Department of Urology, Weill Cornell Medical College/New York-Presbyterian Hospital, New York, NY, USA; Department of Urology, General Hospital Sankt Poelten, Sankt Poelten, Austria.
Eur Urol. 2013 Nov;64(5):837-45. doi: 10.1016/j.eururo.2012.07.026. Epub 2012 Jul 20.
Lymph node metastasis (LNM) is the most powerful pathologic predictor of disease recurrence after radical cystectomy (RC). However, the outcomes of patients with LNM are highly variable.
To assess the prognostic value of extranodal extension (ENE) and other lymph node (LN) parameters.
DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis of 748 patients with urothelial carcinoma of the bladder and LNM treated with RC and lymphadenectomy without neoadjuvant therapy at 10 European and North American centers (median follow-up: 27 mo).
All subjects underwent RC and bilateral pelvic lymphadenectomy.
Each LNM was microscopically evaluated for the presence of ENE. The number of LNs removed, number of positive LNs, and LN density were recorded and calculated. Univariable and multivariable analyses addressed time to disease recurrence and cancer-specific mortality after RC.
A total of 375 patients (50.1%) had ENE. The median number of LNs removed, number of positive LNs, and LN density were 15, 2, and 15, respectively. The rate of ENE increased with advancing pT stage (p<0.001). In multivariable Cox regression analyses that adjusted for the effects of established clinicopathologic features and LN parameters, ENE was associated with disease recurrence (hazard ratio [HR]: 1.89; 95% confidence interval [CI], 1.55-2.31; p<0.001) and cancer-specific mortality (HR: 1.90; 95% CI, 1.52-2.37; p<0.001). The addition of ENE to a multivariable model that included pT stage, tumor grade, age, gender, lymphovascular invasion, surgical margin status, LN density, number of LNs removed, number of positive LNs, and adjuvant chemotherapy improved predictive accuracy for disease recurrence and cancer-specific mortality from 70.3% to 77.8% (p<0.001) and from 71.8% to 77.8% (p=0.007), respectively. The main limitation of the study is its retrospective nature.
ENE is an independent predictor of both cancer recurrence and cancer-specific mortality in RC patients with LNM. Knowledge of ENE status could help with patient counseling, clinical decision making regarding inclusion in clinical trials of adjuvant therapy, and tailored follow-up scheduling after RC.
淋巴结转移（LNM）是根治性膀胱切除术（RC）后疾病复发的最有力病理预测因素。然而，LNM 患者的结局差异很大。
评估淋巴结外侵犯（ENE）和其他淋巴结（LN）参数的预后价值。
设计、地点和参与者：对 10 个欧洲和北美中心的 748 名接受 RC 和淋巴结清扫术治疗且无新辅助治疗的膀胱癌伴 LNM 患者（中位随访时间：27 个月）进行回顾性分析。
所有患者均接受 RC 和双侧盆腔淋巴结清扫术。
每例 LNM 均经显微镜评估是否存在 ENE。记录和计算切除的 LN 数量、阳性 LN 数量和 LN 密度。单变量和多变量分析用于确定 RC 后疾病复发和癌症特异性死亡率的时间。
共有 375 例患者（50.1%）存在 ENE。LN 切除的中位数、阳性 LN 数量和 LN 密度分别为 15、2 和 15。ENE 的发生率随 pT 分期的进展而增加（p<0.001）。在多变量 Cox 回归分析中，调整了既定的临床病理特征和 LN 参数的影响后，ENE 与疾病复发（风险比[HR]：1.89；95%置信区间[CI]，1.55-2.31；p<0.001）和癌症特异性死亡率（HR：1.90；95%CI，1.52-2.37；p<0.001）相关。将 ENE 加入包括 pT 分期、肿瘤分级、年龄、性别、脉管侵犯、手术切缘状态、LN 密度、切除的 LN 数量、阳性 LN 数量和辅助化疗的多变量模型中，提高了疾病复发和癌症特异性死亡率的预测准确性，从 70.3%提高到 77.8%（p<0.001）和从 71.8%提高到 77.8%（p=0.007）。该研究的主要局限性是其回顾性。
ENE 是 RC 伴 LNM 患者癌症复发和癌症特异性死亡率的独立预测因素。了解 ENE 状态有助于患者咨询、临床试验中辅助治疗纳入的临床决策以及 RC 后个体化随访计划的制定。
