Outcomes and prognostic factors in patients with a single lymph node metastasis at time of radical cystectomy
Menée sur 381 patients atteints d'un carcinome urothélial de la vessie traité par cystectomie radicale et lymphadénectomie sans chimiothérapie ou radiothérapie préopératoire (durée médiane de suivi : 41 mois), cette étude identifie les facteurs clinicopathologiques associés à la survie spécifique des patients n'ayant présenté qu'une seule métastase ganglionnaire au moment de l'opération
Study Type – Therapy (outcomes)Level of Evidence 2bWhat's known on the subject? and What does the study add?Lymph node (LN) metastasis is a critical predictor for disease recurrence and cancer-specific survival in patients with urothelial carcinoma of the bladder (UCB) treated with radical cystectomy. Patients with a low LN disease burden (pN1) might be cured by surgery alone, while patients with a high LN disease burden (stage ≥ pN2) might benefit most from adjuvant chemotherapy.We found that outcomes of patients with pN1 UCB are significantly affected by pathological stage and soft tissue surgical margin status. Our nomogram may help to improve outcomes prediction in patients with pN1 UCB. An accurate prediction of the individual risk of outcomes may help risk stratifying patients with pN1 UCB to help improve clinical decision-making. OBJECTIVES * •To identify clinicopathological factors that predict outcomes in patients with a single lymph node (LN) metastasis (pN1) treated with radical cystectomy (RC) for urothelial carcinoma of the bladder (UCB). * •LN metastasis is an established predictor of clinical outcomes in patients. While most patients with large LN burden experience disease recurrence, lymphadenectomy can be curative in patients with pN1 disease. PATIENTS AND METHODS * •We analysed 381 patients with pN1 UCB from a multi-institutional cohort of 4335 patients with UCB treated with RC and lymphadenectomy without preoperative chemo- or radiotherapy. * •Subgroup analyses were performed for patients with ≥9 LNs removed and according to adjuvant chemotherapy administration (n= 215). RESULTS * •The median (interquartile range, IQR) LN number was 15 (19) and the median (IQR) LN density was 6.7 (7.5)%. * •Within a median follow-up of 41 months, the mean (+/−sd) 2- and 5-year cancer-specific survival (CSS) rates were 55 (3)% and 46 (3)%, respectively. * •On multivariable analysis that adjusted for the effects of standard clinicopathological features, female gender (hazard ratio [HR] 1.48, P= 0.023), higher tumour stage (HR 1.68, P= 0.007), positive soft tissue surgical margin (STSM; HR 2.06, P= 0.004), higher LN density (HR 2.99, P= 0.025) and absence of adjuvant chemotherapy (HR 0.70, P= 0.026) were independently associated with CSS. * •In subgroup analyses of patients with ≥9 LNs removed, tumour stage and STSM status remained independent predictors for CSS (P= 0.009 and P < 0.001, respectively). CONCLUSIONS * •About half of the patients with pN1 UCB died from UCB within 5 years of RC. * •Pathological stage and STSM status are strong predictors for outcomes. * •Accurate prediction of the individual risk of CSS may help risk stratifying pN1 UCB in order to help improve clinical-decision making. Patients with pN1 UCB presenting with additional unfavourable risk factors need a closer follow-up scheduling and might receive adjuvant therapy.
BJU International , résumé, 2011