Lymphadenectomy for invasive bladder cancer: I. historical perspective and contemporary rationale

Multiomics analysis of ferroptosis-related molecular subtypes in muscle-invasive bladder cancer immunotherapy

BACKGROUND

The purpose of this study was to identify the ferroptosis-related molecular subtypes in muscle invasive bladder cancer (MIBC) associated with the tumor microenvironment (TME) and immunotherapy.

METHODS

Expression profiles and corresponding clinical information were obtained from The Cancer Genome Atlas (TCGA) dataset and the Gene Expression Omnibus (GEO) dataset. Nonnegative matrix factorization (NMF) analysis was performed to identify two molecular subtypes based on 41 ferroptosis-related prognostic genes. The differences between the two subtypes were compared in terms of prognosis, somatic mutations, gene ontology (GO), cytokines, pathways, immune cell infiltrations, stromal/immune scores, tumor purity and response to immunotherapy. We also constructed a risk prediction model using multivariate Cox regression analysis to analyze survival data based on differentially expressed genes (DEGs) between subtypes. In combination with clinicopathological features, a nomogram was constructed to provide a more accurate prediction for overall survival (OS).

RESULTS

Two molecular subtypes (C1 and C2) of MIBC were identified according to the expression of ferroptosis-related genes. The C2 subtype manifested poor prognosis, high enrichment in the cytokine-cytokine receptor interaction pathway, high abundance of immune cell infiltration, immune/stromal scores and low tumor purity. Additionally, C2 is less sensitive to immunotherapy. The risk prediction model based on five pivotal genes (SLC1A6, UPK3A, SLC19A3, CCL17 and UGT2B4) effectively predicted the prognosis of MIBC patients.

CONCLUSIONS

A novel MIBC classification approach based on ferroptosis-related gene expression profiles was established to provide guidance for patients who are more sensitive to immunotherapy. A nomogram with a five-gene signature was built to predict the prognosis of MIBC patients, which would be more accurate when combined with clinical factors.

Quantitative Analysis of Enhanced Computed Tomography in Differentiating Cystitis Glandularis and Bladder Cancer

Objective

This study was performed to assess the value of quantitative analysis of enhanced computed tomography (CT) values in the differential diagnosis of bladder cancer and cystitis glandularis (CG).

Methods

Eighty patients with bladder masses (39 with CG and 41 with bladder cancer) who underwent enhanced CT were retrospectively reviewed. The CT enhancement values of the lesion and normal bladder wall in the arterial phase, venous phase, and delayed phase were measured. The relative enhancement CT values (relative enhancement CT value = enhancement CT value of lesion - enhancement CT value of normal bladder) in the arterial phase, venous phase, and delayed phase were also calculated. The pathological results were used as the gold standard, and the area under the curve (AUC), sensitivity, and specificity were calculated for the six groups of quantitative indicators (enhanced CT values and relative enhanced CT values of CG and bladder cancer in the arterial, venous, and delayed phases). We performed the leave-group-out cross-validation method to validate the accuracy, AUC, sensitivity, and specificity. The differences in accuracy, AUC, sensitivity, and specificity among the six groups of quantitative indicators were compared by the t-test.

Results

In a combined analysis of the AUC, sensitivity, and specificity performance, the best indicator was the arterial-phase relative enhancement CT value with a cut-off of 25.85 HU (AUC, 0.966; sensitivity, 95.1%; specificity, 92.3%). We used the 100-times leave-group-out cross-validation method to validate the accuracy, AUC, sensitivity, and specificity. Arterial-phase relative enhancement CT values showed the highest AUC and accuracy among the six groups, with statistical significance (P < 0.05).

Conclusion

Quantitative analysis of enhanced CT is of great clinical value in the differential diagnosis of CG and bladder cancer.

Risk factors and oncological outcomes of urethral recurrence in male patients with muscle invasive bladder cancer after radical cystectomy combined with urinary diversion: a propensity score-matched case control study

BACKGROUND

Radical cystectomy (RC) is the primary treatment strategy for muscle invasive bladder cancer (MIBC). However, it carries a high risk of urethral recurrence (UR) in male patients. The risk factors and oncological outcomes of UR remain unclear. We aimed to identify the risk factors and oncological outcomes of UR in male patients with MIBC after RC combined with urinary diversion.

METHODS

After propensity score matching, we evaluated 137 male patients with MIBC who underwent RC combined with urinary diversion at our center between January 1, 2007 and December 31, 2015. Patient demographics, comorbidity, and perioperative data were recorded. Univariate and multivariate Cox proportional hazards regression were used to estimate the hazard ratio and 95% confidence intervals. Cancer-specific survival (CSS) and overall survival (OS) were measured using the Kaplan-Meier curve with log-rank test. P < 0.05 was considered statistically significant.

RESULTS

Of the 310 patients, 30 (9.7%) patients underwent UR. In the matched group, the independent risk factors of UR were history of TURB (HR = 3.069, P = 0.018), tumor stage (T3 vs. T2, HR = 3.997, P = 0.014; T4 vs. T2, HR = 2.962, P = 0.015), and tumor multifocality (HR = 2.854, P = 0.011). The CSS and OS of patients with UR were equivalent to the patients without UR (P = 0.295, P = 0.616).

CONCLUSION

This propensity score-matched case-control study showed that UR is not rare in male patients with MIBC after RC combined with urinary diversion. We identified three independent risk factors of UR: history of TURB, tumor stage, and tumor mutifocality. The oncological outcomes were equivalent between patients with and without UR. These findings could help improve treatment strategies and follow-up schedules.

Risk factors of calculi in upper urinary tract after radical cystectomy with urinary diversion

INTRODUCTION AND OBJECTIVES

The study was conducted to identify the risk factors of upper tract stone formation in patients with diversions after radical cystectomy (RC).

MATERIALS AND METHODS

All patients with diversion after RC were collected in our center from January 2005 to December 2013. Three different common diversions were included: Orthotopic neobladder (ON: 168 patients), Ileal Conduit (IC: 93 patients) or Ureterocutaneostomy (UC: 104 patients). Univariable and multivariable logistic regression analysis were conducted to identify the independent predictors of stone formation in the upper tract.

RESULTS

A total of 365 consecutive patients (316 males, 49 females) were included. At a median follow-up of 48 months (range 12-65 months), 36 patients (9.9%) developed upper tract stone. Among them, 26 (72.2%), 5 (13.9%) and 5 (13.9%) patients underwent ON, IC and UC, respectively. 25 patients had renal stone and 11 ureter stone. Minimally invasive operations (endoscopic laser lithotripsy via the anterograde or retrograde approach in 24 cases, percutaneous nephrolithotomy in 9 cases and shock wave lithotripsy in 3 cases) were carried out successfully in all stone cases. On univariable and multivariable logistic regression analysis, diabetes mellitus, hypertension, urinary tract infection (UTI), anastomotic stenosis and types of diversions (P<.05) were positively associated with upper tract stone formation.

CONCLUSIONS

The variable predictors of upper tract stone may contain diabetes mellitus, hypertension, UTI, anastomotic stenosis and types of diversion.

Superior efficacy of neoadjuvant chemotherapy and radical cystectomy in cT3-4aN0M0 compared to cT2N0M0 bladder cancer

In this study, we compared complete pathological downstaging (pCD, ≤(y)pT1N0) and overall survival (OS) in patients with cT2 versus cT3-4aN0M0 UC of the bladder undergoing radical cystectomy (RC) with or without neoadjuvant chemo- (NAC) or radiotherapy (NAR). A population-based sample of 5,517 patients, who underwent upfront RC versus NAC + RC or NAR + RC for cT2-4aN0M0 UC between 1995-2013, was identified from the Netherlands Cancer Registry. Data were retrieved from individual patient files and pathology reports. pCD-rates were compared using Chi-square tests and OS was estimated by Kaplan-Meier analyses. Multivariable analyses were conducted to determine odds (OR) and hazard ratios (HR) for pCD-status and OS, respectively. We included 4,504 (82%) patients with cT2 and 1,013 (18%) with cT3-4a UC. Median follow-up was 9.2 years. In cT2 UC, pCD-rate was 25% after upfront RC versus 43% (p < 0.001) and 33% (p = 0.130) after NAC + RC and NAR + RC, respectively. In cT3-4a UC, pCD-rate was 8% after upfront RC versus 37% (p < 0.001) and 16% (p = 0.281) after NAC + RC and NAR + RC, respectively. In cT2 UC, 5-year OS was 57% and 51% for NAC + RC and upfront RC, respectively (p = 0.135), whereas in cT3-4a UC, 5-year OS was 55% for NAC + RC versus 36% for upfront RC (p < 0.001). In multivariable analysis for OS, NAC was beneficial in cT3-4a UC (HR: 0.67, 95%CI 0.51-0.89) but not in cT2 UC (HR: 0.91, 95%CI 0.72-1.15). NAR did not influence OS. In conclusion, NAC + RC was associated with superior pCD compared to RC alone and NAR + RC. Superior OS for NAC + RC compared to RC alone was especially evident in cT3-4a disease.

Study of Clinicopathological Spectrum and Pattern of Expression of Cyclooxygenase‑2 in Urothelial Carcinomas of Bladder

Introduction: Overexpression of cyclooxygenase-2 (COX2) in urothelial carcinoma of bladder (UCB) had been studied in the past by different workers and the results were contradictory. The objective of the present study was to evaluate the prognostic implication of COX2 expression in primary urothelial carcinomas of the urinary bladder and its correlation with clinical parameters, tumor stage, grade, and recurrence. Materials and methods: A total of 68 cases who underwent surgery for urothelial carcinoma in our medical college from January 2013 to December 2015 were evaluated in our study. Hematoxylin and eosin-stained slides were examined by two faculties applying standard reporting protocol. Tumor staging and grading was performed as per the WHO guidelines. Immunohistochemistry for expression of COX2 was performed to study any correlation of tumor grade with COX2 expression. The distribution of COX2 positivity was studied in tumors stratified according to established bladder cancer prognostic factor, for example, tumor size, grade, invasion, and spread. Results: Out of 68 cases, 42 cases showed COX2 positivity (61%). In low-grade cases of bladder carcinoma, COX2 positivity was 16 out of 24 cases (60%), and in high-grade cases, COX2 positivity was 10 out of 18 cases (64.28%).Conclusion: In the present study, the association of COX2 overexpression with advanced tumor invasion and tumor grade has been substantiated. Hence, COX2 expression can be taken as a prognostic factor along with other usual prognostic factors in patients of UCB.

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 dissection in bladder cancer: Where do we stand?

Radical cystectomy with lymphadenectomy remains the standard-of-care treatment for muscle-invasive bladder cancer. Lymphadenectomy is a central component of the operation because it continues to play both diagnostic and therapeutic roles. Routinely available preoperative imaging has limited diagnostic accuracy as it relies mostly on size to identify nodal metastasis increasing the value of lymphadenectomy. While the merits of lymphadenectomy are not in question, the extent of lymphadenectomy required to provide maximum benefit while limiting morbidity remains controversial. Furthermore, although robotic-assisted surgery has gained popularity in many centers, concern remains regarding the learning curve required and skill needed to replicate the quality of an open lymphadenectomy. Research efforts have been focused on these unresolved issues, and several trials are currently ongoing to help address these knowledge deficit areas. In this update, we will focus on the current state of lymphadenectomy for bladder cancer and highlight recent advances.

Clinical, demographic and histopathological prognostic factors for urothelial carcinoma of the bladder

INTRODUCTION

Our aim is to evaluate the influence of clinical and histopathological parameters, including age, gender, tumor stage, grade, tumor differentiation, necrosis, lymphovascular/perineural invasion (LVI/PNI) and concomitant carcinoma in situ (CIS), on outcomes of patients with urothelial carcinoma of the bladder (UCB).

MATERIAL AND METHODS

A total of 84 patients who underwent radical cystectomy (RC) (n = 11) and radical cystoprostatectomy (n = 73) for muscle-invasive bladder cancer at our hospital between 2007-2013, were included in the study.

RESULTS

The mean age of patients at diagnosis was 66.1, of whom 75 were males and 9 were females. Of the 84 patients, 38 were ≤65 years and 46 were >65 years. Mean tumor diameter was 3.66 cm. There were 38 cases which showed divergent differentiations. Concomitant CIS was observed in 30 tumors, 41 cases showed tumor necrosis, 44 PNI and 61 LVI. The rate of overall survival (OS) in patients aged ≤65 years was statistically significantly higher than in those aged >65 years. A negative statistical relationship was found between OS with lymph node metastasis (LNM) and tumor differentiation. On the other hand, necrosis did not remain significant on multivariate analysis. No statistically significant relationship was found between smoking, tumor stage, PNI, LVI and concomitant CIS and OS.

CONCLUSIONS

In this study, advanced age, LNM, tumor differentiation were found to be independent prognostic risk factors associated with OS after RC. These additional factors, which may explain the different clinical course in patients with similar tumor stage and lymph node status, should be taken into consideration in treatment planning.

MiRNA-141 and miRNA-200b are closely related to invasive ability and considered as decision-making biomarkers for the extent of PLND during cystectomy

Background

MicroRNAs (miRNAs) are small non-coding RNAs that silence their cognate target genes by specifically binding and cleaving messenger RNAs or inhibiting their translation. In this study, we explored whether miRNA-141 and miRNA-200b are involved in regulation of the invasive ability and epithelial–mesenchymal transition (EMT) of bladder cancer cells in vitro. We also evaluated their potential as biomarkers for deciding the extent of pelvic lymph node dissection (PLND) required during radical cystectomy.

Methods

Pri- and anti-miR cell lines were constructed. The invasive capacity of the cells was tested using a cell invasion assay. The MMP-2, MMP-9 and EMT-related markers were validated through Western blotting analysis. Seventy-eight urine samples from patients undergoing cystectomy and super-extended lymph node dissection were evaluated by qRT-PCR.

Results

Loss of expression of miRNA-141 and miRNA-200b was associated with increased invasion and migration ability, upregulated MMP-2, MMP-9, vimentin and N-cadherin expression, and downregulated E-cadherin expression in bladder cancer cell lines. Urine miRNA-141 and miRNA-200b levels could discriminate patients with lymph node metastasis from those who were lymph node negative (AUC: 0.704 and 0.674, respectively).

Conclusion

MiRNA-141 and miRNA-200b play important roles in the invasive ability and EMT phenotype of bladder cancer. Detection of miRNA-141 and miRNA-200b can help to identify patients undergoing cystectomy who are likely to have lymph node metastasis, and therefore those who may benefit from super-extended PLND.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-015-1110-7) contains supplementary material, which is available to authorized users.

Prognostic markers in renal cell carcinoma: A focus on the 'mammalian target of rapamycin' pathway

Objectives

Increased knowledge about the molecular pathways involved in tumorigenesis has led to the discovery of new prognostic molecular markers and development of novel targeted therapies for renal cell carcinoma (RCC). In this review we describe the prognostic markers of RCC and highlight the areas of recent discovery with a focus on the mammalian target of rapamycin (mTOR) pathway.

Methods

We reviewed previous reports, using PubMed with the search terms ‘renal cell carcinoma’, ‘molecular markers’, ‘prognosis’, ‘outcomes’ and ‘mammalian target of rapamycin pathway’ published in the last two decades. We created a library of 100 references and focused on presenting the recent advances in the field.

Results

Growing evidence suggests that mTOR deregulation is associated with many types of human cancer, including RCC. Consequently, temsirolimus and everolimus, which target mTOR, are approved for treating advanced RCC. There is a demand to integrate clinical, pathological and molecular markers into accurate prognostic models to provide patients with the most personalised cancer care possible.

Conclusions

The mTOR pathway is highly implicated in RCC tumorigenesis and progression, and its constituents might represent a promising prognostic tool and target for treating RCC. Combining newly discovered molecular markers with classic clinicopathological prognostics might potentially improve the management of RCC.

Variation in use of lymph node dissection during radical cystectomy for bladder cancer

OBJECTIVES

To better inform avenues for improving the quality of bladder cancer care, we evaluated whether the variation in pelvic lymph node dissection during radical cystectomy was primarily due to the patient or the surgeon. In the clinical guidelines, pelvic lymph node dissection has been recommended as an adjunct to radical cystectomy. However, its use and extent have varied across providers and regions.

METHODS

Using the national Surveillance, Epidemiology, and End Results-Medicare linked data for 1992-2005, we identified 4472 patients who had undergone radical cystectomy for bladder cancer. Generalized linear multilevel models were fit to assess the relationships between patient and surgeon characteristics and the use and extent (≥10 nodes) of lymphadenectomy. Using a similar modeling framework, we partitioned the variation between the patient and surgeon levels.

RESULTS

Of the 4472 patients who underwent radical cystectomy, 3124 (69.9%) had undergone concurrent lymph node dissection. Of those undergoing lymphadenectomy, only 22% had ≥10 nodes removed. The use of node dissection was primarily determined by the surgeon, which explained 57% of the variation, compared with the patient and disease, which explained only 4.5% of the variability. In contrast, patient level factors explained most of the variation in whether a patient had ≥10 nodes removed.

CONCLUSIONS

Pelvic lymph node dissection is relatively common during radical cystectomy, although nearly 1 in 3 patients do not undergo the procedure. Our results also showed that the physician a patient sees for their bladder cancer matters more than the disease severity in terms of the patient receiving recommended care.

Role of lymphadenectomy for invasive bladder cancer

Radical cystectomy with lymph node dissection remains the standard of care in the treatment of muscle-invasive and refractory non-invasive bladder cancer. Over the past decade, the extent of lymphadenectomy has varied to include dissection up to the common iliac vessels and aortic bifurcation proximally (may also extend up to the level of the inferior mesenteric artery), the genitofemoral nerve laterally, the circumflex iliac vein and lymph node of Cloquet distally, and the hypogastric vessels posteriorly (obturator fossa, presciatic nodes bilaterally and the presacral lymph nodes over the sacral promontory). Evidence supports the role of lymphadenectomy as both a therapeutic and prognostic variable in patients with invasive bladder cancer. We review the literature regarding the role and extent of lymphadenectomy, as well as its impact on patient outcomes.

Does extended lymphadenectomy preclude laparoscopic or robot-assisted radical cystectomy in advanced bladder cancer?

PURPOSE OF REVIEW

Open radical cystectomy with an appropriate bilateral lymph node dissection (LND) is currently the standard treatment for patients with muscle-invasive bladder cancer. Approximately 25% of patients with stages T1-T4 N0 M0 harbour metastatic lymph nodes at the time of radical cystectomy. Results from open high volume radical cystectomy series suggest that a more extended LND provides the best survival outcomes and the lowest local recurrence rates. Currently, there is controversy whether laparoscopic or robot-assisted extended LND at radical cystectomy is technically feasible and whether it can provide oncological control equivalent to open LND series at the time of radical cystectomy.

RECENT FINDINGS

Laparoscopic LND is technically demanding and requires prolonged operation time. Most studies to date indicate that fewer nodes are removed than with an open approach, putting a question mark to this surgical approach from an oncological point of view. Limited data on lymph node yield using a robot-assisted approach are available; however, several series found similar results as in open series.

SUMMARY

At present, there is no conclusive evidence showing that laparoscopic LND gives similar results than open LND. Robot-assisted LND is still in its learning curve and more patient series are needed.

Partial cystectomy does not undermine cancer control in appropriately selected patients with urothelial carcinoma of the bladder: a population-based matched analysist

OBJECTIVES

Cancer control outcomes after partial cystectomy (PC) are not well studied. We compared the population-based rates of overall (OS) and cause-specific survival (CSS) in patients with urothelial carcinoma of the urinary bladder (UCB) treated with PC or radical cystectomy (RC).

METHODS

Within the Surveillance Epidemiology and End Results-9 database, we identified 7243 patients treated with PC (n = 1573) or RC (n = 5670), who had pathologic T(1-4)N(1-2)M(0) UCB. Matched Kaplan-Meier survival analyses compared the effect of PC vs RC on OS and CSS.

RESULTS

In the entire cohort, the OS and CSS estimates at 5 years were 57.2% and 76.4%, respectively, for PC patients and 50.2% and 65.8%, respectively, for RC patients (P < .001). In the cohort matched for age, race, pT stage, pN stage, tumor grade, and year of surgery, at 5 years the OS and CSS estimates were 56.0% and 73.5%, respectively, for PC patients, and 50.9% and 67.5%, respectively, for RC patients (OS, P = .03 and CSS, P < .001). When the number of removed lymph nodes was added to the matching criteria, the 5-year OS and CSS estimates were 57.2% and 70.3%, respectively, for PC patients, and 54.6% and 69.2%, respectively, for RC patients (HR 1.1, P = .3 and HR 1.1, P = .5).

CONCLUSIONS

Partial cystectomy does not undermine cancer control in appropriately selected patients with UCB.

The association between extent of lymphadenectomy and survival among patients with lymph node metastases undergoing radical cystectomy

BACKGROUND

Long-term survival in patients with lymph node-positive bladder cancer who undergo cystectomy suggests a therapeutic role for lymphadenectomy. The objective of this study was to describe the association between extent of lymphadenectomy and survival in lymph node-positive patients who underwent radical cystectomy.

METHODS

The cohort consisted of patients from the Surveillance, Epidemiology, and End Results registry with transitional cell carcinoma who underwent cystectomy with lymphadenectomy and had at least 1 positive lymph node and no distant metastases. The Kaplan-Meier method and multivariate Cox proportional-hazards regression analyses were used to estimate differences in survival among different lymphadenectomy variables.

RESULTS

In total, 1260 patients had at least 1 positive lymph node. A median of 9 lymph nodes were removed (range, 1-48 lymph nodes) with a median of 2 positive lymph nodes (range, 1-18 positive lymph nodes), and the median lymph node density was 22%. In multivariate analysis controlling for patient demographics, tumor classification, and year of diagnosis, the number of positive and total lymph nodes removed remained independent predictors of survival. There was an inverse association between the number of lymph nodes removed and the risk of death for all quartiles. Removal of > 10 lymph nodes was associated with increased overall survival (hazard ratio, 0.52; 95% confidence interval, 0.43-0.64). In addition, with a lymph node density from 0.1% to 12.5% as the referent group, each higher quartile experienced worse survival.

CONCLUSIONS

An increased number of lymph nodes removed at the time of cystectomy was associated with improved survival in patients with lymph node-positive bladder cancer. Improved survival was observed at a lower lymph node density threshold than previously reported. The current findings support performing a more extensive lymphadenectomy at the time of cystectomy.

Open radical cystectomy with lymphadenectomy remains the treatment of choice for invasive bladder cancer

PURPOSE OF REVIEW

Radical cystectomy with an appropriate lymph node dissection and an appropriate form of urinary diversion is the standard treatment for muscle-invasive transitional cell carcinoma of the bladder. Optimal outcomes following radical cystectomy require an extended lymph node dissection, negative surgical margins, and a continent urinary diversion. There has been an increasing number of reports describing initial experiences with laparoscopic radical cystectomy.

RECENT FINDINGS

Intermediate and long-term oncologic outcomes with laparoscopic radical cystectomy remain undefined, and appropriate lymph node dissections laparoscopically have not been uniformly performed. Furthermore, the long-term functional outcomes associated with laparoscopically performed urinary diversions also remain undefined. There appears to be a recent trend toward performing the urinary diversion portion of the procedure extracorporeally, after laparoscopic removal of the bladder. Some studies suggest a decrease in postoperative analgesic requirements and quicker recovery of bowel function in those undergoing laparoscopic radical cystectomy, but these observations have not been corroborated by others.

SUMMARY

In the absence of long-term functional and oncologic outcome data, laparoscopic radical cystectomy should be considered an investigative technique, and potential candidates for this operation should be appropriately counseled.

The role of lymphadenectomy in patients undergoing radical cystectomy for bladder cancer

The role of regional lymph node dissection (LND) in surgical management of high-grade, invasive transitional cell carcinoma of the bladder has evolved over the past several decades. The current concepts and rationale for LND in patients undergoing radical cystectomy for bladder cancer are reviewed and discussed. Evidence suggests that a more extended LND (with cephalad extent to include at least the common iliac vessels) for lymph node-positive and -negative patients undergoing radical cystectomy for bladder cancer may provide therapeutic benefits in addition to prognostic information. Lymph node density also provides risk stratification for lymph node-positive patients and may reduce the surgical bias and extent of the LND, both of which are currently not standardized. Although the absolute limits of the LND remain to be determined, an evolving body of data supports a more extended LND at the time of cystectomy in appropriate surgical candidates.

[The usefulness of pelvic lymphadenectomy in bladder cancer]

OBJECTIVE

[corrected] To assess the usefulness of pelvic lymphadenectomy in bladder cancer.

METHODS AND RESULTS

With the followings key words: "bladder cancer, lymphadenectomy, lymph node metastasis" we search in Medline/PubMed database for papers published during the last ten years. Thirty three papers fulfilling the search criteria were selected.

CONCLUSIONS

It does not exist any randomized prospective study comparing different pelvic lymphadenectomy techniques. Nodal metastasis in bladder cancer after radical cystectomy and pelvic lymphadenectomy ranged between 18% and 28%. Standard lymphadenectomy could improve tumor staging and probably survival in selected patients. It is advisable to remove, as a quality parameter, at least 10 to 14 nodes in a pelvic lymphadenectomy. Lymph node density seems to predict survival better than TNM staging system. It is advisable to perform separate lymph node dissection rather than en-bloc.

Radical cystectomy with extended lymphadenectomy: evaluating separate package versus en bloc submission for node positive bladder cancer

PURPOSE

To provide future mapping analysis of lymph node positive disease we modified our lymphadenectomy at radical cystectomy for bladder cancer from an en bloc packet to 13 separate nodal packets. We evaluated the clinical and pathological findings resulting from this modification.

MATERIALS AND METHODS

A total of 1,359 patients underwent en bloc radical cystectomy and extended lymphadenectomy for bladder cancer. They were compared to 262 patients who underwent radical cystectomy and extended lymphadenectomy with lymph nodes submitted in 13 distinct nodal packets. Overall 317 patients (23%) of the en bloc group (group 1) and 66 of the 262 (25%) in the separately packaged group (group 2) had node positive disease. Clinical and pathological findings were analyzed to compare these 2 groups of patients.

RESULTS

Although the incidence of lymph node positivity was not different, the median number of total lymph nodes removed in group 2 was significantly higher than that in group 1 (68, range 14 to 132 vs 31, range 1 to 96, p<0.001). A trend toward more lymph nodes involved was observed in group 2 compared to group 1 (3, range 1 to 91 vs 2, range 1 to 63, p=0.062). These findings significantly lowered median lymph node density in group 2 compared to that in group 1 (6% vs 9%, p=0.006).

CONCLUSIONS

Although the overall incidence of lymph node positive disease was not different, the submission of 13 separate nodal packets at radical cystectomy significantly increased the total number of lymph nodes removed/analyzed and identified a slightly higher number of positive lymph nodes compared to en bloc submission.

The prognostic and staging value of lymph node dissection in the treatment of invasive bladder cancer

Regional lymph node dissection (LND) at the time of radical cystectomy is an essential component of the surgical management of invasive bladder cancer and might provide diagnostic and therapeutic benefits for both node-negative and node-positive patients. The benefits obtained in pathologically node-negative patients might result from more complete resection of undetected micrometastases or from a more meticulous surgical technique. Advanced nodal disease also seems to be amenable to thorough surgical resection in a subpopulation of patients with bladder cancer. Despite the growing body of evidence to support the role of a more extended LND, no guidelines regarding the optimal boundaries of LND have been established. An increased number of resected nodes and wider LND boundaries have been associated with improved local disease control and prolonged survival. Additionally, mapping series indicate that the common iliac and presacral nodal regions are more frequently involved with tumor metastases than previously recognized. Efforts to limit any unnecessary dissection in patients at low risk for metastases--a tailored approach--has been proposed, but remains unproven. From the available evidence, the most reliable diagnostic and therapeutic approach to LND includes the routine extended LND in all patients undergoing cystectomy with curative intent.

Improving outcomes with radical cystectomy for high-grade invasive bladder cancer

It is clear that the optimal clinical outcomes in bladder cancer patients requiring radical cystectomy are related to standard histopathologic variables of tumor grade, stage and lymph node status. However, other less well defined variables are also critical to the successful outcomes of these patients. Patients with muscle invasive bladder cancer and treating physicians should avoid unnecessary and significant treatment delays. In addition, hospital and surgeon-volume/experience are thought to be factors that may too be important components that relate to the clinical outcomes of patients following surgery. Lastly, there is a growing body of literature to support the concept of an appropriate lymphadenectomy at the time of surgery, for both node-positive and node-negative bladder cancer patients. It is becoming more obvious that there are multiple variables involved in the clinical success and outcomes of patients with bladder cancer following radical cystectomy. As treating physicians and surgeons we must be aware of these components to ensure the best outcomes for our patients.