Anatomic Extent of Pelvic Lymphadenectomy in Bladder Cancer

ContextThe rationale for locoregional staging lymphadenectomy in bladder cancer lies in the accurate diagnosis of occult micrometastases to stratify patients who might benefit from adjuvant therapeutic measures. In bladder cancer, pelvic lymphadenectomy (PLA) as a common procedure of radical cystectomy has not been standardized, although evidence supports a relationship between the extent of lymph node dissection and therapeutic outcome.Evidence acquisitionRecent retrospective and prospective clinical trials have carefully analyzed the distribution of lymph node metastases at time of radical cystectomy, thereby identifying those regions that should be included in a standard pelvic lymph node dissection.Evidence synthesisDissecting all lymphatic tissue along the common iliac region—with the aortic bifurcation as cranial margin—along the external, internal iliac region, and the obturator fossae bilaterally will completely clear 80% of all positive nodes. Only if frozen section examination will demonstrate micrometastases at these regions will extending lymphadenectomy further cranially be worthwhile.ConclusionsCurrently, extended PLA in bladder cancer has been shown to improve progression-free survival if >14 lymph nodes are removed. For the future, prospective trials have to demonstrate a benefit with regard to cancer-specific and overall survival and in terms of regional versus distant recurrences.     

膀胱癌盆腔淋巴结转移的规律及影响因素分析

目的通过分析膀胱尿路上皮癌淋巴结转移的规律及其相关影响因素,结合盆腔淋巴清扫的研究进展,探讨盆腔淋巴清扫策略。 方法收集我院2008年至2016年由同一术者完成腹腔镜根治性膀胱切除和盆腔淋巴清扫的膀胱尿路上皮癌患者的资料,回顾性分析淋巴结转移的规律及其相关影响因素。 结果共收集患者285例,69例（24.2%）发生淋巴结转移。最常见的淋巴结转移部位为髂内/闭孔淋巴结（57/69,82.6%）,其次是髂外淋巴结（37/69,53.6%）;真骨盆外淋巴结转移均伴随髂内/闭孔或髂外淋巴结转移;单侧壁膀胱癌可以向对侧盆腔淋巴结转移。T1组淋巴结转移率4.6%（4/87）,T2组18.0%（18/100）;T3组50.8%（30/59）;T4组68.0%（17/25）。多因素回归分析显示淋巴结转移与肿瘤分期呈正相关,与分级、年龄、性别、体质量指数、吸烟等因素无关。 结论髂内/闭孔和髂外淋巴结是膀胱癌最主要的淋巴结转移部位,肿瘤高分期是影响膀胱癌淋巴结转移的主要因素。根治性膀胱切除术应行至少包括双侧髂内、闭孔、髂外淋巴结的标准淋巴清扫。     

Lymphadenectomy for Bladder Cancer at the Time of Radical Cystectomy

Context

Although the importance of lymphadenectomy during radical cystectomy (RC) in high-risk non–muscle-invasive and muscle-invasive bladder cancer (BCa) is well accepted, the optimal extent of lymphadenectomy, number of lymph nodes (LNs) to be retrieved, and prognostic and therapeutic role of lymphadenectomy remain debated issues.

Objective

In this review, we summarize the existing data on the value of lymphadenectomy for staging and outcome of BCa patients undergoing RC and lymphadenectomy.

Evidence acquisition

A systematic Medline/PubMed literature search of peer-reviewed scientific articles published from 1998 and 2012, concerning the role of lymphadenectomy in BCa patients, was carried out. The terms and permutations used were lymphadenectomy, bladder cancer/carcinoma, urothelial carcinomas, radical cystectomy, lymph node metastasis, lymph node dissection, bladder, recurrence, and survival. Selective older articles were included.

Evidence synthesis

Bilateral pelvic lymphadenectomy is an integral part of RC for BCa. The literature regarding the role of lymphadenectomy in BCa patients in general is retrospective, nonstandardized, and of low-level quality in regard to evidence. Prospective randomized trials designed to define the optimal template of lymphadenectomy and its impact on oncologic outcome are advocated. Some of these studies are ongoing, and their completion and analyses are necessary to resolve controversies.

Conclusions

Many consistent and concordant observations, although of low level of evidence, document that the extent of lymphadenectomy may influence disease-free survival after RC independent of the status of LNs and the pathologic stage of BCa. Lymphadenectomy standardization at the time of RC to create evidence-based guidelines is essential for further improvement of surgical quality and BCa patient survival.     

The prognostic impact of pelvic lymph node metastasis and lymphovascular invasion on bladder cancer

Objectives:   To present long-term results of a single-center series of patients undergoing bilateral pelvic lymphadenectomy and radical cystectomy for bladder cancer and to analyze the impact of pelvic lymph node metastasis and lymphovascular invasion on clinical outcome.
Methods:   Between 1986 and 2005 833 patients were treated with bilateral pelvic lymphadenectomy and radical cystectomy at our institution. 614 of them with valid clinical follow-up information and no neoadjuvant therapy could be evaluated.
Results:   Disease-free and overall survival in the entire cohort was 56.7% and 49.5% at 5 years and 52.4% and 38.2% at 10 years, respectively. 28.1% of all patients had pelvic lymph node metastasis. We found organ-confined tumor stages (≤pT2) in 43.8%. Patients with non-organ-confined tumor stages (≥pT3) and positive pelvic lymph nodes had a significantly shorter overall survival than those without lymph node metastasis ( P  < 0.0001). In the subgroup of ≤pT2, the presence of pelvic lymph node metastasis did not show a statistically significant effect on overall survival ( P  = 0.618). The presence of lymphovascular invasion was associated with an impaired survival ( P  < 0.0001). In multivariate analysis, pathological tumor stage ( P  < 0.0001), lymph node stage (≥pT3) ( P  = 0.004) and lymphovascular invasion ( P  = 0.001) were independent prognostic parameters.
Conclusions:   According to the present series, survival for patients with ≤pT2 does not depend on the lymph node stage. Lymphovascular invasion is an independent parameter of impaired survival and should be determined routinely in cystectomy specimens to identify patients, who may benefit from adjuvant systemic therapy.     

PELVIC LYMPH NODE METASTASES FROM BLADDER CANCER: OUTCOME IN 83 PATIENTS AFTER RADICAL CYSTECTOMY AND PELVIC LYMPHADENECTOMY

PURPOSE: We evaluate the outcome in patients with node positive bladder cancer with particular reference to the effect of individual characteristics of positive nodes on survival after meticulous pelvic lymphadenectomy at cystectomy. MATERIALS AND METHODS: This prospective analysis contains 452 cases of bladder cancer staged preoperatively as N0M0, managed with pelvic lymphadenectomy and cystectomy between 1984 and 1997. A total of 83 (18%) patients with histologically confirmed node positive disease are included in our study. RESULTS: The median overall survival of patients with positive nodes was 20 months. Median 5-year survival was 29%. Patients who survived were found with positive nodes at each site in the pelvis. The median survival of 57 patients with less than 5 positive nodes was 27 months, compared with 15 months for 26 with 5 nodes or more (log-rank test p = 0.0027). Median survival of 26 patients with no lymph node capsule perforation was 93 months, compared with 16 months for 57 with capsule perforation (p = 0.0004). The median survival of 18 patients with a maximum diameter of lymph node metastasis up to 0.5 cm. was 64 months, compared with 16 months for 65 with nodal metastasis greater than 0.5 cm. (p = 0.024). Contralateral positive nodes were found in 16 of 39 (41%) patients with unilateral bladder cancer. CONCLUSIONS: Long-term survival is possible with node positive bladder cancer. Those patients with few as well as smaller and, therefore, unsuspected nodal metastases, and those without lymph node capsule perforation have the best results after removal of pelvic metastatic nodal disease. Because patients who survive may be found regardless of the site of pelvic nodal metastases, meticulous bilateral pelvic lymphadenectomy is warranted in all patients at the time of attempted curative cystectomy for bladder cancer, particularly if there is no clinical evidence of nodal involvement.     

Oncological issues in staging mediastinal lymph node metastasis for left lung cancer

ObjectiveWe aimed to discuss the underlying oncological issues in staging of mediastinal lymph node metastasis in patients with left lung cancer who underwent extended radical lymphadenectomy (ERL).MethodsThis multi-institutional retrospective study analyzed 116 patients with left non-small-cell lung cancer who underwent bilateral paratracheal lymph node dissection (ERL) via median sternotomy. The clinicopathological records of patients with mediastinal lymph node metastasis were examined for prognostic factors, including age, sex, histology, tumor size, cN number, preoperative data, metastatic stations (number and distribution), pT, and adjuvant chemotherapy.ResultsMediastinal lymph node metastases were found in 43 patients, and right paratracheal lymph node metastases (pN3) were found in 13 patients. The 5-year overall survival rate was 25.2% in patients with pN3 tumors (n = 13) and 23.1% in patients with pN2 tumors (n = 30). The prognosis did not differ between patients with pN3 and pN2. Univariate analyses showed that histology, cN, and adjuvant chemotherapy were significant prognostic factors in patients with mediastinal lymph node metastasis. In these 43 patients, cN and adjuvant chemotherapy were significant independent prognostic factors in multivariate analysis.ConclusionsThe prognostic factors for left lung cancer with mediastinal lymph node metastasis were cN status and adjuvant chemotherapy, and not pN status (pN2 or pN3). We hope that the study results, which suggest that there may be no difference in prognosis between pN2 and pN3, would broaden the discussion of oncological issues in the staging of mediastinal lymph node metastasis of left lung cancer.     

A novel predictive model for pelvic lymph node metastasis in patients with penile cancer: A multi-institutional study

PurposeWe determined whether a clinicopathological nomogram is able to predict the risk of pelvic lymph node metastasis (LNM) in penile cancer patients after inguinal lymph node dissection (ILND).MethodsNinety-eight patients with bilateral ILND who underwent pelvic lymphadenectomy at 10 centers were retrospectively analyzed. The most predictive features in the nomogram were selected by the stepwise logistic regression method and then tested and verified by multivariate logistic regression analyses. The nomogram was assessed using concordance indices and calibration curves.ResultsOf the 181 pelvic basins, pelvic LNM was observed in 52 packages (43 patients). Bilateral pelvic LNM was present in 9 patients (9/43, 20.9%). There was no crossover metastatic spread from one inguinal side to the other pelvic side. Age, previous resection, the biopsy procedure for inguinal lymph nodes, vascular invasion, and ipsilateral inguinal lymph node status were all independent risk factors for pelvic LNM (all P < 0.05) in the multivariate logistic regression analysis. The nomogram exhibited a good probability for survival agreement, with a concordance index of 0.868 (95% CI: 0.813–0.922).ConclusionsA novel nomogram suggests that the risk of pelvic LNM can be effectively predicted in penile carcinoma patients and may provide a useful guide for clinicians. Further external validation is needed.     

The Impact of Lymphadenectomy and Lymph Node Metastasis on the Outcomes of Radical Cystectomy for Bladder Cancer

Context

The presence of lymph node metastases and the extent of lymphadenectomy have both been shown to influence the outcome of patients with muscle-invasive bladder cancer.

Objective

Current standards for detection of lymph node metastases, lymph-node mapping studies, histopathologic techniques, and risk factors in relation to lymph node involvement are discussed. The impact of lymph node metastases and the extent of lymphadenectomy on the outcome of patients treated with radical cystectomy are analyzed.

Evidence acquisition

A systematic literature review of bladder cancer and lymph nodes was performed searching the electronic databases Pubmed/Medline, Cochrane, and Embase. Articles were selected based on title, abstract, study format, and content by a consensus of all participating authors.

Evidence synthesis

Lymph node status is highly consequential in bladder cancer patients because the presence of lymph node metastases is predictive of poor outcome. Knowledge of primary landing sites of lymph node metastases is important for optimum therapeutic management. Accurate pathologic work-ups of resected lymph node tissue are mandatory. Molecular markers could potentially guide therapeutic decisions in the future because they may enable the detection of micrometastatic disease. In current series, radical cystectomy with an extended lymphadenectomy seems to provide a clinically meaningful therapeutic benefit compared with a limited approach. However, the anatomic boundaries of lymph node dissection are still under debate. Therefore, large prospective multicenter trials are needed to validate the influence of extended lymph node dissection on disease-specific survival.

Conclusions

An extended pelvic lymph node dissection (encompassing the external iliac vessels, the obturator fossa, the lateral and medial aspects of the internal iliac vessels, and at least the distal half of the common iliac vessels together with its bifurcation) can be curative in patients with metastasis or micrometastasis to a few nodes. Therefore, the procedure may be offered to all patients undergoing radical cystectomy for invasive bladder cancer.     

Infiltrating cancer of the bladder with lymph node invasion: is total cystectomy justified?

In order to assess the potential benefits of radical cystectomy in bladder cancer associated with pelvic lymph node metastasis, a retrospective study compared 2 groups of patients with T2-T3 N+ bladder cancer: 10 treated by radical cystectomy and 14 treated conservatively once the diagnosis of nodal metastasis had been established by fine needle node aspiration or lymphadenectomy. The survival rates were identical in both groups: 80% of the patients died within 2 years, 60% during the first year after diagnosis, mainly due to distant metastasis. No patient in the conservative arm required salvage cystectomy because of local progression. It is concluded that radical cystectomy is of little benefit in T2-T3 N+ bladder cancer, a disease which is no longer amenable to purely local treatment.     

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目的 探讨中下段直肠癌侧方淋巴结转移规律及影响因素。方法 对1995－2000年行侧方淋巴结清扫的105例直肠癌病人进行回顾性分析。结果 中下段直肠癌侧方转移率为21％，肿瘤的大小、部位、病理分型、分化程度及浸润深度是影响侧方转移的重要因素。在侧方淋巴结转移阳性病人中，单纯闭孔及髂内淋巴结转移阳性病人占54．5％，单纯髂外及髂总淋巴结转移阳性病人为18．1％。侧方淋巴结转移阴性病人术后局部复发率为6．7％，阳性病人为36．3％。行侧方清扫局部复发率较传统术式由17．6％降至11．4％。侧方转移阴性病人平均生存期为88个月，阳性病人为37个月，二者差异有显著性。结论 侧方淋巴转移是中下段直肠癌淋巴转移的重要途径。闭孔和髂内淋巴结是侧方淋巴结清扫中需要着重清扫的部位。侧方淋巴清扫较传统术式可明显降低局部复发率。     

侧方淋巴结清扫对进展期低位直肠癌预后的影响

目的 应用治疗指数(therapeutic index,TX)(TX=肿瘤相关5年生存率×区域淋巴结转移的概率)评估侧方淋巴结清扣对于改善进展期低位直肠癌预后的价值.方法 回顾性分析直肠癌行根治性切除+全直肠系膜切除+侧方淋巴结清扫的96例进展期低位直肠癌患者的临床资料.结果 进展期低位直肠癌直肠系膜淋巴结、直肠上动脉旁淋巴结、肠系膜下动脉旁淋巴结和侧方淋巴结转移率分别为21%(20/96),13%(12/96),10%(10/96)和15%(14/96).检出直肠系膜淋巴结、直肠上动脉旁淋巴结、肠系膜下动脉旁淋巴结和侧方淋巴结转移阳性的进展期低位直肠癌患者5年生存率分别为35%,25%,20%和36%.TX:清扫直肠系膜淋巴结和侧方淋巴结的TX分别为7.4和5.4,明显高于清扫直肠上动脉和肠系膜下动脉旁淋巴结的3.3和2.0.侧方淋巴结转移阳性者术后局部复发率为64%(9/14),TX明显高于侧方淋巴结转移阴性者的11%(9/82)(x2=22.308/P=0.000).Kaplan-Meier生存分析显示,侧方淋巴结转移阳性患者平均生存期为(38.0±6.7)个月(95%置信区间:24.8～51.2个月),明显短于侧方淋巴结转移阴性的(80.9±2.1)个月(95%置信区间:76.7～85.1个月),两者差异有统计学意义. 结论侧方淋巴结清扫可降低进展期低位直肠癌根治性切除术后局部复发率以及改善预后.除全直肠系膜切除外,进展期低位直肠癌术中还应进行侧方淋巴结清扫.     

Lateral pelvic node dissection after neoadjuvant chemoradiation in rectal cancer with right internal iliac node metastasis but without regional node metastasis: A case report

Introduction and importanceTotal mesorectal excision (TME) with lateral pelvic node dissection was routinely done in low clinical T3 rectal tumors below the peritoneal reflection as stated in the Japanese guidelines for colorectal cancer. Our institution follows the same practice in selected patients. This is our first reported case wherein a patient with rectal cancer underwent total mesorectal excision with lateral lymphadenectomy after neoadjuvant treatment with a positive lateral node on histopathology.Case presentationA 49 year old female rectal had rectal adenocarcinoma 4 cm FAV. Pelvic MRI revealed a low rectal tumor abutting the mesorectal fascia anteriorly, anal sphincters not involved, and confluent enlarged right iliac nodes. After neoadjuvant treatment, interval decrease in size of the rectal lesion and the right iliac nodes were noted. Patient underwent partial intersphincteric resection, lateral pelvic node dissection and protective loop ileostomy.Clinical discussionHistopathology revealed a rectal adenocarcinoma with one right internal iliac lymph node was positive for tumor involvement. Circumferential resection margin was 4.0 mm. Patient is currently on 4th cycle of adjuvant chemotherapy. Preoperative chemoradiation could not completely eradicate lateral pelvic node metastasis. Therefore, lateral pelvic node dissection should be considered if lateral pelvic lymph node metastasis is suspected even after neoadjuvant therapy.ConclusionUnlike TME, performance of a routine lateral lymphadenectomy in rectal cancer surgery varies by geographic location. Reports from Asian countries and our practice in our institution shows that it can be performed safely. This could improve the oncologic outcomes of patients especially if combined with neoadjuvant chemoradiotherapy.     

The role of lymphadenectomy in high-grade invasive bladder cancer

Radical cystectomy with bilateral pelvic iliac lymphadenectomy is a standard treatment for high-grade, invasive bladder cancer. Cystectomy arguably provides the best survival outcomes and the lowest local recurrence rates. Although the extent or absolute limits of the lymph node dissection are unknown and remain to be better defined, an ever-growing body of data supports a more extended lymphadenectomy at the time of cystectomy in all patients who are appropriate surgical candidates. An extended lymph node dissection should include the distal para-aortic and paracaval lymph nodes as well as the pre-sacral nodes, known anatomic sites of lymph node drainage from the bladder and potential sites of lymph node metastases in patients with bladder cancer. An extended dissection may provide a survival advantage in patients with node-positive and node-negative tumors without significantly increasing the morbidity or mortality of the surgery. The extent of the primary bladder tumor (p stage), the number of lymph nodes removed, and the lymph node tumor burden are important prognostic variables in patients undergoing cystectomy with pathologic evidence of lymph node metastases. Lymph node density may become an even more useful prognostic variable in these high-risk, node-positive patients with bladder cancer. This concept simultaneously incorporates the lymph node tumor burden (number of lymph nodes involved) and the number of lymph nodes removed (extent of the lymphadenectomy), improving the stratification of lymph node-positive patients following radical cystectomy. This notion may also be useful in future staging systems. Adjuvant therapies and clinical trials should consider applying these concepts, because they may help reduce bias and incorporate the extent of the lymphadenectomy, which currently is not standardized.     

The value of CT in detecting pelvic lymph node metastases in cases of bladder and prostate carcinoma

Fifty-one patients, 15 with bladder cancer and 36 with prostatic cancer, were examined by preoperative pelvic CT scanning in order to determine its sensitivity, specificity and accuracy in detecting pelvic lymph node metastases. The poor sensitivity of CT (40%) in detecting lymph node metastases reduces its value for staging lymph nodes. The reason for the low sensitivity is that metastases in nodes which are of normal size cannot be detected by CT. Pelvic lymphadenectomy remains the only accurate method for evaluating the state of pelvic lymph nodes.     

Current Value of Neoadjuvant Chemotherapy Prior to Cystectomy

ContextRadical cystectomy with a pelvic lymph node dissection is considered the most effective treatment option today for patients with muscle-invasive bladder cancer. Unfortunately, in spite of some progress, disease-specific survival rates after cystectomy have not dramatically changed in the last few decades. The significant risk of distant failure indicates that additional systemic treatment is mandatory.ObjectiveThe primary objective of the review was to summarize the data about the benefit of neoadjuvant systemic chemotherapy before cystectomy for muscle-invasive bladder cancer.Evidence acquisitionThe papers evaluating cystectomy cohorts were analyzed including a thorough analysis of treatment failures. The papers presenting prospective randomized trials and meta-analyses on neoadjuvant chemotherapy in bladder cancer were critically reviewed.Evidence synthesisThe rationale for chemotherapy before cystectomy is to treat micrometastases beyond the margins of local therapy already present at the time of diagnosis of invasive bladder cancer. Results of prospective randomized trials indicate survival benefit after neoadjuvant platinum-based combination chemotherapy. To improve the interpretation of data from prospective randomized trials, several meta-analyses were conducted. The most recent meta-analysis, published in 2005, evaluated the individual data from 3005 patients enrolled in 11 prospective controlled trials that compared neoadjuvant chemotherapy plus local treatment with local treatment alone. The data comprised 98% of all patients from known eligible randomized controlled trials. The analysis found significant survival benefit associated with platinum-based combination chemotherapy. It was equivalent to a 5% absolute improvement in overall survival (p = 0.003) and a 9% improvement in disease-free survival (p < 0.0001) at 5 yr.ConclusionsRadical cystectomy with pelvic lymph node dissection remains the standard treatment for muscle-invasive bladder cancer. The quality of surgery is essential for optimal treatment results. The data from prospective randomized trials and meta-analyses provide support for preoperative application of platinum-based combination chemotherapy in all patients.     

Functional imaging in penile cancer: PET/computed tomography, MRI, and sentinel lymph node biopsy

PURPOSE OF REVIEW: The presence and extent of lymph node metastasis and primary tumor are among the most important prognostic factors in penile cancer. While inguinal lymphadenectomy is currently the most accurate means of staging, it is associated with severe morbidity and even mortality. Recent literature was reviewed for alternative means of staging. RECENT FINDINGS: Functional imaging modalities distinguish between inguinal lymph nodes with and without metastasis. The false-negative rate of dynamic sentinel lymph node biopsy has recently improved from approximately 20 to 5% in one study. In 13 patients with penile cancer, (18)F-fluorodeoxyglucose-PET/computed tomography was 80% sensitive and 100% specific for lymph node metastasis, but missed micro-metastasis. In seven patients with penile cancer, MRI with lymphotrophic nanoparticles was 100% sensitive and 97% specific for lymph node metastasis. SUMMARY: Combined PET/computed tomography and sentinel lymph node biopsy may help to detect both inguinal micrometastasis and pelvic and abdominal metastasis. Since MRI is highly accurate for staging of both primary penile cancer and its lymph node metastasis, however, it may turn out to be a powerful tool for a one-stop modality in the staging of penile cancer.     

Clinical feasibility and surgical benefits of video-assisted mediastinoscopic lymphadenectomy in the treatment of resectable lung cancer

Objective: This study was performed to assess the clinical feasibility and surgical outcomes of video-assisted mediastinoscopic lymphadenectomy in the treatment of resectable lung cancer. Methods: Between July 2004 and December 2009, we retrospectively analyzed 108 consecutive video-assisted mediastinoscopic lymphadenectomies in lung cancer patients from a prospectively collected database. Ninety-seven (89.8%) patients underwent combined operation during the same anesthesia and six (5.3%) patients underwent a staged operation for the resection of lung cancer and systematic lymphadenectomy. We reviewed the indication and duration of video-assisted mediastinoscopic lymphadenectomy, its complication, combined or staged operation type, the number of dissected lymph nodes and nodal stations, and pathologic staging of the mediastinal node. Results: Mean operative time of video-assisted mediastinoscopic lymphadenectomy was 39.8 ± 12.3 min (range of 14–85 min). Mean number of resected lymph nodes was 16.0 ± 7.7 (range of 3–37). In video-assisted mediastinoscopic lymphadenectomy, the rates of lymph node dissection of stations 4R, 4L, and 7 were 71.3%, 88.0%, and 100%, respectively, whereas the rates of dissection of lymph nodes in station 2R and 2L were only 22.2% and 17.6%, respectively. There was no operative mortality. We identified five complications of recurrent nerve palsy. Conclusions: Video-assisted mediastinoscopic lymphadenectomy is a clinically feasible procedure with acceptable complication rate and provides more accurate staging of mediastinal node in lung cancer patients. It may be also an excellent supplementary technique used for complete mediastinal node dissection at minimal invasive surgery for cancer resection, especially with left-sided video-assisted thoracoscopic lobectomy.     

Current status of establishing standards for lymphadenectomy in the treatment of bladder cancer

PURPOSE: Pelvic lymph node dissection at the time of radical cystectomy is a crucial component of the surgical management of invasive bladder cancer. No established therapeutic or diagnostic guidelines regarding pelvic lymph node dissection are, however, currently available. We reviewed the past and contemporary literature to clarify the current role of pelvic lymph node dissection both as a staging modality as well as potential therapeutic intervention. RECENT FINDINGS: The role of pelvic lymph node dissection has evolved over the past 60 years. Although the added benefits of radical cystectomy over simple cystectomy alone are accepted, an optimal template for pelvic lymph node dissection has not been established. Increasing evidence suggesting therapeutic and diagnostic benefits by extending the boundaries of lymphadenectomy or by increasing the number of nodes excised has been reported. Much of the recent literature, however, is based on retrospective studies, and is influenced by factors such as node count variability, inconsistencies in the quality of the surgery, and the biases in patient selection. Currently, the optimal boundaries of pelvic lymph node dissection and the minimum number of nodes to be pathologically examined remain undetermined. SUMMARY: The diagnostic and therapeutic benefits obtained by extending the limits of lymphadenectomy are compelling but inconclusive. Establishing standards for pelvic lymph node dissection will not only increase the consistency of staging and improve the design and interpretation of clinical trials in invasive bladder cancer but also help to identify and optimize the therapeutic benefits of lymphadenectomy. Prospective, randomized trials will be needed to properly establish the extent of lymphadenectomy required to obtain such benefits.     

Risk of station 12a lymph node metastasis in patients with lower-third gastric cancer

BACKGROUNDControversy over the issue that No. 12a lymph node involvement is distant or regional metastasis remains, and the possible inclusion of 12a lymph nodes in D2 lymphadenectomy is unclear. As reported, gastric cancer (GC) located in the lower third is highly related to the metastasis of station 12a lymph nodes.AIMTo investigate whether the clinicopathological factors and metastasis status of other perigastric nodes can predict station 12a lymph node metastasis and evaluate the prognostic significance of station 12a lymph node dissection in patients with lower-third GC.METHODSA total of 147 patients with lower-third GC who underwent D2 or D2+ lymphadenectomy, including station 12a lymph node dissection, were included in this retrospective study from June 2003 to March 2011. Survival prognoses were compared between patients with or without station 12a lymph node metastasis. Logistic regression analyses were used to clarify the association between station 12a lymph node metastasis and clinicopathological factors or metastasis status of other perigastric nodes. The metastasis status of each regional lymph node was evaluated to identify the possible predictors of station 12a lymph node metastasis.RESULTSMetastasis to station 12a lymph nodes was observed in 18 patients with lower-third GC, but not in 129 patients. The incidence of station 12a lymph node involvement was reported as 12.2% in patients with lower-third GC. The overall survival of patients without station 12a lymph node metastasis was significantly better than that of patients with station 12a metastasis (P < 0.001), which could also be seen in patients with or without extranodal soft tissue invasion. Station 12a lymph node metastasis and extranodal soft tissue invasion were identified as independent predictors of poor prognosis in patients with lower-third GC. Advanced pN stage was defined as independent risk factor significantly correlated with station 12a lymph node positivity. Station 3 lymph node staus was also proven to be significantly correlated with station 12a lymph node involvement.CONCLUSIONMetastasis of station 12a lymph nodes could be considered an independent prognosis factor for patients with lower-third GC. The dissection of station 12a lymph nodes may not be ignored in D2 or D2+ lymphadenectomy due to difficulties in predicting station 12a lymph node metastasis.     

Whither pelvic lymphadenectomy in prostatic cancer?

In the last decade pelvic lymphadenectomy has gained in popularity as a staging maneuver designed to improve the selection of patients with localized prostatic cancer for curative treatment, by uncovering lymph node metastases. The presence of tumor in the regional nodes portends substantial risk for the later appearance of distant metastases. With rare exceptions, lymphadenectomy is widely regarded as a staging procedure without therapeutic benefits. Unfortunately, the operation as routinely performed carries a significant complication rate. The survival results of total prostatectomy for well-selected nodules of prostatic cancer are excellent without preliminary lymphadenectomy. The morbidity of lymphadenectomy is compounded by superimposed external irradiation. Because of the low complication rate from external radiation alone, it is suggested that patients selected for pelvic radiation be spared the discomfort of lymphadenectomy. Clinical trials of adjuvant chemotherapy in patients with minimal nodal disease may answer the question of whether pelvic lymphadenectomy should ever be performed. It is predicted that noninvasive imaging will improve to the point that staging lymphadenectomy may be relegated to the surgical archives.