A fourteen-year review of radical cystectomy for transitional cell carcinoma demonstrating the usefulness of the concept of lymph node density

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.

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.

Prognostic factors in radical cystectomy affecting survival

INTRODUCTION

The aim of the study was to evaluate the prognostic factors in radical cystectomy affecting survival.

MATERIAL AND METHODS

A total of 100 hundred patients were included in the study. Incontinent diversion was applied to 73 of these, and continent diversion to 27. Prospective and retrospective data of the patients were examined. The prognostic value for survival was evaluated for of lymph node involvement, tumor grade (low grade: grade 0-II, high grade: ≥ III or epidermoid carcinoma), tumor stage (low stage: stage pT0-2, high stage: stage ≥ 3a pT3a), presence of preoperative unilateral of bilateral hydronephrosis, presence of preoperative uremia (serum urea value: ≤ 60), and age (> 70 and ≤ 70 years of age) on survival were investigated. Kaplan-Meier survival analysis and Log-Rank statistical methods were used in the study.

RESULTS

Grade, stage, uremia, and lymph node involvement had significant effects on survival (p values 0.0002, 0.03, 0.01, and 0.02, respectively). Presence of preoperative hydronephrosis and age had no statistically significant effects on survival (p values 0.8 and 0.2, respectively).

CONCLUSIONS

Tumor grade, tumor stage, preoperative uremia, and lymph node involvement are prognostic factors affecting survival. Advanced age and presence of preoperative hydronephrosis have no prognostic value for survival. The presence of uremia in the preoperative assessment of the patients is more important than hydronephrosis.

Biomarkers vs conventional histological analysis to detect lymph node micrometastases in bladder cancer: a real improvement?

Study Type - Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Muscle invasive bladder cancer has a mortality rate at 5 years of 50%, despite radical therapy, as a result of tumour progression and dissemination. This suggests that half of patients have disseminated disease at the time of diagnosis, which is not detected by the staging techniques currently used. The prognostic factors (histological grade and tumour stage) and current staging techniques do not discriminate between those patients who will be cured with surgical treatment and those who will die from metastatic spread. New diagnostic and prognostic tools that complement the existing methods and provide a proper assessment of carcinoma invading bladder muscle are therefore essential. Molecular staging techniques using specific biomarkers have been applied in various solid tumours to determine the presence of missed tumour cells in lymph nodes (LNs) during routine pathological examination. These techniques could identify patients with LN micrometastases who may potentially benefit from early treatment with chemotherapy. This study compares the performance of conventional histological analysis and molecular biomarkers in detecting bladder cancer LN micrometastases and predicting patient's clinical outcome. The study found that, even though a clear trend to a worse outcome was shown in those patients who became node-positive after molecular analysis, no statistical differences were found in cancer-specific and recurrence-free survival analysis between those patients who were negative by histology but positive by molecular analysis and those who were negative by both techniques. We concluded that molecular analysis of LN spreading in bladder cancer has a better detection rate than conventional histological examination.

OBJECTIVE

• To improve the sensitivity of histological examination in detecting occult lymph node (LN) dissemination of bladder cancer using gene expression analysis.

PATIENTS AND METHODS

• We carried out a retrospective study that included 504 formalin-fixed paraffin-embedded LNs from 90 patients with muscle invasive bladder cancer and 35 controls. • Gene expression values of two molecular biomarkers (FXYD3 and KRT20) were analysed using reverse transcription real-time quantitative PCR (RT-qPCR). • Molecular results were compared with histological status and patients' clinical outcomes.

RESULTS

• Of the 90 patients analysed, 16 were positive and 74 were negative by histological analysis. Of these 74, 19 were classified as positive using RT-qPCR. • Significant differences in cancer-specific (P= 0.011) and recurrence-free (P= 0.009) survival were found between the three patient groups (patients positive by both techniques, patients negative by both techniques, and patients negative by histological but positive by molecular analysis). • A significant difference was not found between histologically negative but molecularly positive patients and patients who were negative by both techniques, but a clear trend to a worse outcome was found in those patients who became node-positive after molecular analysis.

CONCLUSIONS

• The analysis of FXYD3 and KRT20 could improve current pathological examination for the detection of micrometastases in LNs. • Further and more extensive studies will determine the real prognostic value of such LN micrometastases.

The impact of lymphadenectomy and lymph node metastasis on the outcomes of radical cystectomy for bladder cancer

CONTEXT

The presence of lymph node metastases and the extent of lymphadenectomy have both been shown to influence the outcome of patients with muscle-invasive bladder cancer.

OBJECTIVE

Current standards for detection of lymph node metastases, lymph-node mapping studies, histopathologic techniques, and risk factors in relation to lymph node involvement are discussed. The impact of lymph node metastases and the extent of lymphadenectomy on the outcome of patients treated with radical cystectomy are analyzed.

EVIDENCE ACQUISITION

A systematic literature review of bladder cancer and lymph nodes was performed searching the electronic databases Pubmed/Medline, Cochrane, and Embase. Articles were selected based on title, abstract, study format, and content by a consensus of all participating authors.

EVIDENCE SYNTHESIS

Lymph node status is highly consequential in bladder cancer patients because the presence of lymph node metastases is predictive of poor outcome. Knowledge of primary landing sites of lymph node metastases is important for optimum therapeutic management. Accurate pathologic work-ups of resected lymph node tissue are mandatory. Molecular markers could potentially guide therapeutic decisions in the future because they may enable the detection of micrometastatic disease. In current series, radical cystectomy with an extended lymphadenectomy seems to provide a clinically meaningful therapeutic benefit compared with a limited approach. However, the anatomic boundaries of lymph node dissection are still under debate. Therefore, large prospective multicenter trials are needed to validate the influence of extended lymph node dissection on disease-specific survival.

CONCLUSIONS

An extended pelvic lymph node dissection (encompassing the external iliac vessels, the obturator fossa, the lateral and medial aspects of the internal iliac vessels, and at least the distal half of the common iliac vessels together with its bifurcation) can be curative in patients with metastasis or micrometastasis to a few nodes. Therefore, the procedure may be offered to all patients undergoing radical cystectomy for invasive bladder cancer.

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.