence, and death stratified into different regions.

RESULTS

In total, 1105 patients were from the east region (group 1), 601 from the centre region (group 2), and 581 from the west region of Canada (group 3). The median follow-up of groups 1, 2, and 3 was 22.1, 17.1, and 28.6 months, respectively. Although the overall rate of neoadjuvant chemotherapy was low (3.1%), rates were higher in group 2 compared with groups 1 and 3 (p = 0.07). Continent diversions and extended lymphadenectomy were performed in 23.5%, 8.5%, 23.9% and 39.7%, 27.7%, 12.6% across groups 1, 2, and 3, respectively. There were statistically significant differences in gender distribution, performance of lymphadenectomy, presence of concomitant carcinoma in situ and lymphovascular invasion across the 3 groups. There were no differences among the 3 geographical locations in terms of stage, surgical margin status, and use of adjuvant chemotherapy. The mean number of days from the transurethral resection of the bladder tumour to cystectomy was 50, 79, 69 days for groups 1, 2, 3, respectively (p = 0.0006). The 5-year overall survival was 53.6%, 66.8%, and 52.4% for groups 1, 2 and 3, respectively (p < 0.0001).

CONCLUSIONS

Significant variations in practice patterns were noted across different geographic regions in a universal healthcare system. Use of continent diversions, extended lymphadenectomy, and neoadjuvant chemotherapy remains low across all 3 regions. Treatment delays are significant.

Lymph node-positive bladder cancer: surgical, pathologic, molecular and prognostic aspects

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.

18 F-fluorodeoxyglucose positron emission tomography-computed tomography for preoperative lymph node staging in patients undergoing radical cystectomy for bladder cancer: a prospective study

OBJECTIVES

The objective of our study was to analyze the diagnostic performance of (18) F-fluorodeoxyglucose positron emission tomography-computed tomography for lymph node staging in patients with bladder cancer before radical cystectomy and to compare it with that of computed tomography.

METHODS

A total of 52 patients operated on between 2005 and 2010 were prospectively included in this prospective, mono-institutional, open, non-randomized pilot study. Patients who had received neoadjuvant chemotherapy or radiotherapy were excluded. (18) F-fluorodeoxyglucose positron emission tomography-computed tomography in addition to computed tomography was carried out for lymph node staging of bladder cancer before radical cystectomy. Lymph node dissection during radical cystectomy was carried out. Findings from (18) F-fluorodeoxyglucose positron emission tomography-computed tomography and computed tomography were compared with the results of definitive histological examination of the lymph node dissection. The diagnostic performance of the two imaging modalities was assessed and compared.

RESULTS

The mean number of lymph nodes removed during lymph node dissection was 16.5 ± 10.9. Lymph node metastasis was confirmed on histological examination in 22 cases (42.3%). This had been suspected in five cases (9.6%) on computed tomography and in 12 cases (23.1%) on (18) F-fluorodeoxyglucose positron emission tomography-computed tomography. Sensitivity, specificity, positive predictive value, negative predictive value, relative risk and accuracy were 9.1%, 90%, 40%, 57.4%, 0.91 and 55.7%, respectively, for computed tomography, and 36.4%, 86.7%, 66.7%, 65%, 2.72, 65.4%, respectively, for (18) F-fluorodeoxyglucose positron emission tomography-computed tomography.

CONCLUSIONS

(18) F-fluorodeoxyglucose positron emission tomography-computed tomography is more reliable than computed tomography for preoperative lymph node staging in patients with invasive bladder carcinoma undergoing radical cystectomy.

Differences in histopathological evaluation of standard lymph node dissections result in differences in nodal count but not in survival

OBJECTIVE

To analyse whether the reported differences in nodal yield at pelvic lymph node dissection (PLND) for bladder cancer, between two hospitals, are reflected in the survival rates.

PATIENTS AND METHODS

We assessed follow-up data of all 174 patients (mean age: 62.7, median follow-up: 3 years) who underwent PLND between 1 January 2007 and 31 December 2009 at two different hospitals. PLND was performed according to a standardized template by the same urologists for comparable bladder cancer patients. Mean number of reported lymph nodes was 16 at hospital A versus 28 at hospital B. We compared the overall survival (OS), disease-specific survival (DSS) and recurrence-free survival (RFS) between both cohorts and performed a multivariate analysis.

RESULTS

The cumulative probability for 2-year OS, DSS and RFS for hospital A are 61, 64 and 54 %, versus 58, 58 and 53 % for hospital B, respectively. Kaplan-Meier survival curves did not reveal statistically significant differences between both groups (OS: p log-rank = 0.75, DSS: p log-rank = 0.56, and RFS: p log-rank = 0.80). Also after adjustment for pT stage and neoadjuvant chemotherapy, survival was not significantly different between hospital A and hospital B.

CONCLUSION

Despite differences in lymph node yield in PLND specimens, this study reveals no significant differences in survival outcomes between both hospitals. Standardized histopathological methods should be agreed upon by pathologists before integrating nodal yield and subsequent lymph node density as indicators of the quality of surgery and as prognostic factors.