Jensen Jørgen Bjerggaard
Department of Urology, Aarhus University Hospital, Brendstrupgaardvej 100, 8200 Aarhus N, Denmark.
Dan Med J. 2012 Dec;59(12):B4559.
The present thesis consists of 8 original articles focusing on lymph node dissection (LND) in patients undergoing radical cystectomy (RC) because of bladder cancer. LND is considered an essential part of the surgical procedure when performing an RC to achieve the correct staging and for prognostic reasons. However, the boundaries of LND have been the subject of debate. Proximal limit above, at, or below the aortic bifurcation has been suggested to define the perfect LND. Two questions have driven the present thesis. First, which extent of LND is needed to make the most accurate identification of patients with nodal involvement? And second, which extent of LND is needed to provide the most favourable prognosis in patients undergoing RC? During a 5-year period, all patients undergoing RC and LND to the level of the inferior mesenteric artery at the Department of Urology, Aarhus University Hospital, Skejby, were prospectively enrolled in meticulous registration of several LN variables including burden and location of metastasis based on standard pathological examination. From these patients, mapping of the metastatic LNs were made. Moreover, we included patients from a historical cohort undergoing limited LND to evaluate the possible prognostic impact of a more extended LND. Standard pathological examination was found to be reliable regarding identification of LN metastasis. A proximal limit of LND at the aortic bifurcation was found to be sufficient from a staging perspective, whereas less extensive LND was associated with a risk of under-staging. From a prognostic perspective, LND at least to the aortic bifurcation should be performed. It is still controversial and unclarified whether LND above the aortic bifurcation has any prognostic value. By extending the limits of LND from a limited dissection involving only the LNs in the obturator fossae to a dissection including all pelvic and lower lumbar LNs, a survival benefit in at least 5% of the patients was found. We also found that an extensive LND should be performed in all patients irrespective of T-stage of the primary tumour and in patients undergoing chemotherapy before RC. Previous radiotherapy, on the other hand, apparently eradicated LN metastasis in the irradiation field within the pelvic region and made subsequent LND difficult and possibly superfluous. In evaluation of a molecular marker, KPNA2, we found that the more accurate staging and more favourable prognosis achieved by extended LND compared to a limited LND was essential in evaluation of the prognostic impact of KPNA2.
本论文由8篇原创文章组成，重点关注因膀胱癌接受根治性膀胱切除术（RC）患者的淋巴结清扫术（LND）。在进行RC时，LND被认为是手术过程的重要组成部分，以实现正确分期并出于预后考虑。然而，LND的边界一直是争论的焦点。有人建议以主动脉分叉上方、处或下方的近端界限来定义理想的LND。两个问题推动了本论文的研究。第一，需要何种程度的LND才能最准确地识别有淋巴结转移的患者？第二，需要何种程度的LND才能为接受RC的患者提供最有利的预后？在5年期间，奥胡斯大学医院斯基比校区泌尿外科所有接受RC和LND至肠系膜下动脉水平的患者，均被前瞻性纳入，基于标准病理检查对多个淋巴结变量进行细致登记，包括转移负担和位置。从这些患者中，绘制了转移淋巴结的图谱。此外，我们纳入了来自历史队列中接受有限LND的患者，以评估更广泛LND可能的预后影响。发现标准病理检查在识别淋巴结转移方面是可靠的。从分期角度来看，发现LND在主动脉分叉处的近端界限就足够了，而范围较小的LND与分期不足的风险相关。从预后角度来看，应至少进行至主动脉分叉处的LND。主动脉分叉上方的LND是否具有任何预后价值仍存在争议且未明确。通过将LND的范围从仅涉及闭孔窝淋巴结的有限清扫扩展到包括所有盆腔和下腰椎淋巴结的清扫，发现至少5%的患者有生存获益。我们还发现，无论原发肿瘤的T分期如何，所有患者以及在RC前接受化疗的患者都应进行广泛的LND。另一方面，先前的放疗显然消除了盆腔区域照射野内的淋巴结转移，并使后续的LND变得困难且可能多余。在评估一种分子标志物KPNA2时，我们发现与有限LND相比，通过扩展LND实现的更准确分期和更有利预后对于评估KPNA2的预后影响至关重要。
