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


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.


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.


1 Whitmore WF Jr (1975) Total cystectomy. In: Cooper EH and Williams RE (eds) The Biology and Clinical Management of Bladder Cancer. Blackwell Scientific Publications: Oxford, pp. 193-227.

2 Montie JE (1999) Against bladder sparing surgery. J Urol 162: 452-7.

3 Lerner SP, Skinner DG, Lieskovsky G et al. (1993) The rationale for en bloc pelvic lymph-node dissection for bladder cancer patients with nodal metastases: longterm results. J Urol 149: 758-65.

4 Vieweg J, Withmore WR Jr, Herr HW et al. (1994) The role of pelvic lymphadenectomy and radical cystectomy for lymph node positive bladder cancer. Cancer 73(12): 3020-8.

5 Vieweg J, Gschwend JE, Herr, HW and Fair WR (1999) The impact of primary stage on survival in patients with lymph node positive bladder cancer. J Urol 161: 72-6.

6 Vieweg J, Gschwend JE, Herr HW and Fair WR (1999) Pelvic lymph-node dissection can be curative in patients with node-positive bladder cancer. J Urol 161: 449-54.

7 Herr HW and Donat SM (2001) Outcome of patients with grossly node-positive bladder cancer after pelvic lymph-node dissection and radical cystectomy. J Urol 165: 62-4.

8 Jewett HJ and Strong GH (1946) Infiltrating carcinoma of the bladder: relation to depth of penetration of the bladder wall to incidence of local extension and metastasis. J Urol 55: 366-72.

9 Brunschwig A (1948) Complete excision of pelvic viscera for advanced carcinoma: a one-stage abdominoperineal operation with end colostomy and bilateral ureteral implantation into the colon above the colostomy. Cancer 1: 177-83.

10 Whitmore WF Jr and Marshall VF (1962) Radical total cystectomy for cancer of the bladder: 230 consecutive cases five years later. J Urol 87: 853-62.

11 Skinner DG (1981) Management of invasive bladder cancer: a meticulous pelvic node dissection can make a difference. J Urol 128: 34-6.

12 Poulson AL, Horn T and Steven K (1998) Radical cystectomy: extending limits of pelvic lymph-node dissection improves survival for patients with bladder cancer confined to the bladder wall. J Urol 160: 2015.

13 Herr HW, Bochner BH, Dalbagni G, Donat SM, Reuter VE and Bajorin DF (2002) Impact of the number of lymph nodes retrieved on outcome in patients with muscle-invasive bladder cancer. J Urol 167: 1295-8.

14 Mills RD, Turner WH, Fleischmann A, Markwalder R, Thalmann GN and Studer UE (2001) Pelvic lymph node metastases from bladder cancer: outcome in 83 patients after radical cystectomy and pelvic lymphadenectomy. J Urol 166: 19-23.

15 Smith JA and Whitmore WF Jr (1981) Regional lymph node metastasis from bladder cancer. J Urol 126: 591-3.

16 Gschwend JE, Fair WR and Vieweg J (2000) Radical cystectomy for invasive bladder cancer: contemporary results and remaining controversies. European Urology 38: 121-30.

17 Wilkinson EJ and Hause L (1974) Probability in lymph node sectioning. Cancer 33: 1269-1269.

18 Sobin LH and Greece FL (2001) TNM classification: clarification of number of regional lymph nodes for pN0. Cancer 92: 452.

19 Tepper JE, O'Connell MJ, Niedzwiecki D et al. (2001) Impact of number of nodes retrieved on outcome in patients with rectal cancer. Journal of Clinical Oncology 19: 157-63.

20 Stroumbakis N, Herr HW, Cookson MS et al. (1997) Radical cystectomy in the octogenarian. J Urol 158: 2113-17.

21 Malkowicz SB, Nichols P, Lieskovsky G, Boyd SD, Huffman J and Skinner DG (1990) The role of radical cystectomy in the management of high-grade superficial bladder cancer (pA, p1, pIS and p2). J Urol 144: 641-5.

22 Amling CL, ThrasherJB, Frazier HA, Dodge RK, RobertsonJE and Paulson DF (1994) Radical cystectomy for stages TA, TIS and T1 transitional cell carcinoma of the bladder. J Urol 151: 31-6.

23 Studer UE and Zingg EJ (1997) Ileal orthotopic bladder substitutes: what we have learned from 12 years' experience with 200 patients. Urol Clin North Am 24(4): 781-93.

24 Hautmann RE and Simon J (1999) Ileal neobladder and local recurrence of bladder cancer: patterns of failure and impact on function in men. J Urol 162: 1963-6.

25 Hautmann RE, de Petriconi R, Gottfried HW, Kleinschmidt K, Mattes R and Paiss T (1999) The ileal neobladder: complications and functional results in 363 patients after 11 years of follow-up. J Urol 161: 422-8.

26 Hubner WA, Trigo-Rocha F, Plas EG and Tanagho EA (1993) Urethral function after cystectomy: a canine in-vivo experiment. Urol Res 21: 45-8.

27 Skinner DG, Daniels JR, Russell CA et al. (1991) The role of adjuvant chemotherapy following cystectomy for invasive bladder cancer: a prospective comparative trial. J Urol 145: 459-64.

28 Stöckle M, Meyenburg W, Wellek S et al. (1995) Adjuvant polychemotherapy of non-organ-confined bladder cancer after radical cystectomy revisited: longterm results of a controlled prospective study and further clinical experience. J Urol 153: 47-52.

29 Sylvester R and Sternberg C (2000) The role of adjuvant combination chemotherapy after cystectomy in locally advanced bladder cancer: what we do not know and why. Ann Oncol 11(7): 851-6.

30 Bassi P, Ferrante GD, Piazza N et al. (1999) Prognostic factors of outcome after radical cystectomy for bladder cancer: A retrospective study of a homogeneous patient cohort. J Urol 161: 1494-7.

31 Gschwend JE, Dahm P and Fair WR (2002) Disease specific survival as endpoint of outcome for bladder cancer patients following radical cystectomy. Eur Urol 41: 440-448.

32 Dretler SP, Ragsdale BD and Leadbetter WF (1973) The value of pelvic lymphadenectomy in the surgical treatment of bladder cancer. J Urol 109: 414-16.

33 Reid EC, Oliver JA and Fishman IJ (1976) Pre-operative irradiation and cystectomy in 135 cases of bladder cancer. Urology 8: 247-50.

34 Bredael JJ, Croker BP and Glenn JF (1980) The curability of invasive bladder cancer treated by radical cystoprostatectomy. Eur Urol 6: 206-10.

35 Zincke H, Patterson DE, Utz DC and Benson RC (1985) Pelvic lymphadenectomy and radical cystectomy for transitional cell carcinoma of the bladder with pelvic nodal disease. Br J Urol 57: 156-9.

36 Wishnow KI, Johnson DE, Ro JY, Swanson DA, Babaian RJ and von Eschenbach AC (1987) Incidence, extent and location of unsuspected pelvic lymph node metastasis in patients undergoing radical cystectomy for bladder cancer. J Urol 137: 408-10.

37 Grossman HB and Konnak JW (1988) Is radical cystectomy indicated in patients with regional lymphatic metastases? Urology 31: 214-16.

38 Roehrborn CG, Sagalowsky AI and Peters PC (1991) Longterm patient survival after cystectomy for regional metastatic transitional carcinoma of the bladder. J Urol 146: 36-9.

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