title: Is there a therapeutic role for post-chemotherapy retroperitoneal lymph node dissection in metastatic transitional cell carcinoma of the bladder?
abstract: OBJECTIVE
  We identified a subset of patients with bladder cancer (transitional cell carcinoma) and regional nodal metastasis to the retroperitoneal lymph nodes without detectable systemic dissemination. While the majority of these patients respond initially to chemotherapy, most have disease relapse at the same site within a year. We report the results of a phase II study exploring the potential benefit of retroperitoneal lymph node dissection in patients with transitional cell carcinoma of the bladder in whom disease has shown a significant response to chemotherapy.
  
  
  METHODS
  A total of 11 patients with biopsy proven metastatic transitional cell carcinoma in the retroperitoneal lymph nodes and no evidence of visceral metastatic disease in whom disease showed a significant response to chemotherapy underwent complete bilateral retroperitoneal lymph node dissection. The end point of study was disease specific survival, calculated from the time of retroperitoneal lymph node dissection to death from transitional cell carcinoma of the bladder.
  
  
  RESULTS
  Four patients underwent delayed retroperitoneal lymph node dissection. Seven patients underwent concurrent cystectomy, and pelvic and retroperitoneal lymph node dissection. There was no perioperative mortality. Nine patients had evidence of residual disease in the retroperitoneal nodes. Seven patients have recurrence outside of the original surgical field with a median time to recurrence of 7 months and 6 died at a median time to death of 8 months (range 5 to 14). One patient with retrocrural recurrence attained a complete response to salvage chemotherapy and remained disease-free 57 months after retroperitoneal lymph node dissection. For all 11 patients median disease specific and recurrence-free survival rates were 14 and 7 months, respectively. Four-year disease specific and recurrence-free survival rates were 36% and 27%, respectively. We stratified the patients based on the number of involved lymph nodes at retroperitoneal lymph node dissection and noted that viable tumor in no more than 2 lymph nodes correlated with greater disease specific and recurrence-free survival (p = 0.006 and 0.01, respectively).
  
  
  CONCLUSIONS
  Retroperitoneal lymph node dissection can be safely performed for metastatic transitional cell carcinoma. Retroperitoneal lymph node dissection has curative potential, particularly in patients with viable tumor in no more than 2 lymph nodes after chemotherapy.
authors.affiliation: Department of Urology, University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
authors.forename: Paul
authors.initials: P
authors.lastname: Sweeney
authors.forename: Randall
authors.initials: R
authors.lastname: Millikan
authors.forename: Machelle
authors.initials: M
authors.lastname: Donat
authors.forename: Christopher G
authors.initials: CG
authors.lastname: Wood
authors.forename: Arlene Siefker
authors.initials: AS
authors.lastname: Radtke
authors.forename: Curtis A
authors.initials: CA
authors.lastname: Pettaway
authors.forename: H Barton
authors.initials: HB
authors.lastname: Grossman
authors.forename: Colin P N
authors.initials: CP
authors.lastname: Dinney
authors.forename: David A
authors.initials: DA
authors.lastname: Swanson
authors.forename: Louis L
authors.initials: LL
authors.lastname: Pisters
mesh_terms: D002295:Carcinoma, Transitional Cell / Q000188:drug therapy* / Q000401:mortality / Q000556:secondary*; D006801:Humans; D008197:Lymph Node Excision; D008207:Lymphatic Metastasis; D012187:Retroperitoneal Space; D015996:Survival Rate; D001749:Urinary Bladder Neoplasms / Q000188:drug therapy* / Q000401:mortality / Q000473:pathology