title: Prognostic value of extranodal extension and other lymph node parameters in patients with upper tract urothelial carcinoma.
abstract: OBJECTIVE
  We assessed the prognostic value of extranodal extension and other lymph node parameters in a large multicenter cohort of patients with lymph node metastasis after radical nephroureterectomy.
  
  
  METHODS
  We retrospectively analyzed the records of 222 patients with lymph node metastasis treated with radical nephroureterectomy for upper tract urothelial carcinoma without neoadjuvant therapy. Each lymph node metastasis was microscopically evaluated for extranodal extension.
  
  
  RESULTS
  A median of 4 lymph nodes (IQR 8) was removed. Two lymph nodes (IQR 2) were positive. Lymph node density was 51.3% (IQR 71.7%). Overall 110 patients (49.5%) had extranodal extension, which was associated with more advanced pT stage (p = 0.026). On multivariable analysis extranodal extension was associated with disease recurrence (p = 0.01) and cancer specific mortality (p = 0.013). When stratified by a 30% cutoff, lymph node density was associated with disease recurrence and cancer specific mortality on univariable but not multivariable analysis (p = 0.048 and 0.049, respectively). Adding extranodal extension to a multivariable model including pT stage and tumor architecture improved predictive accuracy for disease recurrence from 70.3% to 74.5% (p <0.001). Adding extranodal extension to a multivariable model including age, pT stage and tumor architecture improved predictive accuracy for cancer specific mortality from 70.6% to 74.4% (p <0.001).
  
  
  CONCLUSIONS
  Extranodal extension is a powerful predictor of clinical outcomes in patients with upper tract urothelial carcinoma with lymph node metastasis. While other lymph node parameters seem to have limited clinical value, extranodal extension could help risk stratify patients with upper tract urothelial carcinoma and lymph node metastasis for better counseling and clinical trial design.
authors.affiliation: Department of Urology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York 10065, USA.
authors.forename: Harun
authors.initials: H
authors.lastname: Fajkovic
authors.forename: Eugene K
authors.initials: EK
authors.lastname: Cha
authors.forename: Claudio
authors.initials: C
authors.lastname: Jeldres
authors.forename: Gerhard
authors.initials: G
authors.lastname: Donner
authors.forename: Thomas F
authors.initials: TF
authors.lastname: Chromecki
authors.forename: Vitaly
authors.initials: V
authors.lastname: Margulis
authors.forename: Giacomo
authors.initials: G
authors.lastname: Novara
authors.forename: Yair
authors.initials: Y
authors.lastname: Lotan
authors.forename: Jay D
authors.initials: JD
authors.lastname: Raman
authors.forename: Wassim
authors.initials: W
authors.lastname: Kassouf
authors.forename: Christian
authors.initials: C
authors.lastname: Seitz
authors.forename: Karim
authors.initials: K
authors.lastname: Bensalah
authors.forename: Alon
authors.initials: A
authors.lastname: Weizer
authors.forename: Eiji
authors.initials: E
authors.lastname: Kikuchi
authors.forename: Marco
authors.initials: M
authors.lastname: Roscigno
authors.forename: Mesut
authors.initials: M
authors.lastname: Remzi
authors.forename: Kazumasa
authors.initials: K
authors.lastname: Matsumoto
authors.forename: Eckart
authors.initials: E
authors.lastname: Breinl
authors.forename: Armin
authors.initials: A
authors.lastname: Pycha
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Ficarra
authors.forename: Francesco
authors.initials: F
authors.lastname: Montorsi
authors.forename: Pierre I
authors.initials: PI
authors.lastname: Karakiewicz
authors.forename: Douglas S
authors.initials: DS
authors.lastname: Scherr
authors.forename: Shahrokh F
authors.initials: SF
authors.lastname: Shariat
mesh_terms: D017024:Chemotherapy, Adjuvant; D016009:Chi-Square Distribution; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008197:Lymph Node Excision; D008207:Lymphatic Metastasis / Q000473:pathology*; D008297:Male; D009364:Neoplasm Recurrence, Local; D009367:Neoplasm Staging; D009392:Nephrectomy; D011379:Prognosis; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D018709:Statistics, Nonparametric; D016896:Treatment Outcome; D014516:Ureteral Neoplasms / Q000188:drug therapy / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D001749:Urinary Bladder Neoplasms / Q000188:drug therapy / Q000401:mortality / Q000473:pathology* / Q000601:surgery*