title: Cancer-specific survival after radical cystectomy and standardized extended lymphadenectomy for node-positive bladder cancer: prediction by lymph node positivity and density.
abstract: OBJECTIVE
  To investigate the associations between different overall or topographically restricted lymph node (LN) variables and cancer-specific survival (CSS) after radical cystectomy (RC) and extended LN dissection (LND) with curative intent in patients with LN-positive bladder cancer.
  
  
  METHODS
  Between 2001 and 2006, 152 patients had RC with standardized extended LND for bladder cancer with curative intent. Patients with positive LNs were stratified according to the median of the LN variables (LNs removed, number of positive LNs, LN density). CSS was related to overall and topographically restricted LN variables, e.g. different levels of LND, and relationships were tested by univariate and multivariate analyses. Level 1 LND comprised the regions of the external and internal iliac LNs and of the obturator LNs, level 2 the templates of common iliac and presacral LNs, and level 3 the para-aortic and paracaval LNs up to the inferior mesenteric artery. The mean (range) follow-up was 22 (1-84) months.
  
  
  RESULTS
  LN metastases were diagnosed in 46 of the 152 patients (30%) with extended LND. In these 46 patients, the median number of removed LNs was 33 (level 1, 15.5; level 2, 9.0; level 3, 7.0), the median number of positive LNs was 3 (1.5, 0.5 and 0.0, respectively) and the median LN density was 0.11 (0.10, 0.02 and 0.0, respectively). The CSS was 76% at 1 year and 23% at 3 years. There were significant correlations between the 3-year CSS and the overall LN density (< or =0.11 vs >0.11; 34% vs 8%, P = 0.008), and the total number of positive LNs (< or =3 vs >3; 33% vs 8%; P = 0.05). Overall LN density (hazard ratio 0.33, 95% confidence interval 0.15-0.72; P = 0.006) was an independent predictor for CSS in multivariate analysis. CONCLUSIONS Overall LN density is an independent predictor of survival after RC and extended LND with curative intent. Evaluation of topographically restricted LN positivity and density for different regions and levels of LND does not improve the prediction of CSS compared with overall LN positivity and density. A low incidence of level 3 LN positivity questions the clinical relevance of removing para-aortic and paracaval LNs. However, our data need to be confirmed by a prospective randomized trial.
authors.affiliation: Department of Urology, Johannes Gutenberg-University, Mainz, Germany. christophws@aol.com
authors.forename: Christoph
authors.initials: C
authors.lastname: Wiesner
authors.forename: Alice
authors.initials: A
authors.lastname: Salzer
authors.forename: Christian
authors.initials: C
authors.lastname: Thomas
authors.forename: Claudia
authors.initials: C
authors.lastname: Gellermann-Schultes
authors.forename: Rolf
authors.initials: R
authors.lastname: Gillitzer
authors.forename: Christian
authors.initials: C
authors.lastname: Hampel
authors.forename: Joachim W
authors.initials: JW
authors.lastname: Thüroff
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002295:Carcinoma, Transitional Cell / Q000401:mortality* / Q000556:secondary / Q000601:surgery; D015653:Cystectomy / Q000379:methods* / Q000401:mortality; D004812:Epidemiologic Methods; D005260:Female; D006801:Humans; D008197:Lymph Node Excision / Q000379:methods* / Q000401:mortality; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D016896:Treatment Outcome; D001749:Urinary Bladder Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery