Ginsburg Kevin B, Bell Spencer, Bukavina Laura, Schober Jared P, Magee Diana, Kutikov Alexander
Department of Surgical Oncology, Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
Department of Urology, Wayne State University School of Medicine, Detroit, MI, USA.
Eur Urol Open Sci. 2022 Dec 15;47:43-47. doi: 10.1016/j.euros.2022.11.004. eCollection 2023 Jan.
While multiple mechanisms have been hypothesized to explain the therapeutic effect of lymph node (LN) yield in patients with urothelial cell carcinoma (UCC) undergoing radical cystectomy (RC), the effect of stage migration, commonly known as the Will Rogers effect, is often discounted. We reviewed the National Cancer Database for patients with UCC undergoing RC with pathologically node-negative (pN0) disease from 2004 to 2016. We tested for an adjusted association between LN yield and overall survival using multivariable Cox proportional-hazard models. Median survival was estimated using the Kaplan-Meier method. We identified 19 939 patients with pN0 UCC treated with RC. After adjustment, patients in the highest quantile for LN yield (≥26 LNs) had a 34% lower risk of death in comparison to patients in the lowest quantile (≤5 LNs). As we increased the threshold for LN yield for dichotomization from >5 to >15 to >25 LNs, median survival increased from 83 to 95 to 103 mo. The pN0 group with higher LN yield appeared to live longer in this analysis owing to the mathematical artifact of how patients are indexed. Resection of a greater number of negative LNs will lead to higher fidelity for pN0 cohorts being evaluated, as the likelihood of contamination by pN+ cases that were missed will be lower.
A strategy to dissect a high number of lymph nodes in patients undergoing removal of their bladder for bladder cancer can be associated with side effects, and the benefit in terms of cancer control or survival remains uncertain. Urologists and their patients should engage in shared decision-making and consider the risks and benefits of more extensive lymph node dissection during surgery.
虽然已经提出了多种机制来解释根治性膀胱切除术（RC）治疗尿路上皮细胞癌（UCC）患者时淋巴结（LN）获取量的治疗效果，但分期迁移的影响，即通常所说的威尔·罗杰斯效应，常常被忽视。我们回顾了国家癌症数据库中2004年至2016年接受RC且病理淋巴结阴性（pN0）疾病的UCC患者。我们使用多变量Cox比例风险模型测试了LN获取量与总生存之间的校正关联。使用Kaplan-Meier方法估计中位生存期。我们确定了19939例接受RC治疗的pN0 UCC患者。校正后，LN获取量处于最高四分位数（≥26个LN）的患者与最低四分位数（≤5个LN）的患者相比，死亡风险降低了34%。当我们将二分法的LN获取量阈值从>5个增加到>15个再增加到>25个LN时，中位生存期从83个月增加到95个月再增加到103个月。在该分析中，由于患者索引方式的数学假象，LN获取量较高的pN0组似乎存活时间更长。切除更多阴性LN将导致评估的pN0队列具有更高的准确性，因为被遗漏的pN+病例污染的可能性会更低。
对于因膀胱癌接受膀胱切除的患者，切除大量淋巴结的策略可能会带来副作用，而在癌症控制或生存方面的益处仍不确定。泌尿外科医生及其患者应共同参与决策，并在手术期间考虑更广泛淋巴结清扫的风险和益处。
