Vieweg J, Gschwend J E, Herr H W, Fair W R
Division of Urology, Duke University Medical Center, Durham, North Carolina, USA.
J Urol. 1999 Jan;161(1):72-6.
Contemporary series indicate that survival of cystectomy candidates with node positive bladder cancer is favorable when the primary tumor is confined to the bladder wall and lymph node involvement is minimal. However, these series lack node negative controls with a similar tumor stage to determine accurately the true impact of pelvic lymphadenectomy and radical cystectomy on survival.
We retrospectively analyzed disease specific survival in 686 consecutive cystectomy candidates of whom 193 (28.1%) had node positive disease at radical cystectomy. To correct for bias towards higher P category in the node positive group we subdivided groups into organ and nonorgan confined categories to compare outcome between node negative and node positive cases.
The frequency of organ confined disease in node positive cases was 22.8% compared to 59.2% in node negative cases. Although when analyzing the entire group disease specific survival was significantly decreased in node positive cases, after correction for P stage we found no statistically significant differences in survival between N0 and N1 cases in the organ confined group (p = 0.4267). Differences between N0 and N1 cases in nonorgan confined disease were statistically significant (p = 0.0276). Significance levels were more pronounced when cases with N2 or N3 categories were compared with node negative cases. Comparison of survival between node negative and N2 or N3 in either group revealed significant differences indicating limited impact of surgery alone at this disease stage.
Patients with N1 disease seem to benefit from pelvic lymphadenectomy and radical cystectomy as evidenced by similar outcome in those with node negative disease and similar P stage of the primary tumor. However, the observed benefit rapidly disappears when more than 1 lymph node is involved and additional therapy other than surgery seems appropriate.
当代系列研究表明，对于原发性肿瘤局限于膀胱壁且淋巴结受累极少的膀胱癌淋巴结阳性患者，膀胱切除术的生存率较高。然而，这些系列研究缺乏肿瘤分期相似的淋巴结阴性对照，无法准确确定盆腔淋巴结清扫术和根治性膀胱切除术对生存率的真正影响。
我们回顾性分析了686例连续接受膀胱切除术患者的疾病特异性生存率，其中193例（28.1%）在根治性膀胱切除术中出现淋巴结阳性疾病。为纠正淋巴结阳性组中P分类较高的偏差，我们将组分为器官局限型和非器官局限型类别，以比较淋巴结阴性和阳性病例的预后。
淋巴结阳性病例中器官局限型疾病的发生率为22.8%，而淋巴结阴性病例为59.2%。虽然在分析整个组时，淋巴结阳性病例的疾病特异性生存率显著降低，但在纠正P分期后，我们发现器官局限型组中N0和N1病例的生存率无统计学显著差异（p = 0.4267）。非器官局限型疾病中N0和N1病例之间的差异具有统计学意义（p = 0.0276）。当将N2或N3类别的病例与淋巴结阴性病例进行比较时，显著性水平更为明显。比较两组中淋巴结阴性和N2或N3病例的生存率显示出显著差异，表明在此疾病阶段单纯手术的影响有限。
N1期疾病患者似乎从盆腔淋巴结清扫术和根治性膀胱切除术中获益，这在淋巴结阴性疾病且原发性肿瘤P分期相似的患者中表现出相似的预后。然而，当涉及多个以上淋巴结时，观察到的益处迅速消失，似乎除手术外还需要其他治疗。
