Wiesner Christoph, Salzer Alice, Thomas Christian, Gellermann-Schultes Claudia, Gillitzer Rolf, Hampel Christian, Thüroff Joachim W
Department of Urology, Johannes Gutenberg-University, Mainz, Germany.
BJU Int. 2009 Aug;104(3):331-5. doi: 10.1111/j.1464-410X.2009.08403.x. Epub 2009 Feb 11.
To investigate the associations between different overall or topographically restricted lymph node (LN) variables and cancer-specific survival (CSS) after radical cystectomy (RC) and extended LN dissection (LND) with curative intent in patients with LN-positive bladder cancer.
Between 2001 and 2006, 152 patients had RC with standardized extended LND for bladder cancer with curative intent. Patients with positive LNs were stratified according to the median of the LN variables (LNs removed, number of positive LNs, LN density). CSS was related to overall and topographically restricted LN variables, e.g. different levels of LND, and relationships were tested by univariate and multivariate analyses. Level 1 LND comprised the regions of the external and internal iliac LNs and of the obturator LNs, level 2 the templates of common iliac and presacral LNs, and level 3 the para-aortic and paracaval LNs up to the inferior mesenteric artery. The mean (range) follow-up was 22 (1-84) months.
LN metastases were diagnosed in 46 of the 152 patients (30%) with extended LND. In these 46 patients, the median number of removed LNs was 33 (level 1, 15.5; level 2, 9.0; level 3, 7.0), the median number of positive LNs was 3 (1.5, 0.5 and 0.0, respectively) and the median LN density was 0.11 (0.10, 0.02 and 0.0, respectively). The CSS was 76% at 1 year and 23% at 3 years. There were significant correlations between the 3-year CSS and the overall LN density (< or =0.11 vs >0.11; 34% vs 8%, P = 0.008), and the total number of positive LNs (< or =3 vs >3; 33% vs 8%; P = 0.05). Overall LN density (hazard ratio 0.33, 95% confidence interval 0.15-0.72; P = 0.006) was an independent predictor for CSS in multivariate analysis. CONCLUSIONS Overall LN density is an independent predictor of survival after RC and extended LND with curative intent. Evaluation of topographically restricted LN positivity and density for different regions and levels of LND does not improve the prediction of CSS compared with overall LN positivity and density. A low incidence of level 3 LN positivity questions the clinical relevance of removing para-aortic and paracaval LNs. However, our data need to be confirmed by a prospective randomized trial.
探讨在根治性膀胱切除术（RC）及扩大淋巴结清扫术（LND）且具有治愈目的的淋巴结阳性膀胱癌患者中，不同的总体或局部受限淋巴结（LN）变量与癌症特异性生存（CSS）之间的关联。
2001年至2006年间，152例患者接受了具有治愈目的的标准化扩大LND的RC治疗。LN阳性患者根据LN变量的中位数（切除的LN数量、阳性LN数量、LN密度）进行分层。CSS与总体和局部受限的LN变量相关，例如不同水平的LND，并通过单因素和多因素分析来检验两者之间的关系。第1级LND包括髂外和髂内淋巴结区域以及闭孔淋巴结区域，第2级包括髂总淋巴结和骶前淋巴结区域，第3级包括肠系膜下动脉水平以下的腹主动脉旁和腔静脉旁淋巴结。平均（范围）随访时间为22（1 - 84）个月。
152例行扩大LND的患者中有46例（30%）诊断为LN转移。在这46例患者中，切除LN的中位数为33个（第1级，15.5个；第2级，9.0个；第3级，7.0个），阳性LN的中位数为3个（分别为1.5个、0.5个和0.0个），LN密度的中位数为0.11（分别为0.10、0.02和0.0）。CSS在1年时为76%，3年时为23%。3年CSS与总体LN密度（≤0.11 vs >0.11；34% vs 8%，P = 0.008）以及阳性LN总数（≤3 vs >3；33% vs 8%；P = 0.05）之间存在显著相关性。在多因素分析中，总体LN密度（风险比0.33，95%置信区间0.15 - 0.72；P = 0.006）是CSS的独立预测因素。结论总体LN密度是RC及具有治愈目的的扩大LND术后生存的独立预测因素。与总体LN阳性和密度相比，评估不同区域和水平LND的局部受限LN阳性和密度并不能改善CSS的预测。第3级LN阳性的低发生率质疑了切除腹主动脉旁和腔静脉旁淋巴结的临床相关性。然而，我们的数据需要通过前瞻性随机试验来证实。
