title: Prediction of true nodal status in patients with pathological lymph node negative upper tract urothelial carcinoma at radical nephroureterectomy.
abstract: OBJECTIVE
  The role of lymph node dissection is still controversial in patients treated with radical nephroureterectomy for upper tract urothelial cancer. We developed a pathological nodal staging model that allows quantification of the likelihood that a patient with pathologically node negative disease has, indeed, no lymph node metastasis.
  
  
  METHODS
  We analyzed data on 814 patients treated with radical nephroureterectomy and lymph node dissection, and estimated the sensitivity of pathological nodal staging using a β-binomial model. We developed a pathological nodal staging score that represents the probability that a case is correctly staged as node negative.
  
  
  RESULTS
  A median of 5 lymph nodes (range 1 to 46) was removed and 593 patients (73%) had pN0 disease. The probability of missing lymph node metastasis decreased as the number of nodes examined increased. If only a single node was examined, 44% of patients would have been misclassified as having pN0 disease while harboring lymph node metastasis. Even when 5 nodes were examined, 12% of patients would have been misclassified. The proportion of those with a positive node increased with advancing pathological T stage and lymphovascular invasion. Patients with pT0-Ta-Tis-T1/lymphovascular invasion had more than a 95% chance of correct pathological nodal staging with 2 examined nodes. However, if a patient had pT3-T4 and positive lymphovascular invasion, even 20 examined lymph nodes did not attain 95% accuracy.
  
  
  CONCLUSIONS
  Lymph node dissection provides more accurate staging and prediction of survival. The number of examined nodes needed for adequate staging depends on pT stage and lymphovascular invasion. We developed a tool to estimate the likelihood of false-negative lymph node metastasis, which could help refine clinical decision making regarding the administration of adjuvant chemotherapy.
authors.affiliation: Department of Urology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York 10065, USA.
authors.forename: Evanguelos
authors.initials: E
authors.lastname: Xylinas
authors.forename: Michael
authors.initials: M
authors.lastname: Rink
authors.forename: Vitaly
authors.initials: V
authors.lastname: Margulis
authors.forename: Talia
authors.initials: T
authors.lastname: Faison
authors.forename: Evi
authors.initials: E
authors.lastname: Comploj
authors.forename: Giacomo
authors.initials: G
authors.lastname: Novara
authors.forename: Jay D
authors.initials: JD
authors.lastname: Raman
authors.forename: Yair
authors.initials: Y
authors.lastname: Lotan
authors.forename: Bertrand
authors.initials: B
authors.lastname: Guillonneau
authors.forename: Alon
authors.initials: A
authors.lastname: Weizer
authors.forename: Armin
authors.initials: A
authors.lastname: Pycha
authors.forename: Douglas S
authors.initials: DS
authors.lastname: Scherr
authors.forename: Christian
authors.initials: C
authors.lastname: Seitz
authors.forename: Maxine
authors.initials: M
authors.lastname: Sun
authors.forename: Quoc-Dien
authors.initials: QD
authors.lastname: Trinh
authors.forename: Pierre I
authors.initials: PI
authors.lastname: Karakiewicz
authors.forename: Francesco
authors.initials: F
authors.lastname: Montorsi
authors.forename: Marc
authors.initials: M
authors.lastname: Zerbib
authors.forename: Mithat
authors.initials: M
authors.lastname: Gönen
authors.forename: Shahrokh F
authors.initials: SF
authors.lastname: Shariat
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002295:Carcinoma, Transitional Cell / Q000473:pathology* / Q000601:surgery*; D005260:Female; D006801:Humans; D007680:Kidney Neoplasms / Q000473:pathology* / Q000601:surgery*; D008207:Lymphatic Metastasis / Q000473:pathology; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000379:methods; D011379:Prognosis; D012189:Retrospective Studies; D014513:Ureter / Q000601:surgery*; D014516:Ureteral Neoplasms / Q000473:pathology* / Q000601:surgery*