A thorough pelvic lymph node dissection in presence of positive margins associated with better clinical outcomes in radical cystectomy patients.
OBJECTIVE
To evaluate the effect of positive surgical margins in patients with muscle-invasive transitional cell carcinoma of the bladder on survival.


METHODS
A retrospective evaluation of a prospectively maintained radical cystectomy database consisting of the data from 344 patients was performed. Cox regression analysis was done, and Kaplan-Meier tables were developed to evaluate the contribution of this finding to clinical outcomes.


RESULTS
A total of 304 (88.4%) patients had negative surgical margins in the radical cystectomy specimen, and 40 (11.6%) had positive surgical margins. On univariate analysis, positive surgical margins conferred a significant risk of poorer clinical outcomes. The 5-year overall (OS) and disease-specific survival (DSS) rate was 9% and 18% for patients with positive margins compared with 48% and 65% for patients with negative margins, respectively. The multivariate analysis demonstrated a significant independent risk of decreased recurrence-free survival, DSS, and OS for patients with positive surgical margins. The corresponding hazard ratios were 2.29 (95% confidence interval 1.54-3.41, P < .001), 1.71 (95% confidence interval 1.15-2.56, P < .009), and 1.70 (95% confidence interval 1.23-2.34, P < .001). Despite these findings, patients with positive margins and node-negative disease experienced improved DSS and recurrence-free survival (P = .001 P and = .009, respectively) if >15 lymph nodes were removed during surgery.


CONCLUSIONS
The presence of positive surgical margins in the pathologic specimen confers a significant independent risk of reduced recurrence-free survival, DSS, and overall survival. Nevertheless, patients with positive surgical margins will still benefit from a meticulous pelvic lymph node dissection.
Department of Surgery, Division of Urology, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA. daniel.canter@uphs.upenn.edu
Daniel
D
Canter
Thomas J
TJ
Guzzo
Matthew J
MJ
Resnick
Meredith R
MR
Bergey
Seema S
SS
Sonnad
John
J
Tomaszewski
Keith
K
VanArsdalen
S Bruce
SB
Malkowicz
D000368:Aged; D002295:Carcinoma, Transitional Cell / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D015653:Cystectomy; D005260:Female; D006801:Humans; D008197:Lymph Node Excision / Q000379:methods*; D008207:Lymphatic Metastasis; D008297:Male; D012189:Retrospective Studies; D015996:Survival Rate; D016896:Treatment Outcome; D001749:Urinary Bladder Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery*