根治性膀胱切除术和盆腔淋巴结清扫术中施行最小淋巴结清扫策略对膀胱癌患者的淋巴结检出数、淋巴结阳性率、淋巴结密度和生存率的影响。
Effect of a minimum lymph node policy in radical cystectomy and pelvic lymphadenectomy on lymph node yields, lymph node positivity rates, lymph node density, and survivorship in patients with bladder cancer.
机构信息
Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California at San Francisco, San Francisco, California, USA.
出版信息
Cancer. 2010 Apr 15;116(8):1901-8. doi: 10.1002/cncr.25011.
BACKGROUND
Extended pelvic lymphadenectomy (PLND) during radical cystectomy (RC) reportedly improves bladder cancer-specific survival. Lymph node counts are often a proxy for the extensiveness of a dissection. In the current study, the impact of an institutional policy requiring a minimum number of lymph nodes was assessed.
METHODS
Patients undergoing RC and PLND for invasive bladder cancer between March 2000 and February 2008 were retrospectively reviewed at the study institution. Beginning March 1, 2004, a policy was established that at least 16 lymph nodes had to be examined. Specimens with <16 lymph nodes were resubmitted (including any fat) to detect additional lymph nodes. Lymph node yields, lymph node positivity, lymph node density (LND), and survivorship before and after policy implementation were compared.
RESULTS
A total of 147 patients underwent surgery 4 years before policy implementation and 202 underwent surgery 4 years after. The median number of lymph nodes increased from 15 to 20. Percentage of cases with >or=16 lymph nodes increased from 42.9% to 69.3% (P <.01). The lymph node positivity rates did not change significantly, but the proportion of patients with LND <20% increased from 43.9% to 65.5% (P = .04). Overall survival increased from 41.5% to 72.3% (P <.01). Univariate and multivariate regression demonstrated that policy implementation, and subsequent increase in median lymph node yield, decreased mortality risk by 30% (hazards ratio [HR], 0.70; P = .04) and 48% (HR, 0.52; P = .01), respectively.
CONCLUSIONS
Thorough evaluation of PLND specimens obtained at RC can be influenced by an institutional policy mandating a minimum number of lymph nodes. This could lead to greater confidence in pathologic staging and reliability of LND as a predictor of prognosis. Survival can improve due to increased awareness to perform a more thorough PLND.
背景
根治性膀胱切除术（RC）时扩大盆腔淋巴结清扫术（PLND）据称可提高膀胱癌特异性存活率。淋巴结计数常作为解剖范围的替代指标。本研究评估了一项要求至少清扫一定数量淋巴结的机构政策的影响。
方法
本研究回顾性分析了研究机构于 2000 年 3 月至 2008 年 2 月间接受 RC 和 PLND 治疗的浸润性膀胱癌患者。自 2004 年 3 月 1 日起，制定了一项政策，要求至少检查 16 个淋巴结。对标本中＜16 个淋巴结（包括任何脂肪）进行重新检查，以发现更多的淋巴结。比较实施该政策前后的淋巴结检出量、淋巴结阳性率、淋巴结密度（LND）和生存情况。
结果
实施该政策前 4 年共手术治疗 147 例患者，后 4 年共手术治疗 202 例患者。淋巴结中位数从 15 个增加到 20 个。有≥16 个淋巴结的病例比例从 42.9%增加到 69.3%（P＜0.01）。淋巴结阳性率无显著变化，但 LND＜20%的患者比例从 43.9%增加到 65.5%（P=0.04）。总生存率从 41.5%增加到 72.3%（P＜0.01）。单因素和多因素回归分析显示，政策实施及随后的中位淋巴结检出量增加，分别使死亡率降低 30%（风险比[HR]，0.70；P=0.04）和 48%（HR，0.52；P=0.01）。
结论
RC 时 PLND 标本的全面评估可能会受到机构政策的影响，该政策要求至少清扫一定数量的淋巴结。这可能会增加对病理分期的信心，并提高 LND 作为预后预测指标的可靠性。由于对更彻底的 PLND 的认识提高，生存率可能会提高。
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