No survival difference between super extended and standard lymph node dissection at radical cystectomy: what can we learn from the first prospective randomized phase III trial?
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SUBMITTER: Muilwijk T
PROVIDER: S-EPMC6511709 | biostudies-literature | 2019 Mar
REPOSITORIES: biostudies-literature
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No survival difference between super extended and standard lymph node dissection at radical cystectomy: what can we learn from the first prospective randomized phase III trial?
Muilwijk Tim T Akand Murat M Gevaert Thomas T Joniau Steven S
Translational andrology and urology 20190301 Suppl 1
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Project description: Not available
| S-EPMC6528183 | biostudies-literature
Project description:Radical cystectomy (RC) with a pelvic lymph node dissection (LND) is the gold standard for the treatment of muscle invasive bladder cancer (MIBC) as well as for some high-risk non-muscle invasive bladder cancers. The therapeutic advantage of LND, in terms of cancer-specific survival (CSS), still divides opinion and, certainly, the question of the extent of LND at the time of cystectomy is still debated. In this article, we have reviewed the evidence supporting the practice of extending LND in order to help clinicians determine what is appropriate in their practice. There still remains a lack of prospective randomized studies addressing whether extended LND provides a survival benefit in patients undergoing RC for BC. However, there is large body of evidence that suggests there is a positive impact on the oncological outcomes in these patients without an apparent cost of unacceptable adverse events.
| S-EPMC8057354 | biostudies-literature
Project description:The number of lymph node dissections (LNDs) is an independent factor influencing the survival time of patients with bladder cancer (BCa) after radical resection (RC). The present study aimed to investigate the association between the number of LNDs and the survival of patients with BCa at different stages and who underwent RC in the United States of America and China. Records from 17,730 American patients with BCa and 158 Chinese patients with BCa were collected from the Surveillance, Epidemiology and End Results (SEER) and the Shanghai Tenth People's Hospital (China) databases, respectively. Kaplan-Meier curve and χ2 test were used to determine the overall survival time (OS) of patients with BCa. Cox regression analysis was used to analyze the effects of LND number on OS. Overall, 13,421 (75.7%) patients were negative for lymph node metastasis (N0) and 4,309 (24.3%) were positive for lymph node metastasis (N+) among the 17,730 American patients with BCa. In the group of 158 Chinese patients, 125 (79.1%) were N0 and 33 (20.9%) were N+. In the American patients, the median number of dissected nodes was 11.0 [interquartile range (IQR)=3.0-21.0] for N0 patients and 14.0 (IQR=8.0-23.0) for N+ patients. The median number of LNDs was 5.0 (IQR=2.0-7.0) for Chinese N0 patients and 5.0 (IQR=1.5-10.5) for Chinese N+ patients. The number of LNDs may therefore be an independent factor associated with survival in patients who underwent RC. Furthermore, a higher number of LNDs was associated with longer OS in patients with BCa [American patients, ≥13 nodes vs. ≤5 nodes, hazard ratio (HR)=0.62, 95% confidence interval (CI)=0.59-0.65, P<0.001; Chinese patients, ≥5 nodes vs. ≤1 node, HR=0.27, 95% CI=0.12-0.62, P=0.002]. The number of LNDs in patients with BCa and N+ was higher compared with number of LNDs in patients with BCa and N0 who underwent RC. More extensive LND improved the OS in both the patients from USA and China. Increasing the number of LNDs may therefore be crucial when treating patients with BCa.
| S-EPMC7285989 | biostudies-literature
Project description:ObjectiveTo evaluate the effectiveness of extended (e-PLND) and super-extended pelvic lymph node dissection (se-PLND) during robot-assisted radical prostatectomy (RARP) by examining lymph node (LN) yield, complications, LN metastasis, and biochemical recurrence (BCR) incidence.MethodsBetween January 2016 and January 2020, 354 consecutive patients with > 5% risk of lymph node involvement (LNI), as predicted by the Memorial Sloan Kettering Cancer Center nomogram, underwent RARP with (s)e-PLND at a high-volume center. The e-PLND involved removing fibrofatty lymphatic tissue around the obturator fossa, internal iliac region, and external iliac vessels. The se-PLND, performed at the discretion of the surgeons, also included lymph nodes from the pre-sacral and common iliac regions. Outcomes included histopathological findings by anatomical region; complications; and BCR incidence during follow-up.ResultsThe median LNI risk was 18% (IQR 9-31%). A median of 22 LN (IQR 16-28) were removed, with se-PLND yielding a higher number: 25 (IQR 20-32) compared to e-PLND: 17 (IQR 13-24) (p < 0.001). pN1 disease was detected in 22% of patients overall, higher in se-PLND (29%) than e-PLND (14%) (p < 0.001). Of metastatic LNs, 14% were situated outside the e-PLND template. Operation time was longer for se-PLND, but perioperative complications were similar between both groups. After a median follow-up of 24 months (IQR 7-33), BCR incidence was comparable between the two groups.ConclusionCompared to standard extended pelvic lymph node dissection (PLND), super extended PLND increases lymph node yield and removal of metastatic deposits but does not contribute to progression free survival at mid-term.
| S-EPMC11525387 | biostudies-literature
Project description:BackgroundUrinary continence and erectile function (EF) are best preserved when meticulous dissection of prostate and nerve sparing technique are used during radical prostatectomy (RP). However, extent of lymph node dissection (LND) may also adversely affect functional results.ObjectiveTo determine whether performing a super-extended LND (seLND) has a significant effect on recovery of urinary continence and EF after RP.Design setting and participantsAll patients who underwent RP from January 2007 until December 2013 were handed questionnaires assessing continence and EF. All patients in whom at least an extended LND (eLND) was performed were selected. This search yielded 526 patients. 172 of these patients had filed out 2 or more questionnaires and were included in our analysis.Outcome measurements and statistical analysisAll questionnaires were reviewed. We used Kaplan-Meier analyses and multivariate Cox analysis to assess the difference in recovery of continence and EF over time for eLND/seLND. Primary endpoints were full recovery of continence (no loss of urine) and full recovery of EF (successful intercourse possible). Patients who did not reach the endpoint when the last questionnaire was filled out were censored at that time. Median follow-up was 12.43 months for continence, and 18.97 months for EF.Results and limitationsPatients undergoing seLND have a lower chance of regaining both urinary continence [hazard ratio (HR) 0.59, 95% CI 0.39-0.90, p = 0.026] and EF (HR 0.28, 95% CI 0.13-0.57, p = 0.009). Age at surgery had a significant influence on both continence and EF in multivariate analysis. Major limitation of the study was that no formal preoperative assessment of continence and potency was done.ConclusionExtending the LND template beyond the eLND template may cause at least a significant delay in recovery of urinary continence and leads to less recovery of EF.
| S-EPMC5702642 | biostudies-literature
Project description:Our aim is to evaluate the association between body mass index (BMI) and preoperative total testosterone (TT) levels with the risk of single and multiple metastatic lymph node invasion (LNI) in prostate cancer patients undergoing radical prostatectomy and extended pelvic lymph node dissection. Preoperative BMI, basal levels of TT, and prostate-specific antigen (PSA) were evaluated in 361 consecutive patients undergoing radical prostatectomy with extended pelvic lymph node dissection between 2014 and 2017. Patients were grouped into either nonmetastatic, one, or more than one metastatic lymph node invasion groups. The association among clinical factors and LNI was evaluated. LNI was detected in 52 (14.4%) patients: 28 (7.8%) cases had one metastatic node and 24 (6.6%) had more than one metastatic node. In the overall study population, BMI correlated inversely with TT (r = -0.256; P < 0.0001). In patients without metastases, BMI inversely correlated with TT (r = -0.282; P < 0.0001). In patients with metastasis, this correlation was lost. In the overall study population, BMI (odds ratio [OR] = 1.268; P = 0.005) was the only independent clinical factor associated with the risk of multiple metastatic LNI compared to cases with one metastatic node. In the nonmetastatic group, TT was lower in patients with BMI >28 kg m-2 (P < 0.0001). In patients with any LNI, this association was lost (P = 0.232). The median number of positive nodes was higher in patients with BMI >28 kg m-2 (P = 0.048). In our study, overweight and obese patients had a higher risk of harboring multiple prostate cancer lymph node metastases and lower TT levels when compared to patients with normal BMI.
| S-EPMC7275807 | biostudies-literature
Project description:IntroductionLymph node counts have become a surrogate measure for the extent and quality of pelvic lymph node dissection (PLND) at radical cystectomy, but little consideration has been given to the methodology of lymph node processing. We report results from a prospective series comparing a conventional protocol for processing PLND specimens to a fat-emulsifying protocol. We hypothesized that the rate of node positivity would increase with the fat-emulsifying protocol.MethodsPatients undergoing radical cystectomy for cTis-T4aN0-1M0 urothelial carcinoma of the bladder were eligible for this trial. Palpable lymph nodes were isolated from the PLND specimens in the conventional protocol. The remaining tissue was then processed with fat-emulsifying solution to identify further nodes visually. Nodal counts were compared between techniques.ResultsThe median number of nodes counted in the PLND specimens of 26 patients was 24.5 (range: 20-40) with conventional processing and 37 (range: 24-52) with the fat-emulsifying solution (p < 0.001). Three patients had lymph node positive disease detected by conventional means, and a single patient was found to have a single positive node by the fat-emulsifying solution alone. The study was closed early after conducting a futility analysis.ConclusionsA fat-emulsifying protocol identified more lymph nodes than a conventional protocol and may be an appropriate method to standardize lymph node processing following PLND. However, we were unable to show that such a standardized approach significantly increased the rate of node positivity in patients undergoing radical cystectomy.
| S-EPMC4662397 | biostudies-literature
Project description:The practice of extended pelvic lymph node dissection (ePLND) remains one of the most controversial topics in the management of clinically localized prostate cancer. Although most urologists agree on its benefit for staging and prognostication, the role of the ePLND in cancer control continues to be debated. The increased perioperative morbidity makes it unpalatable, especially in patients with low likelihood of lymph node disease. With the advent of robotic assisted laparoscopic prostatectomy, many surgeons were slow to adopt ePLND in the robotic setting. In this study, we summarize the evidence for the prognostic and therapeutic roles of ePLND, review the clinical tools used for lymph node metastasis prediction and survey the numerous experiences of ePLND compiled by robotic urologic surgeons over the years.
| S-EPMC5161019 | biostudies-literature
Project description:Objective This study aims to determine the optimal pelvic lymph node dissection (PLND) template for radical cystectomy (RC). Methods A systematic search was conducted using the PubMed, Embase and Cochrane Library database in December 2021. Articles comparing recurrence-free survival (RFS), disease-specific survival (DSS), overall survival (OS), and postoperative complications among patients undergoing limited PLND (lPLND), standard PLND (sPLND), extended PLND (ePLND), or super-extended PLND (sePLND) were included. A Bayesian approach was used for network meta-analysis. Results We included 18 studies in this systematic review, and 17 studies met our criteria for network meta-analysis. We performed meta-analyses and network meta-analyses to investigate the associations between four PLND templates and the RFS, DSS, OS, or postoperative complications. We found that the ePLND group and the sePLND group were associated with better RFS than the sPLND group (Hazard Ratio [HR]: 0.65, 95% Credible Interval [CrI]: 0.56 to 0.78) (HR: 0.67, 95% CrI: 0.56 to 0.83) and the lPLND group (HR: 0.67, 95% CrI: 0.50 to 0.91) (HR: 0.70, 95% CrI: 0.49 to 0.99). For RFS, Analysis of the treatment ranking revealed that ePLND had the highest probabilities to be the best template. There was no significant difference between the four templates in DSS, however, analysis of the treatment ranking indicated that sePLND had the highest probabilities to be the best template. And We found that the sePLND group and the ePLND group were associated with better OS than lPLND (HR: 0.58, 95% CrI: 0.36 to 0.95) (HR: 0.63, 95% CrI: 0.41 to 0.94). For OS, analysis of the treatment ranking revealed that sePLND had the highest probabilities to be the best template. The results of meta-analyses and network meta-analyses showed that postoperative complications rates did not differ significantly between any two templates. Conclusion Patients undergoing sePLND and ePLND had better RFS but not better DSS or OS than those undergoing lPLND or sPLND templates, however, RFS did not differ between patients undergoing sePLND or ePLND. Considering that sePLND involves longer operation time, higher risk, and greater degree of difficulty than ePLND, and performing sePLND may not result in better prognosis, so it seems that there is no need for seLPND. We think that ePLND might be the optimal PLND template for RC. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, identifier CRD42022318475.
| S-EPMC9732561 | biostudies-literature
Project description:Background: Benefits of adjuvant chemotherapy (AC) and extent of pelvic lymph node dissection (PLND) in radical cystectomy (RC) are debated. Results from randomized trials are still expected. Objective: To analyze the effects of AC and PLND in two academic centers with opposite policies regarding their use. Methods: 581 bladder cancer patients who underwent RC without neoadjuvant chemotherapy, from Toronto (University Health Network), Canada, and Turku University Hospital, Finland were included. Disease specific survival (DSS) and failure patterns were assessed. Results: Centers differed in PLND rate (93% and 36% in Toronto and Turku respectively, p?< ?0.001), PLND extent (?10 removed nodes, 58% vs. 8%, p?< ?0.001) and AC rate (21% vs. 2%, p?< ?0.001). Survival between centers among pT?1 or pT4 patients was similar. pT3 patients in Toronto had an improved 10 year DSS (43% vs. 22%, p?=?0.025). Distant failures were less common after AC (HR 0.56, 95% ?CI 0.33-0.98, p?< ?0.042). In node positive (N+) patients, mortality was significantly higher in Turku (HR 2.19, 95% ?CI 1.44-3.34, p?< ?0.001) and lower in patients receiving AC (HR 0.60, 95% ?CI 0.37-0.99, p?=?0.044). 41% DSS at 10 years was observed in N+?Toronto patients. Limitations included the non-randomized retrospective design and absence of propensity score analysis. Conclusion: Combining AC and PLND to RC is associated with improved survival in pT3 and N+?patients. PLND did not affect survival independently but helps in selecting patients for AC. Our data adds to the growing body of evidence supporting the usefulness of AC in addition to PLND in high risk patients operated by cystectomy.
| S-EPMC4927915 | biostudies-other