Clinical nodal staging scores for bladder cancer: a proposal for preoperative risk assessment.
BACKGROUND
Radical cystectomy (RC) with pelvic lymph node dissection (LND) is the standard of care for refractory non-muscle-invasive and muscle-invasive bladder cancer. Although consensus exists on the need for LND, its extent is still debated.


OBJECTIVE
To develop a model that allows preoperative determination of the minimum number of lymph nodes (LNs) needed to be removed at RC to ensure true nodal status.


METHODS
We analyzed data from 4335 patients treated with RC and pelvic LND without neoadjuvant chemotherapy at 12 academic centers located in the United States, Canada, and Europe.


METHODS
We estimated the sensitivity of pathologic nodal staging using a beta-binomial model and developed clinical (preoperative) nodal staging scores (cNSS), which represent the probability that a patient has LN metastasis as a function of the number of examined nodes.


CONCLUSIONS
The probability of missing a positive LN decreased with an increasing number of nodes examined (52% if 3 nodes were examined, 40% if 5 were examined, and 26% if 10 were examined). A cNSS of 90% was achieved by examining 6 nodes for clinical Ta-Tis tumors, 9 nodes for cT1 tumors, and 25 nodes for cT2 tumors. In contrast, examination of 25 nodes provided only 77% cNSS for cT3-T4 tumors. The study is limited due to its retrospective design, its multicenter nature, and a lack of preoperative staging parameters.


CONCLUSIONS
Every patient treated with RC for bladder cancer needs an LND to ensure accurate nodal staging. The minimum number of examined LNs for adequate staging depends preoperatively on the clinical T stage. Predictive tools can give a preoperative estimation of the likelihood of nodal metastasis and thereby allow tailored decision-making regarding the extent of LND at RC.
Brady Urologic Health Center, Weill Cornell Medical College, 525 East 68th St., Box 94, Starr 900, New York, NY 10065, USA. sfshariat@gmail.com
Shahrokh F
SF
Shariat
Behfar
B
Ehdaie
Michael
M
Rink
Eugene K
EK
Cha
Robert S
RS
Svatek
Thomas F
TF
Chromecki
Harun
H
Fajkovic
Giacomo
G
Novara
Scott G
SG
David
Siamak
S
Daneshmand
Yves
Y
Fradet
Yair
Y
Lotan
Arthur I
AI
Sagalowsky
Thomas
T
Clozel
Patrick J
PJ
Bastian
Wassim
W
Kassouf
Hans-Martin
HM
Fritsche
Maximilian
M
Burger
Jonathan I
JI
Izawa
Derya
D
Tilki
Firas
F
Abdollah
Felix K
FK
Chun
Guru
G
Sonpavde
Pierre I
PI
Karakiewicz
Douglas S
DS
Scherr
Mithat
M
Gonen
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002277:Carcinoma / Q000473:pathology* / Q000601:surgery; D015653:Cystectomy / Q000379:methods*; D005260:Female; D006801:Humans; D008197:Lymph Node Excision; D008198:Lymph Nodes / Q000473:pathology* / Q000601:surgery*; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D057234:Preoperative Period; D012189:Retrospective Studies; D018570:Risk Assessment; D001749:Urinary Bladder Neoplasms / Q000473:pathology* / Q000601:surgery*; D055815:Young Adult