How To Proceed When Bladder Cancer Is Found In Lymph Nodes During Cystectomy

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17% (p = 0.012). Thus, pT-category of the primary tumour in addition to nodal tumour burden (pN-category) are the most important stratification variables in determining who may or may not benefit from radical surgery, and may influence the surgeon's decision as to whether to proceed with cystectomy when lymph node involvement becomes evident.

Herr et al. have reported a detailed analysis of the outcome of patients with grossly node-positive bladder cancer.7 Among patients with grossly positive nodes, 24% survived for 10 years after radical cystectomy and complete pelvic lymph-node dissection. The authors conclude from their data that the prevailing opinion of the limited value of radical surgery in such circumstances needs to be modified, and that a minority of patients with extended node-positive disease can be cured by a visibly, complete pelvic node dissection.

Many other clinical and pathological factors that may predict risk of relapse and survival in node-positive patients have been analyzed, although no further factors have been consistently found to be significant survival predictors in node-positive disease. However, more factors need to be considered carefully on the subject of survival improvement. First, Herr et al. have demonstrated that the net result of examining an adequate number of lymph nodes is the improved survival of patients with both stages pN0 and pN+, since the increased number of nodes identified during surgery reflects a more complete radical cystectomy and lymphadenectomy.13 In this context, the role of an extended pelvic lymph-node dissection, as suggested by Poulsen et al., may also play an important role as the number of resected nodes correlates clearly with the limited or extended boundaries ofPLND.12 Second, Mills et al. have presented evidence that lymph-node capsule perforation by the tumour is a sign for an ominous prognosis.14 They found a significant decrease in survival when capsule perforation was present at the pathology examination of resected nodes. This factor achieved independent significance in a multivariate analysis. However, these factors still emerge from single institution observations and deserve further confirmation by future studies.

During the last two decades, PLND along with radical cystectomy has proven to benefit a small but significant number of patients with node-positive bladder cancer, and should be performed especially in cases where the tumour is still confined to the bladder wall. However, non-organ-confined tumours with positive nodes generally indicate a poor prognosis. In these cases, radical surgery alone is unlikely to be curative and it is hypothesized that adjuvant treatment options appear to be necessary to improve survival chances. However, this needs again to be tested in properly designed clinical trials. So far, only few controlled preliminary studies for these therapies have demonstrated a significant survival benefit in patients with low tumour burden in an adjuvant setting.27,28 Up to now, no prospective randomized study has convincingly demonstrated that systemic chemotherapy impacts on longterm survival of these patients.29

Summary

1 The regional lymph node status is one of the strongest predictors of survival.

2 A meticulous pelvic node dissection can add a survival advantage when limited nodal involvement is present in patients with organ-confined bladder tumours.

3 A minority of patients with extended node-positive disease may be cured by a visibly, complete pelvic node dissection.

4 The number of resected lymph nodes may impact on the survival of patients with both, stages pN0 and pN + .

5 There is evidence that lymph node capsule perforation by the tumour is a poor prognostic factor.

Conclusions

Pathologic stage and nodal status are the main factors determining outcome in patients with node-positive bladder cancer.6,16,30,31 PLND appears to be a safe procedure, provides the most accurate staging, and, along with radical cystectomy, benefits a substantial number of patients with node-positive bladder cancer. In particular in cases where the tumour is still confined to the bladder wall, a meticulous pelvic node dissection can add a survival advantage when limited nodal involvement is present. In such cases, overall disease specific survival rates of more than 50% can be expected following complete resection of limited nodal disease (N1 and N2).5 Moreover, an overall cure rate of about 25% can be expected even in the presence of grossly positive nodes.7 Since PLND renders every fourth of such patients tumour free, it doesn't seem further justified to routinely abandon planned cystectomy in patients with evident lymph node involvement, or in the face of lymph node metastasis at frozen section. However, a proven extravesical tumour extension (pT3), together with grossly node-positive bladder cancer, does generally indicate a poor prognosis.

References

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