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Alberto Briganti Pierre I Karakiewicz Felix K-H Chun Nazareno Suardi rea Gallina Firas Abdollah Massimo Freschi Claudio Doglioni Patrizio Rigatti Francesco Montorsi 《International journal of urology》2009,16(8):676-681
Objectives: Several studies have shown that obesity is associated with more aggressive prostate cancer (PCa) variants. We hypothesized that obesity, quantified as body mass index (BMI), is associated with a higher risk of lymph node invasion (LNI) in patients undergoing extended pelvic lymph node dissection (ePLND). Methods: Clinical and pathological data were available for 994 consecutive men with PCa treated with radical prostatectomy (RP) and ePLND at a single European tertiary academic centre. Univariable and multivariable logistic regression analyses addressed the rate of LNI. Covariates consisted of pre‐treatment prostate specific antigen (PSA), biopsy Gleason sum, clinical stage history of diabetes mellitus as well as BMI coded as either continuous or categorized (<25, 25.0–29.9, 30 kg/m2 or more) variable. Predictive accuracy was assessed with area under curve estimates. Results: Overall LNI was diagnosed in 105 patients (10.6%). Mean number of removed lymph nodes was 18.3 (range 7–60). Of all 994 patients, 372 (37.4%) were normal weight, 518 (52.1%) overweight, and 104 (10.5%) were clinically obese. Prevalence of LNI did not significantly differ across different BMI categories (<25, 25.0–29.9 and 30 kg/m2 or more; 9.9, 10.6 and 12.5%, respectively; P = 0.75). In logistic regression models, neither continuously coded nor categorized BMI was a significant predictor of LNI at univariable or multivariable analyses (all P‐values ≥0.1). Moreover, inclusion of BMI with PSA, clinical stage, biopsy Gleason sum and presence of DM did not increase the ability of these variables to predict LNI (82.2% without BMI vs 82.5% and 82.9% with BMI coded as continuous and categorized variable, respectively; all P ≥ 0.4). Conclusions: In men undergoing RP and ePLND, increased BMI was not associated with increased risk of lymph node metastases. Therefore, routinely considering patient BMI in risk stratification schemes or prognostic LNI models may not be warranted. 相似文献
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The role of extended pelvic lymphadenectomy with radical prostatectomy for high-risk prostate cancer
《Urologic oncology》2015,33(5):208-216
IntroductionThe role of pelvic lymph node dissection (PLND) during radical prostatectomy (RP) for prostate cancer (PCa) is controversial. Despite extensive research in both patterns of lymphatic drainage and the clinical effect of lymph node involvement, the exact role of PLND in PCa is yet to be defined.MethodsA systematic search of the MEDLINE database was performed, and all relevant articles were reviewed in depth.ResultsWe included 84 relevant articles in our review and subdivided the information into the following categories: preoperative patient evaluation, procedure/extent of dissection, complications, and robotic surgery era. Most authors agree that the greatest benefit is seen in patients with high-risk PCa undergoing RP. Multiple imaging modalities have been evaluated for assistance in patient selection, but the use of preoperative nomograms appears to be the most helpful selection tool. The role of limited PLND vs. extended PLND (e-PLND) is yet to be defined, though many authors agree that e-PLND is preferred in the setting of high-risk PCa. Although PLND is associated with a higher incidence of complications, especially lymphocele formation, it is unclear whether e-PLND leads to more complications than limited PLND. The introduction of minimally invasive surgery may have had a negative effect on implementation of PLND in the appropriate patients undergoing RP.ConclusionDespite a lack of prospective, randomized trials evaluating PLND in RP, there does appear to be a consistent benefit in patients with high-risk disease. 相似文献
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Alberto Briganti Umberto Capitanio Felix K-H Chun Andrea Gallina Nazareno Suardi Andrea Salonia Luigi F Da Pozzo Renzo Colombo Valerio Di Girolamo Roberto Bertini Giorgio Guazzoni Pierre I Karakiewicz Francesco Montorsi Patrizio Rigatti 《European urology》2008,54(4):794-804
BACKGROUND: Previous trials have shown that the number of procedures done by a single surgeon, that is, surgical volume (SV), is associated with several outcomes after radical prostatectomy (RP). OBJECTIVE: To test the association between SV and the detection of lymph node metastases during extended pelvic lymph node dissection (ePLND). DESIGN, SETTING, AND PARTICIPANTS: The study cohort consisted of 1020 men surgically treated for clinically localized prostate cancer. INTERVENTION: All patients underwent RP and ePLND by a group of six surgeons who were trained by the surgeon with the highest SV. All surgeons performed an anatomically extended PLND, including removal of obturator, external iliac, and hypogastric nodes. MEASUREMENTS: Univariable and multivariable logistic regression models tested the association between SV (either continuously coded or dichotomized according to the most informative cut-off, namely >144 vs =144 ePLNDs) and the rate of lymph node invasion (LNI) after accounting for preoperative (baseline prostate-specific antigen [PSA], clinical stage, biopsy Gleason sum) and postoperative (pathologic stages and Gleason score, surgical margin status) patient characteristics. RESULTS AND LIMITATIONS: Mean number of nodes removed was 19.1 (median, 16; range, 7-63). Mean overall SV was 227 (range, 87-379). Overall, LNI rate was 11.8% (120/1020). No significant differences were found among patients treated by the different surgeons in terms of clinical and pathologic characteristics (all p>/=0.06). Conversely, the surgeon with the highest SV removed more nodes and found more nodal metastases compared with the other surgeons (21.1 vs 17.9 mean number of nodes removed; p<0.001, and 15 vs 9.8% of LNI; p=0.01, respectively). At univariable logistic regression analysis, either continuously coded or dichotomized SV was a significant predictor of LNI (p=0.007 and p<0.001, respectively). In multivariable models, continuously coded as well as dichotomized SV maintained a significant association with the rate of LNI, after accounting for preoperative (p=0.04 and p=0.009, respectively) as well as for postoperative variables (p=0.03 and p=0.002, respectively). CONCLUSIONS: After adjusting for clinical and pathologic case-mix differences, patients treated by the highest-volume surgeons (>144 ePLNDs) were more likely to have LNI than those treated by low-volume surgeons, even though all surgeons used a similar extended template for node removal. 相似文献
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根治性膀胱全切+尿流改道术是目前肌层浸润性膀胱肿瘤的首选治疗,盆腔淋巴结清扫术是其中的必要步骤,其对进行肿瘤准确分期、判断患者预后、提高患者的生存率至关重要,而是否所有膀胱癌患者都应该行扩大淋巴结清扫术学界尚无定论。在此,作者结合文献报道和临床诊治体会,就根治性膀胱切除术中扩大淋巴结清扫术的意义与适应征作一简要探讨。 相似文献
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Extended pelvic lymph node dissection in patients with prostate cancer previously treated with surgery for lower urinary tract symptoms 下载免费PDF全文
Nicola Fossati Daniel D. Sjoberg Umberto Capitanio Giorgio Gandaglia Alessandro Larcher Alessandro Nini Vincenzo Mirone Andrew J Vickers Francesco Montorsi Alberto Briganti 《BJU international》2015,116(3):366-372
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Douglas C. Cheung Neil Fleshner Shomik Sengupta Dixon Woon 《Translational andrology and urology》2020,9(6):3049
Pelvic lymph node dissection (PLND) is an important component in the staging and prognostication of prostate cancer. We performed a narrative review to assess the literature surrounding PLND: (I) the current guideline recommendations and contemporary utilization, (II) the calculation of patient-specific risk to perform PLND using available nomograms, (III) to review the extent of dissection, and its associated outcomes and complications. Due to the improved lymph node yield, better staging, and theoretical improvement in the control of micro-metastatic disease, guidelines have supported the use of (extended-) PLND in patients deemed to be at intermediate or high risk of lymph node involvement (often at a threshold of 5% on modern risk nomograms). However, in practice, real-world utilization of PLND varies considerably due to multiple reasons. Conflicting evidence persists with no clear oncological benefit to PLND, and a small, but important, risk of morbidity. Complications are rare, but include lymphoceles; thromboembolic events; and more rarely, obturator nerve, vascular, and ureteric injury. Furthermore, changing disease incidence and stage migration in the context of earlier detection overall have led to a decreased risk of nodal disease. The trade-offs between the benefits, harms, and risk tolerance/threshold must be carefully considered between each patient and their clinician. 相似文献
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A total of 587 cases with gastric cancer was reviewed. Particular emphasis was placed on the comparative studies on the stages
of stomach cancer and end-results of the R2 (with a conventional lymph node dissection) and the R3-resections (with an extended lymph node dissection). R3-resections were found to be generally associated with higher 5-year survival rates than R2-resections. Especially for the positive lymph node cases not having a marked serosal invasion, the 5-year survival rate was
considerably higher with R3-resections than with R2-resections (55.3 percent versus 21.5 percent). Although the differences were not significant statistically, it has been suggested
from these results that the end-results might be improved more effectively by performing R3 resection for cases without a marked serosal invasion. 相似文献
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Schiavina R Manferrari F Garofalo M Bertaccini A Vagnoni V Guidi M Borghesi M Baccos A Morselli-Labate AM Concetti S Martorana G 《BJU international》2011,108(8):1262-1268
Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Pelvic lymph‐node dissection during radical prostatectomy for prostate cancer is certainly a fundamental staging procedure but its therapeutic role is yet under debate. This retrospective study suggests that, in patients with intermediate‐ and high‐risk of prostate cancer, the greater the number of lymph‐nodes removed, the lower the risk of biochemical relapse, even in the presence of 1 or 2 lymph‐node metastasis. However, the Will Rogers phenomenon must be considered due to the retrospective nature of the present study.
OBJECTIVE
- ? To assess the impact of pelvic lymph node dissection (PLND) and of the number of lymph nodes (LNs) retrieved during radical prostatectomy (RP) on biochemical relapse (BCR) in pNX/0/1 patients with prostate cancer according to the clinical risk of lymph node invasion (LNI).
PATIENTS AND METHODS
- ? We evaluated 872 pT2‐4 NX/0/1 consecutive patients submitted to RP between October 1995 and June 2009, with the following inclusion criteria: (i) a follow‐up period ≥12 months; (ii) the avoidance of neoadjuvant hormonal therapy or adjuvant hormonal and/or adjuvant radiotherapy; (iii) the availability of complete follow‐up data; (iv) no pathological T0 disease; (v) complete data regarding the clinical stage and Gleason score (Gs), the preoperative prostate‐specific antigen (PSA) level and the pathological stage.
- ? The patients were stratified as having low risk (cT1a‐T2a and cGs ≤6 and PSA level < 10 ng/mL), intermediate risk (cT2b‐T2c or cGs = 7 or PSA level = 10–19.9) or high risk of LNI (cT3 or cGs = 8–10 or PSA level ≥ 20).
- ? The 872 patients were divided into two LN groups according to the number of LNs retrieved: group 1 had no LN or one to nine LNs removed; group 2 had 10 or more LNs.
- ? The variables analysed were LN group, age, PSA level, clinical and pathological stage and Gs, surgical margin status, LN status and number of LN metastases; the primary endpoint was the BCR‐free survival.
RESULTS
- ? The mean follow‐up was 55.8 months.
- ? Of all the patients, 305 (35%) were pNx and 567 (65.0%) were pN0/1.
- ? Of the 567 patients submitted to PLND, the mean number of LNs obtained was 10.9, and 49 (8.6%) were pN1.
- ? In the 402 patients at low risk of LNI, LN group was not a significant predictor of BCR at univariate analysis, while in the 470 patients at intermediate and high risk of LNI, patients with ≥10 LNs removed had a significantly lower BCR‐free survival at univariate and multivariate analysis.
CONCLUSION
- ? In our study population, a more extensive PLND positively affects the BCR‐free survival regardless of the nodal status in intermediate‐ and high‐risk prostate cancer.
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Mazzola C Savage C Ahallal Y Reuter VE Eastham JA Scardino PT Guillonneau B Touijer KA 《BJU international》2012,109(9):1323-1328
Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? In lymph node dissections for cancer, the more extended the dissection, the higher the number of lymph nodes removed. In addition, the higher the number of nodes retrieved, the better the staging. This leads many investigators to set a threshold of a minimal number of nodes below which the dissection is considered inadequate. Although the minimal threshold concept is generally good, it is not based on very objective data. a number of factors might influence the final number of nodes removed: (i) the surgeon and the surgical technique; (ii) the pathologists and tissue processing technique; (iii) the patient; and (iv) the audit effect and feedback to the surgeons about the number of nodes removed.
OBJECTIVE
- ? To examine the number of lymph nodes removed over time for men undergoing a standard pelvic lymph node dissection (PLND) during radical prostatectomy.
PATIENTS AND METHODS
- ? In total, 2119 consecutive patients with clinically localized prostate cancer were scheduled for non‐salvage radical prostatectomy between February 2005 and September 2009.
- ? All patients underwent PLND, including the external iliac, hypogastric and obturator fossa nodal groups.
- ? We tested whether the number of lymph nodes increased over time by including the date of each patient's surgery into a linear regression model using nonlinear terms.
RESULTS
- ? From 2008 onward, there appears to be a large increase in the number of nodes removed.
- ? Date of surgery was a significant predictor of the number of nodes removed (P < 0.001).
- ? The anatomical template of dissection, the specimen submission and pathological assessment were reportedly unchanged.
- ? The nodal yield increase in the later part of the study coincides with an increase in the academic interest in PLND and nodal metastasis in prostate cancer at the institutional level and worldwide.
CONCLUSIONS
- ? Without any intentional change in surgical technique or pathological processing, the number of lymph nodes removed in our radical prostatectomy experience increased.
- ? This change coincided with an increased academic interest in the subject and highlights the positive feedback effect.
- ? The change also raises concerns about unaccounted for confounding factors that could affect multi‐institutional datasets and surgical clinical trials.
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Marco Oderda Romain Diamand Simone Albisinni Giorgio Calleris Antonio Carbone Marco Falcone Gaelle Fiard Giorgio Gandaglia Alessandro Marquis Giancarlo Marra Cinzia Parola Antonio Pastore Alexandre Peltier Guillaume Ploussard Thierry Roumeguère Rafael Sanchez-Salas Giuseppe Simone Salvatore Smelzo Jorn H. Witt Paolo Gontero 《BJU international》2021,127(3):318-325
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目的:探讨保留肋间臂神经和胸前神经在乳腺癌改良根治腋窝淋巴结清扫术中的应用。方法回顾性分析84例乳腺癌改良根治术患者的临床资料,其中腋窝淋巴结清扫时保留肋间臂神经和胸前神经的41例,另切除该组神经的43例;比较两组的手术时间、术中出血量、腋窝淋巴结清扫数目、上臂内侧、腋部及胸壁皮肤感觉异常及胸大肌萎缩情况。结果两组手术时间、术中出血量及清扫腋窝淋巴结数目分别为[(104.7±10.3)min vs (97.0±7.2)min]、[(100.8±15.2)ml vs (97.1±9.3)ml]、[(18.6±2.6)枚 vs (19.3±2.3)枚],组间差异均无统计学意义(P>0.05);随访6个月感觉异常及胸大肌萎缩的发生率分别为14.6% vs 62.8%、17.1% vs 74.4%,两组相比保留神经组的发生率均显著低于未保留神经组(P<0.01)。结论在乳腺癌改良根治腋窝淋巴结清扫术中保留肋间臂神经和胸前神经是安全可行的,可有效防止皮肤感觉障碍及胸大肌萎缩。 相似文献
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Desai MM Berger AK Brandina RR Zehnder P Simmons M Aron M Skinner EC Gill IS 《European urology》2012,61(2):350-355