BERKELEY, CA (UroToday Inc.) - Recent data from the invasive bladder cancer literature showed that pathologic information obtained from the pelvic lymphadenectomy may be very useful for segregating patients based on risk. In particular, the number of harvested lymph nodes has been shown to be important, as is the density of positive lymph nodes involved with cancer. In penile cancer the number of lymph nodes involved has been correlated with survival, along with the presence of extranodal extension in patients with positive lymph nodes (Horenblas et al, J Urol 1993:149(3):492-7).

In the April 1st issue of the Journal of Clinical Oncology, Fleischmann, Studer and colleagues from the University of Bern report their extensive experience with invasive bladder cancer and attempt to identify risk factors for poor outcome in patients with positive lymph nodes after radical cystectomy.

Of a total of 507 patients with clinical stage TXN0M0 tumor who underwent cystectomy with pelvic lymphadenectomy, 124 patients had positive lymph nodes. A median of 22 nodes was harvested per patient. Median recurrence-free and overall survival rates were 17 months and 21 months, respectively. In univariate analysis, the risk factors most highly predictive of recurrence-free survival were tumor stage (T3 or greater), having 5 or more lymph nodes involved with cancer, having 20% or more of lymph nodes involved with cancer and the presence of any extranodal extension. The only risk factor predictive of survival in the univariate model that persisted as a predictor of survival in the multivariate model was extranodal extension.

Patients with N1 disease and extracapsular extension of tumor in involved lymph nodes had a worse 5-year recurrence free survival (approximately 15%) and overall survival (20%) than patients with N2 disease without extracapsular extension (recurrence-free: 60%; overall survival: approximately 65%). In other words, patients with a smaller nodal burden (N1= metastasis to a single lymph node, 2cm or less in dimension) had a worse outcome if extracapsular extension was present compared with patients with a larger positive node (N2 = metastasis to a single lymph node, more than 2 cm but smaller than 5 cm) without extracapsular extension.

In patients with bladder carcinoma with positive lymph nodes after radical cystectomy and pelvic lymphadenectomy, the presence of extracapsular extension of lymph node metastases was the most important factor predicting recurrence and survival. This may serve as a marker for closer surveillance or for selecting patients with low volume metastases for adjuvant chemotherapy if they were otherwise likely to undergo observation.

J Clin Oncol. 2005 Apr 1;23(10):2358-65