Extended lymph node dissection in patients with urothelial cell carcinoma of the bladder: can it make a difference?

Holmer, Magnus; Bendahl, Pär‐Ola; Davidsson, Thomas; Guðjónsson, Sigurður; Månsson, Wiking

doi:10.1007/s00345-008-0366-9

Cited by 42 publications

(34 citation statements)

References 17 publications

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“…They found a survival benefit of extended LND in patients with non-organ confined disease. 7 This is in agreement with the findings of the present study and the two-center study published by Dhar et al 6 Methodologically limitations are, however, encountered in follow-up studies using different historical cohorts or cohorts from different institutions. A more favorable prognosis might not exclusively be the result of a change in surgical procedure.…”

Section: Discussionsupporting

confidence: 93%

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

Hellenthal

2011

Int J of Urology

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Abbreviations & Acronyms CT = computed tomography DSS = disease-specific survival LN = lymph node LND = lymph node dissection OS = overall survival RC = radical cystectomy RFS = recurrence free survival TNM = tumor, node, metastasis Objectives: To compare recurrence patterns and survival of patients with carcinoma of the urinary bladder undergoing radical cystectomy and extended or limited lymph node dissection. Methods: From a consecutive series of 469 patients undergoing radical cystectomy, two different historical cohorts were constructed; one with 265 patients intentionally undergoing extended lymph node dissection and one with 204 patients undergoing limited lymph node dissection. Results: Early lymph node recurrences were more frequently located outside the pelvic region in patients from the extended lymph node dissection cohort, whereas the overall risk of recurrence was not reduced by carrying out an extended lymph node dissection compared with the limited lymph node dissection cohort (8% vs 6%, P = 0.5). However, positive node patients had a significantly better prognosis after extended lymph node dissection (5-year disease-specific survival 29% vs 8%, P = 0.002). Improved survival was also found in negative node patients with non-organ confined tumors undergoing extended lymph node dissection compared with limited lymph node dissection (5-year disease-specific survival 76% vs 62%, P = 0.008). A total of 16 positive node patients (6%) in the extended lymph node dissection cohort were identified as possible stage migrators with metastasis exclusively in lymph nodes outside the limited template. A total of 5% of patients undergoing extended lymph node dissection had an evident survival benefit of an extended lymph node dissection compared with a limited lymph node dissection. Conclusions: Extended lymph node dissection provides more accurate nodal staging than a limited lymph node dissection. However, recurrence patterns are not significantly altered by extending the limits of lymph node dissection, suggesting a survival benefit only in a minority of patients. Improved survival is more likely in patients with locally advanced disease.

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Section: Discussionsupporting

confidence: 93%

“…6,7 However, none of the patients in the present study received adjuvant chemotherapy. The present study is therefore the first study that shows that the potential survival benefit in patients with locally advanced disease is a true benefit obtained by surgery and not by chemotherapy.…”

Section: Discussionmentioning

confidence: 80%

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

Hellenthal

2011

Int J of Urology

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“…The template we used is usually called a standard extended LND, and a total node count of 29 is consistent with previous studies (11)(12)(13). On the other hand, some researchers now advocate more aggressive dissection up to the inferior mesenteric artery level, called a super-extended LND (14,15).…”

Section: Discussionmentioning

confidence: 59%

Prospective mapping of lymph node metastasis in Japanese patients undergoing radical cystectomy for bladder cancer: characteristics of micrometastasis

Matsumoto

Takada

Abe

et al. 2015

Jpn. J. Clin. Oncol.

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Objective: To investigate node-disease prevalence including micrometastases and its survival impact on bladder cancer patients. Methods: A total of 60 patients participated in this study, in which extended lymph node dissection was carried out according to the prospective rule (below aortic bifurcation). Radical cystectomy and extended lymph node dissection were performed by open surgery (n = 23) or laparoscopically (n = 37). Perioperative, pathological and follow-up data were collected. Micrometastasis in lymph nodes was investigated by pan-cytokeratin immunohistochemistry. Recurrence-free survival was estimated with the Kaplan-Meier method. Results: The median number of lymph nodes removed was 29 (range: 10-103) and there was no significant difference between the two groups (open group: median 30, laparoscopic group: median 29). Routine pathological examination revealed that 10 patients had lymph node metastases. Immunohistochemistry revealed micrometastases in four additional patients (pNmicro+), who had been diagnosed with pN0 on routine pathological examination. After excluding the three patients with pure nonurothelial carcinoma on the final pathology (small cell carcinoma: n = 2, adenocarcinoma: n = 1), 10 out of the 57 urothelial carcinoma patients (17.5%) had node metastasis, and an additional 4 out of the 47 pN0 patients (4/47, 8.5%) had micrometastasis. The 2-year recurrence-free survival rates divided by pN stage were 82.4% for pN0, 66.7% for pNmicro+ and 12.5% for pN+ (three-sample log-rank test, P < 0.0001). Three out of the four patients with pNmicro+ were disease free at the last follow-up. Conclusions: We confirmed under extended lymph node dissection that a substantial proportion of the patients had node metastasis ( pN+: n = 10 and pNmicro+: n = 4), and the pN stage influenced patient survival. Our observations of micrometastasis yielded additional evidence for the potential survival benefit of extended lymphadenectomy by eliminating microdisease.

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“…Holmer et al [45] analyzed 69 and 101 patients undergoing limited PLND (perivesical and obturator nodes) and standard PLND (limited regions plus the internal, external, and common iliac nodes and presacral nodes), respectively. They found no significant difference in DSS between the two groups.…”

Section: Should We Perform Extended Ln Dissection?mentioning

confidence: 99%

Role of lymph node dissection in management of bladder cancer

2011

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Radical cystectomy (RC) with pelvic lymph node dissection (PLND) is the gold standard for treatment of muscle-invasive bladder cancer. Recent retrospective series suggest that extended PLND provides a survival benefit, probably by removing undetected micrometastases. There have been several studies suggesting the survival benefit of extended PLND, not only for patients with node-negative disease but also for those who are node positive. The optimal boundaries of PLND seem to be at least up to the level of aortic bifurcation, including Marcille's fossa, under the present circumstances. Because retrieval of more lymph nodes may help to improve the prognosis of patients, careful approaches should be considered both surgically and pathologically. PLND should be performed for all patients who undergo RC. Prospective randomized studies will give us the answer to the question of whether extended PLND should be performed routinely.

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Extended lymph node dissection in patients with urothelial cell carcinoma of the bladder: can it make a difference?

Cited by 42 publications

References 17 publications

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

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

Prospective mapping of lymph node metastasis in Japanese patients undergoing radical cystectomy for bladder cancer: characteristics of micrometastasis

Role of lymph node dissection in management of bladder cancer

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