The Influence of Lymph Node Count on Oncological Outcome of Radical Cystectomy in Chemotherapy Pre-Treated and Chemotherapy-Naïve Patients with Muscle Invasive Bladder Cancer

Abstract

Radical cystectomy (RC) with pelvic lymph node dissection (PLND) remains the mainstay of treatment for muscle-invasive bladder cancer (MIBC). The extent of PLND and number of removed lymph nodes (LNs) have been associated with improved staging and survival outcomes in several series of RC patients. Neoadjuvant chemotherapy (NAC) has become standard of care for cisplatin-eligible patients qualified to RC, yet few studies on PLND stratified cases according to the receipt of NAC. We aimed to address this issue and reevaluate the prognostic value of PLND nodal yields in series of patients who underwent RC on the verge of the NAC era. This single-center, retrospective, clinical follow-up study enrolled 439 consecutive patients, out of whom 83 received NAC. We analyzed survival outcome of RC according to the number of removed nodes between NAC and non-NAC subgroups. We found PLND thresholds of 10 and 15 LNs prognostically meaningful in our study cohort, and this association was particularly pronounced in the non-NAC subgroup. Higher numbers of LNs provided a 25% reduction in risk of all-cause mortality and correspondingly correlated with up to a 14% increase in 3-year overall survival. The receipt of NAC diminished the benefit of adequate PLND, as the number of retrieved LNs was not associated with survival in the NAC-RC cohort. Given the limitations of our study, additional research is needed to verify these findings.

Relationship between the number of lymph nodes dissected and prognosis in muscle‐invasive bladder cancer in the era of neoadjuvant chemotherapy

“…However, little is known about the therapeutic significance of LND for patients receiving NAC. Lemeninski et al 19 found that the 3-year OS did not improve with more DLNs in patients undergoing NAC (56.3% vs. 54.63%, p = 0.465). However, the number of patients who received NAC was small (n = 83), and a multivariate analysis was not performed.…”

The View Outside of the Box: Reporting Outcomes Following Radical Cystectomy Using Pentafecta From a Multicenter Retrospective Analysis

“…Additionally, a prospective randomized controlled trial showed that extended lymphadenectomy does not have the superiority over limited one with regard to RFS (5-year RFS 65% vs. 59%; HR = 0.84; p = 0.36) and CSS (5-year CSS 76% vs. 65%; HR = 0.70; p = 0.10) (38). Moreover, Leminski et al proved a range of 10-15 LNs to have prognostic significance, while greater numbers of removed nodes resulted in an increase of OS up to 14% (24). According to Koppie et al (25), removing 10 LNs may represent a thorough LN cleanout from a limited LN template, or a relatively incomplete dissection of LNs from an extended LN template, but found no support for a concept of a minimum number of LNs sufficient for optimizing bladder cancer outcomes.…”

“…-no Clavien-Dindo grade III-V complications at 90 days and no long-term complications related to UD < 12 months -negative surgical margins (all soft tissue and urethral and ureteral) in post-cystectomy pathological report, ≥10 LN removal during the procedure, and no clinical relapse of bladder cancer ≤12 months after RC found in the follow-up CT. Based on other authors' observations, we included the threshold of 10 LNs in further analyses (24)(25)(26).…”

“…Even though different definitions and modifications of these models are available, the one proposed by Aziz et al (20) and revised by Cacciamani et al (21) are most commonly cited. The debate, however, continues about the value and number of resected lymph nodes (LNs), and many authors lower the threshold to 10 and 15 ones (24)(25)(26). It is also speculated about other possible explanations of incoherent data on the influence of lymphadenectomy on survival, e.g., due to the technique of nodal submission (separate templates) or pathological reporting standards (27).…”

Advances in Management of Bladder Cancer

“…We still do not have a certain answer on the impact of the extension of lymphadenectomy on survival. Leminsky et al also attempt to find a further correlation between the number of lymph nodes removed, neoadjuvant chemotherapy, and survival [ 4 ]. However, the increased use of the currently optimal therapeutic choice, based on NAC and RC, seems to reduce the importance of the number of lymph nodes removed on survival.…”