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

Abstract

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.

The Phenomenon of “Therapeutic” Nodal Yield at Cystectomy for Bladder Cancer: Do Not Discount the Will Rogers Effect

“…Multiple retrospective studies have demonstrated a survival advantage when more, compared with fewer, LNs are removed [1] , [2] . Multiple potential mechanisms for the improvement in outcomes with higher LN yield have been proposed: (1) a direct therapeutic benefit of removal of cancerous LNs; (2) modification of treatments and earlier intensification of adjuvant treatments on identification of pN+ disease; and (3) LN yield acting as a surrogate marker for surgeon or institutional factors associated with a higher quality of care across the disease continuum [3] . While the effect of these factors on patient survival is a matter of debate, the influence of stage migration, also known as the Will Rogers effect, is an often-underappreciated and yet simpler (and arguably more likely) explanation of these findings.…”