EAU 2018: The Role of Lymphadenectomy in Urological Cancers – Urothelial Cancer
As he stated up front, lymphadenectomy in bladder cancer is unlike the other GU malignancies – it is not for staging purposes per se, it is primarily for treatment.
Don Skinner (USC), in the 1970’s, demonstrated that a proportion of patients with metastatic bladder cancer, with node positive disease, have long-term durable survival with cystectomy and node dissection. Approximately 35% of these patients have long-term survival.
However, the extent of the node dissection has always been under debate. Dr. Jensen put a nice diagram of possible TNM virtual patients, ranging from true TxN0 to TxN+M1. As you extend the extent of the node dissection, you potential cure a larger proportion of patients – all the way up to the TxNpositiveM0 (no occult distant metastases). However, that extended node dissection may come with a cost.
Lymphatic drainage of the bladder.
- Roth EU 2010 – nice study on the drainage of bladder cancer. By increasing the extent of the node dissection, you exclude a smaller proportion of node positive disease sites. Dr. Jansen recommends a dissection up to bifurcation of the aorta, which would only exclude 2% of occult nodal metastases.
- Unfortunately, there is a very wide, varying definition of limited/standard node dissection and extended (aka sub-total, super-extended) node dissection
o They are all broadly called limited or extended
Extent of dissection and outcomes
- Poulsen JU 1998 – limited retrospective series that demonstrated early evidence that ePLND may be associated with sPLND
- Holmer WJU 2009 – seLND superior to limited PLND in terms of DFS/CSS, particularly for the pT3-4 patients
- Jensen IJU 2012 – sePLND vs. sPLND (retrospective), sePLND had better DFS and RFS
- The benefit is not for pN0 patients, only for pN+ patients – intuitive. So pN0 patients are getting overtreated.
Randomized trials
1. LEA (European) – 375 patients randomized between 2006-2010. 5-year CSS and RFS was superior in the ePLND arms, but not clinically significant
2. SWOF 1011 (American) – 620 patients enrolled. Study results pending
However, all of these are in the absence of neoadjuvant chemotherapy. It is uncertain what the benefit of node dissection in patients who have received NAC.
Now, we briefly addressed UTUC.
- Kondo JU 2007 – Complete LND provided superior CSS in pT3+ UTUC patients. Not in the entire cohort.
- Briganti EU 2008 – Patients who were pN1 did worse than patients who were pN0. But combined, they still did better than patients who were pNx (not sampled). More importantly, if more than 6 nodes were removed, CSS was improved.
Ongoing RCT in Denmark, randomized 1:1 for LND, may help answer some questions.
Evidence at this point is low.
Speaker: J. Bjerggaard Jensen
Written by: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, Twitter: @tchandra_uromd at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark