MORE EXTENSIVE LYMPHADENECTOMY IMPROVES OUTCOMES OF RADICAL CYSTECTOMY FOR BLADDER CANCER IN A NATIONWIDE MULTICENTER EVALUATION

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THE JOURNAL OF UROLOGY®

Vol. 181, No. 4, Supplement, Sunday, April 26, 2009

Urothelial Cancer: Surgical Therapy Podium 11 Sunday, April 26, 2009

10:30 am - 12:30 pm

341 REMOVAL OF AT LEAST 8 NODES IMPROVES CANCERSPECIFIC SURVIVAL IN NON METASTATIC PATIENTS WITH UPPER TRACT UROTHELIAL CARCINOMA Marco Roscigno*, Milano, Italy; Shahrokh F. Shariat, Huston, TX; Roberto Bertini, Milano, Italy; Pierre I Karakiewicz, Montreal, QCCanada; Nazareno Suardi, Milano, Italy; Vitaly Margulis, Huston, TX; Mesut Remzi, Vienna, Austria; Richard E Zigeuner, Graz, Austria; Christian Bolenz, Mannheim, Germany; Eiji Kikuchi, Tokio, Japan; Alon Z Weizer, Ann Arbour, MI; Karim Bensalah, Rennes, France; Yair Lotan, Dallas, TX; Theresa M Koppie, Sacramento, CA; Jay D Raman, New York, NY; Mario I Fernandez, Santiago De Chile, Chile; Philipp Stroebel, Mannheim, Germany; Wareef Kabbani, Dallas, TX; Masaru Murai, Tokio, Japan; Cord Langner, Graz, Austria; Jeffrey Wheat, Ann Arbour, MI; Charles C Guo, Huston, TX; Andrea Haitel, Vienna, Austria; Christopher G Wood, Huston, TX; Francesco Montorsi, Milano, Italy INTRODUCTION AND OBJECTIVE: To analyze whether we can establish a minimum number of lymph nodes (LN) that should be removed to improve cancer-specific survival (CSS) in patients with urothelial carcinoma of the upper urinary tract (UTUC) managed with radical nephroureterectomy (RNU) and lymph node dissection . METHODS: : Institutional radical nephroureterectomy databases containing detailed information on UTUC patients were obtained from centers of excellence worldwide. Data were collected on 551 patients and combined into a relational database. All pathologic slides were rereviewed by genito-urinary pathologist who were blinded to the original pathology slides and clinical outcomes. Univariable and multivariable Cox regression models determined the effect of age, T stage, grade, pN, number of LN removed, ECOG Performance Status (PS), lymphovascular invasion (LVI) and architecture (sessile versus papillary) on CSS in UTUC patients. The number of LNs removed was coded as a cubic spline, to allow for non-linear effects. Finally, we identified the most informative cutoff for the number of removed LN. RESULTS: : Median follow-up for patients alive at last follow-up was 48 months (range, 1-246). In the entire population (n=551), the number of LNs removed was not associated with CSS (HR 0.98; p=0.16), in univariable as well as in multivariable analyses. In the subgroup of pN0 patients (n=411), more extended lymphadenectomy increased the rate of CSS (HR 0.962 p=0.038). Moreover, cubic spline curve showed that the probability of survival did not plateau but instead continued to rise as the number of LN removed increased (p=0.4). In multivariable analysis, the number of LN removed was independently associated with CSS (HR 0.93; p=0.016). The cut-off of 8 LN removed was the most informative discriminator for CSS (HR 0.416; p=0.004). The inclusion of the variable defining dichotomously the number of removed LNs (<8 vs q8) in the base model (age, ECOG PS, pathologic stage, grade, architecture and LVI) increased the accuracy in predicting cancer-specific mortality (+1.7%, p <0.001). CONCLUSIONS: In pN0 UTUC patients, the probability of cancer-specific mortality decreases with the increase in the number of removed LN. A better clinical outcome was observed in patients in whom at least eight LNs had been removed. A more extended lymphadenectomy improves disease staging, might remove undetected lymph node micrometastases and consequently improve survival in those patients. Source of Funding: None

342 MORE EXTENSIVE LYMPHADENECTOMY IMPROVES OUTCOMES OF RADICAL CYSTECTOMY FOR BLADDER CANCER IN A NATIONWIDE MULTICENTER EVALUATION Arne Tiemann*, Münster, Germany; Christian Bolenz, Mannheim, Germany; Edwin Herrmann, Christian Wülfing, Münster, Germany; Hans-Martin Fritsche, Regensburg, Germany; Derya Tilki, Munich, Germany; Thomas Höfner, Heidelberg, Germany; Stafan C Müller, Bonn, Germany; Lutz Trojan, Mannheim, Germany; Maximilian Burger, Regensburg, Germany; Alexander Buchner, Munich, Germany; Axel Haferkamp, Heidelberg, Germany; Maurice S Michel, Mannheim, Germany; Wolf Wieland, Regensburg, Germany; Lothar Hertle, Münster, Germany; Christian G. Stief, Munich, Germany; Markus Hohenfellner, Heidelberg, Germany; Patrick J Bastian, Munich, Germany INTRODUCTION AND OBJECTIVE: We aimed to validate recent evidence for lower recurrence rates and improved survival when more extensive lymphadenectomy (LA) is performed in conjunction with radical cystectomy (RC). The role of the extent of LA in patients with bladder cancer (BC) undergoing RC was evaluated. METHODS: We collected data and retrospectively reviewed 1145 patients from 6 different institutions in Germany, who underwent bilateral pelvic LA and RC between 1990 and 2007. Lymph node density (LND) in node-positive patients was defined as the ratio of positive lymph nodes and the total number of lymph nodes examined. RESULTS: A higher number of lymph nodes dissected during LA (>10 lymph nodes) was associated with improved cancer-specific survival compared to less than 10 lymph nodes removed (median 60 vs. 34 months, p=0.001,). The median follow up in this cohort was 32.7 months (range 1 to 285 months). In 313 (27.3%) patients at least one positive pelvic lymph node was found during LA (pN1 = 124 (39.6%), pN2 = 185 (59.1%), pN3 =4 (1.3%) patients, respectively). Cancer-related death occurred in 125 (40%) of the lymph node positive patients during a median follow-up duration of 19.7 months (range 1 to 112 months). The mean value of LND was 29% (range 2-100%). Patients with a LND of >20% were at greater risk of cancer-related death, with a median survival rate of 11.8 months (LND > 20%) vs. 23.5 months (LND < 20%) (p=0.001). CONCLUSIONS: Our large multicenter study confirms that an increased number of lymph nodes removed during LA is associated with improved cancer-specific survival. Patients with >10 dissected lymph nodes are found to have a favorable outcome compared to <10 dissected lymph nodes. In patients with nodal involvement LND provides additional prognostic information. Source of Funding: None

343 TRENDS IN PELVIC LYMPHADENECTOMY AT THE TIME OF RADICAL CYSTECTOMY: 1988-2004 Nicholas J Hellenthal*, Michelle L Ramirez, Christopher P Evans, Ralph W deVere White, Theresa M Koppie, Sacramento, CA INTRODUCTION AND OBJECTIVE: Studies suggest that patients who undergo thorough lymphadenectomy for bladder cancer benefit from improved survival. The purpose of this study was to evaluate the incidence of and trends in lymphadenectomy in conjunction with radical cystectomy for bladder cancer. METHODS: Utilizing the Surveillance, Epidemiology, and End Results registry, we identified 8,072 eligible patients with bladder cancer who underwent radical cystectomy with or without lymphadenectomy over the years 1988-2004. After stratification by age group, race, stage, grade, and year of diagnosis, we performed logistic and linear regression to correlate variables to the mean number of lymph nodes sampled and the likelihood of undergoing lymphadenectomy (defined as q1, q5 and q10 nodes removed). RESULTS: In the final cohort, 1660 patients (21%) did not have any lymph nodes sampled at the time of radical cystectomy. This number decreased from 37% in 1988 to 16% in 2004. Over this time period, the