Evaluation of different lymph node (LN) variables as prognostic markers in patients undergoing radical cystectomy and extended LN dissection to the level of the inferior mesenteric artery


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Abstract

Study Type – Therapy (case series)Level of Evidence 4What's known on the subject? and What does the study add?Different lymph node variables have been suggested as prognostic factors to improve substratification of lymph node positive patients undergoing cystectomy.In this uniform surgery only series the classical TNM classification still provided the most relevant stratification, whereas several other tested variables proved to have little or no relevant influence regarding prognosis.OBJECTIVETo evaluate the prognostic impact of lymph node (LN) variables in patients undergoing radical cystectomy (RC) and extended LN dissection.PATIENTS AND METHODSFrom January 2004 to January 2009, 167 patients with bladder cancer underwent RC and extended LN dissection to the level of the inferior mesenteric artery in a surgery-only series with no neoadjuvant or adjuvant chemotherapy.Correlation to prognosis of different LN variables according to presence of LN metastasis, number, localization, extracapsular extension (ECE), size, volume, LN density and N-stage according to two different Tumour-Node-Metastasis (TNM) classifications were analysed.RESULTSIn all, 43 patients (26%) had LN metastases.In univariate analysis, gender, T-stage and several different LN variables stratified by presence of LN metastasis, number of positive LNs, anatomical localisation, ECE, LN density, size and volume of positive LNs, were significant prognostic predictors.Female gender, advanced T-stage, presence of LN metastasis, non-regional LN metastases (M-positive) and number of positive LNs (1 vs >1) were significant adverse prognostic predictors in multivariate analysis, whereas the other LN variables were not.Inclusion of the common iliac LNs in the regional LNs as suggested in the seventh edition of the TNM classification was relevant regarding prognosis. However, subclassification based on location was not correlated to prognosis. The new N3 category therefore seems superfluous.CONCLUSIONSLN-positive patients have a poor prognosis, especially if >1 positive LN is present.Despite several different suggestions of new LN-dependent prognostic factors, none of the tested variables were independently significant in the present series.

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