Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
Eur Urol. 2012 May;61(5):1025-30. doi: 10.1016/j.eururo.2012.01.049. Epub 2012 Feb 7.
The extent of lymphadenectomy needed to optimize oncologic outcomes after radical cystectomy (RC) for patients with regionally advanced bladder cancer (BCa) is unclear.
Evaluate the effect of the location of lymph node metastasis on recurrence-free survival (RFS) and cancer-specific survival (CSS) for patients undergoing RC with a mapping pelvic lymph node dissection (PLND).
DESIGN, SETTING, AND PARTICIPANTS: A study of 591 patients undergoing RC with mapping PLND was completed between 2000 and 2010. Median follow-up was 30 mo.
RC with mapping PLND.
We evaluated the impact of lymph node involvement by location on disease outcomes using the 2010 TNM staging system. Survival estimates were described using Kaplan-Meier methods. Gender, age, pathologic stage, histology, number of positive nodes, location of positive nodes, node density, use of perioperative chemotherapy, and grade were evaluated as predictors of RFS and CSS using multivariate Cox proportional hazard regression.
Overall, 114 patients (19%) had lymph node involvement, and 42 patients (7%) had pN3 disease. On multivariate analysis, the number of positive lymph nodes (one or two or more) was significantly associated with increased risk of cancer-specific death (hazard ratio [HR]: 1.9 [95% confidence interval (CI), 1.04-3.46], p=0.036; versus HR: 4.3 [95% CI, 2.25-8.34], p<0.0005). Positive lymph node location was not an independent predictor of RFS or CSS. Five-year RFS for pN3 patients undergoing RC with PLND was 25% (95% CI, 10-42). This finding was not statistically different from our pN1 and pN2 patients (38% [95% CI, 22-54] and 35% [95% CI, 11-60], respectively). This study is limited by the lack of prospective randomization and a control group.
The outcome for patients with involved common iliac lymph nodes was similar to the outcome for patients with primary nodal basin disease. These data support inclusion of the common iliac lymph nodes (pN3) in the nodal staging system for BCa. Lymph node location was not an independent predictor of outcome, whereas the number of positive lymph nodes was an independent predictor of worse oncologic outcome (pN1, pN2). Further refinements of the TNM system to provide improved prognostication are warranted.
根治性膀胱切除术（RC）后，为了优化局部晚期膀胱癌（BCa）患者的肿瘤学结果，需要进行多大范围的淋巴结切除术尚不清楚。
评估在接受 RC 加图谱式盆腔淋巴结清扫术（PLND）的患者中，淋巴结转移部位对无复发生存（RFS）和癌症特异性生存（CSS）的影响。
设计、地点和参与者：这项研究共纳入了 591 例接受 RC 加图谱式 PLND 的患者，研究时间为 2000 年至 2010 年，中位随访时间为 30 个月。
RC 加图谱式 PLND。
我们使用 2010 年 TNM 分期系统评估了淋巴结受累部位对疾病结局的影响。使用 Kaplan-Meier 方法描述生存估计。使用多变量 Cox 比例风险回归分析评估性别、年龄、病理分期、组织学、阳性淋巴结数量、阳性淋巴结部位、淋巴结密度、围手术期化疗的使用以及分级等因素对 RFS 和 CSS 的预测作用。
总体而言，114 例患者（19%）存在淋巴结受累，42 例患者（7%）存在 pN3 疾病。多变量分析显示，阳性淋巴结数量（1 个、2 个或更多个）与癌症特异性死亡风险增加显著相关（风险比[HR]：1.9[95%置信区间（CI）：1.04-3.46]，p=0.036；与 HR：4.3[95%CI：2.25-8.34]，p<0.0005）。阳性淋巴结部位不是 RFS 或 CSS 的独立预测因素。接受 RC 加 PLND 的 pN3 患者的 5 年 RFS 为 25%（95%CI：10-42）。这一发现与我们的 pN1 和 pN2 患者（分别为 38%[95%CI：22-54%]和 35%[95%CI：11-60%]）没有统计学差异。本研究的局限性在于缺乏前瞻性随机分组和对照组。
累及髂总淋巴结的患者的结局与原发性淋巴结盆区疾病患者的结局相似。这些数据支持将髂总淋巴结（pN3）纳入 BCa 的淋巴结分期系统。淋巴结部位不是结局的独立预测因素，而阳性淋巴结数量是肿瘤学结局较差的独立预测因素（pN1、pN2）。需要进一步改进 TNM 系统以提供更好的预后预测。
