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Impact of Adequate Pelvic Lymph Node Dissection on Overall Survival After Radical Cystectomy: A Stratified Analysis by Stage and Receipt of Neoadjuvant Chemotherapy
Alexander P. Cole, MD1, Nicolas von Landenburg, MD2, Philipp Gild, MD3, Jacqueline Speed, MD1, Thomas Seisen, MD4, Quoc-Dien Trinh, MD1.
1Brigham & Women's Hospital- Division of Urological Surgery, Boston, MA, USA, 2Ruhr-University Bochum, Marien Hospital Herne- Department of Urology, Herne, Germany, 3University Medical Center Hamburg-Eppendorf- Department of Urology, Hamburg, Germany, 4Hopital Pitié-Salpétrière- Service d'Urologie, Paris, France.
BACKGROUND: The benefit of pelvic lymph node dissection (PLND) at the time of radical cystectomy (RC) for bladder cancer is well-documented. In addition to providing information on nodal stage, an adequate PLND—with many studies using a cutoff of ten or more nodes—provides a survival benefit even when cancer is confined to the bladder. Neoadjuvant, platinum-based chemotherapy (NAC) also confers a survival benefit—possibly by treating occult or “micro” metastatic disease prior to cystectomy. Given that NAC may perform a similar function, the benefit of PLND may differ depending on receipt of NAC. This has not previously been assessed. Therefore, we designed a study to assess the stage-specific benefit of an extended PLND depending on whether a patient receives NAC.
METHODS: Using the National Cancer DataBase (2004-2012), we identified 14,139 patients with clinically localized bladder cancer (Ta-T4 and N0M0) who received RC. For each patient, we extracted data on (1) whether the patient received neoadjuvant chemotherapy and (2) whether the patient received adequate pelvic lymph node dissection (defined as at least 10 nodes removed). Inverse probability of treatment weighting (IPTW) -adjusted Kaplan-Meier curves were used to compare overall survival (OS) between men and women who received extended PLND, and those who did not. We then performed a stratified analysis of overall survival by clinical T-Stage and NAC. RESULTS: Overall, 5,466 (38.66%) and 8,673 (61.34%) patients underwent RC for localized or locally advanced bladder cancer. Median time to last follow-up was 54.24 months [IQR, 33.64-74.41 months]. IPTW-adjusted Kaplan-Meier curves showed that median OS was improved in men who received an extended PLND (46.49 vs. 60.85 months). In stage-specific sub-analyses of men and women who did not receive NAC, an adequate PLND was associated with a OS benefit for cT2 (HR=0.86; p<0.001) Among men and women who received NAC, appropriate LND was associated with significant OS benefit among men with cT2 (HR=0.76; p=0.005), but not cT3/4 (HR=0.82; p=0.188). CONCLUSIONS: These data suggest the survival benefit of an adequate pelvic node dissection is preserved in men with T1 and T2 disease regardless of whether they receive NAC. In men with T3 and T4 disease who have received NAC, the benefit seems to be attenuated -perhaps due to the already poor prognostic category in which these patients find themselves or due to the ability of T3/T4 tumors to spread through alternate lymphatic drainage routes.
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