Werntz Ryan P, Riedinger Christopher B, Fantus Richard J, Smith Zachary L, Packiam Vignesh T, Adamsky Melanie A, Smith Norm, Steinberg Gary D
Department of Surgery, Section of Urology, The University of Chicago, Chicago, IL.
Department of Surgery, Section of Urology, The University of Chicago, Chicago, IL.
Urol Oncol. 2018 Dec;36(12):526.e1-526.e6. doi: 10.1016/j.urolonc.2018.09.014. Epub 2018 Nov 13.
Urethral squamous cell cancer is a rare disease with limited clinical recommendations regarding management of the inguinal lymph nodes. Despite the similarities to penile cancer in terms of squamous cell carcinoma (SCC) histology and lymphatic drainage, there is not enough evidence to recommend for or against a prophylactic inguinal lymph node dissection (ILND) in patients with clinically negative groins and a primary tumor stage of T1b or higher. The objective of the study was to identify the rate of prophylactic inguinal lymph node dissection, node positive rate, and overall survival in patients with clinical T1 to T4 stage. The patients were separated into clinical N stage and the rates of node positivity were compared. We hypothesize that the node positivity rate would be similar to that observed in penile cancer of similar clinical T and N stage and provide evidence for prophylactic inguinal lymph node dissection in urethral squamous cancer. We also sought to determine the value of ILND in clinically node positive (cN+) and clinically node negative (cN-) patients.
The National Cancer Database was queried for all cases of primary urethral cancer in men from 2004 to 2014. Patients with other cancer diagnoses, metastasis, nonsquamous histology, female patients, and patients with a history of radiation therapy were excluded. Male patients with urethral squamous cell cancer of the anterior urethra with T1 or higher T stage were included in this study. All-cause mortality was compared using multivariable Cox regression controlling for covariates.
The study included 725 men with urethral SCC with T1 or higher clinical T stage. The median age was 63 years (33-83 interquartile range). Of the 725 men, 536 men did not receive an ILND and 189 (26%) underwent ILND. Patients who received LND had significantly higher clinical T and clinical N stage. There was no difference in age, sex, or histology between those with ILND versus no ILND. In patients with T1 to T4 and clinical N0, the ILND rate was 21.8% (89/396). The lymph node positive rate in patients with N0 and T1 to T4 primary tumor was 9%. In patients with clinically node positive disease (N1/N2), the overall ILND rate was 76%. The lymph node positive rate for patients with clinical nodal disease was 84%. On multivariable analysis cox regression, lymph node positivity was associated with worse overall survival when controlling for T stage, clinical N stage, and age (HR 1.56, 95% 1.3-1.9, P = 0.000). On multivariable analysis after controlling for T stage, sex, and age, having an ILND was associated with improved OS in patients with clinical N1 or N2 disease (HR 0.46, 95% 0.28-0.78 P = 0.002).
The node positivity rate in patients with T1 to T4 and N0 is 9%, much lower than reported in penile cancer with a high-risk primary tumor but clinically negative groins. This argues against routine prophylactic inguinal ILND in patients with urethral SCC who are clinically N0, perhaps suggesting different biological behavior of urethral SCC compared to penile SCC. Performing a lymph node dissection in patients with clinically N1 or N2 disease is associated with improved OS.
尿道鳞状细胞癌是一种罕见疾病，关于腹股沟淋巴结管理的临床建议有限。尽管在鳞状细胞癌（SCC）组织学和淋巴引流方面与阴茎癌相似，但对于临床腹股沟阴性且原发肿瘤分期为T1b或更高的患者，尚无足够证据支持或反对进行预防性腹股沟淋巴结清扫术（ILND）。本研究的目的是确定临床T1至T4期患者的预防性腹股沟淋巴结清扫率、淋巴结阳性率和总生存率。将患者按临床N分期进行分组，并比较淋巴结阳性率。我们假设淋巴结阳性率与临床T和N分期相似的阴茎癌患者的观察结果相似，并为尿道鳞状细胞癌的预防性腹股沟淋巴结清扫提供证据。我们还试图确定ILND在临床淋巴结阳性（cN +）和临床淋巴结阴性（cN -）患者中的价值。
查询国家癌症数据库中2004年至2014年男性原发性尿道癌的所有病例。排除有其他癌症诊断、转移、非鳞状组织学、女性患者以及有放射治疗史的患者。本研究纳入前尿道鳞状细胞癌且T分期为T1或更高的男性患者。使用多变量Cox回归控制协变量比较全因死亡率。
该研究纳入了725例临床T分期为T1或更高的尿道SCC男性患者。中位年龄为63岁（四分位间距33 - 83岁）。在这725名男性中，536名男性未接受ILND，189名（26%）接受了ILND。接受LND的患者临床T和临床N分期显著更高。接受ILND与未接受ILND的患者在年龄、性别或组织学方面无差异。在T1至T4且临床N0的患者中，ILND率为21.8%（89/396）。N0且T1至T4原发性肿瘤患者的淋巴结阳性率为9%。在临床淋巴结阳性疾病（N1/N2）患者中，总体ILND率为76%。临床淋巴结疾病患者的淋巴结阳性率为84%。在多变量分析Cox回归中，控制T分期、临床N分期和年龄后，淋巴结阳性与较差的总生存率相关（风险比1.56，95% 1.3 - 1.9，P = 0.000）。在控制T分期、性别和年龄后的多变量分析中，对于临床N1或N2疾病患者，进行ILND与改善总生存期相关（风险比0.46，95% 范围0.28 - 0.78，P = 0.002）。
T1至T4且N0患者的淋巴结阳性率为9%，远低于具有高危原发性肿瘤但临床腹股沟阴性的阴茎癌报告率。这表明不支持对临床N0的尿道SCC患者进行常规预防性腹股沟ILND，这可能提示尿道SCC与阴茎SCC的生物学行为不同。对临床N1或N2疾病患者进行淋巴结清扫与改善总生存期相关。
