title: Lymph node-positive bladder cancer treated with radical cystectomy and lymphadenectomy: effect of the level of node positivity.
abstract: BACKGROUND
  The extent of lymphadenectomy needed to optimize oncologic outcomes after radical cystectomy (RC) for patients with regionally advanced bladder cancer (BCa) is unclear.
  
  
  OBJECTIVE
  Evaluate the effect of the location of lymph node metastasis on recurrence-free survival (RFS) and cancer-specific survival (CSS) for patients undergoing RC with a mapping pelvic lymph node dissection (PLND).
  
  
  METHODS
  A study of 591 patients undergoing RC with mapping PLND was completed between 2000 and 2010. Median follow-up was 30 mo.
  
  
  METHODS
  RC with mapping PLND.
  
  
  METHODS
  We evaluated the impact of lymph node involvement by location on disease outcomes using the 2010 TNM staging system. Survival estimates were described using Kaplan-Meier methods. Gender, age, pathologic stage, histology, number of positive nodes, location of positive nodes, node density, use of perioperative chemotherapy, and grade were evaluated as predictors of RFS and CSS using multivariate Cox proportional hazard regression.
  
  
  CONCLUSIONS
  Overall, 114 patients (19%) had lymph node involvement, and 42 patients (7%) had pN3 disease. On multivariate analysis, the number of positive lymph nodes (one or two or more) was significantly associated with increased risk of cancer-specific death (hazard ratio [HR]: 1.9 [95% confidence interval (CI), 1.04-3.46], p=0.036; versus HR: 4.3 [95% CI, 2.25-8.34], p<0.0005). Positive lymph node location was not an independent predictor of RFS or CSS. Five-year RFS for pN3 patients undergoing RC with PLND was 25% (95% CI, 10-42). This finding was not statistically different from our pN1 and pN2 patients (38% [95% CI, 22-54] and 35% [95% CI, 11-60], respectively). This study is limited by the lack of prospective randomization and a control group.
  
  
  CONCLUSIONS
  The outcome for patients with involved common iliac lymph nodes was similar to the outcome for patients with primary nodal basin disease. These data support inclusion of the common iliac lymph nodes (pN3) in the nodal staging system for BCa. Lymph node location was not an independent predictor of outcome, whereas the number of positive lymph nodes was an independent predictor of worse oncologic outcome (pN1, pN2). Further refinements of the TNM system to provide improved prognostication are warranted.
authors.affiliation: Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
authors.forename: Tatum V
authors.initials: TV
authors.lastname: Tarin
authors.forename: Nicholas E
authors.initials: NE
authors.lastname: Power
authors.forename: Behfar
authors.initials: B
authors.lastname: Ehdaie
authors.forename: John P
authors.initials: JP
authors.lastname: Sfakianos
authors.forename: Jonathan L
authors.initials: JL
authors.lastname: Silberstein
authors.forename: Caroline J
authors.initials: CJ
authors.lastname: Savage
authors.forename: Daniel
authors.initials: D
authors.lastname: Sjoberg
authors.forename: Guido
authors.initials: G
authors.lastname: Dalbagni
authors.forename: Bernard H
authors.initials: BH
authors.lastname: Bochner
mesh_terms: D000368:Aged; D002277:Carcinoma / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D015653:Cystectomy / Q000379:methods*; D018572:Disease-Free Survival; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008197:Lymph Node Excision / Q000379:methods*; D008198:Lymph Nodes / Q000601:surgery; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D060787:Neoplasm Grading; D011379:Prognosis; D011446:Prospective Studies; D016896:Treatment Outcome; D001749:Urinary Bladder Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery*