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Re: Identifying Additional Lymph Nodes in Radical Cystectomy Lymphadenectomy Specimens
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BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY
Bladder, Penis and Urethral Cancer, and Basic Principles of Oncology Re: Oncologic Outcomes and Survival in pT0 Tumors After Radical Cystectomy in Patients Without Neoadjuvant Chemotherapy: Results from a Large Multicentre Collaborative Study M. Rouprêt, S. J. Drouin, S. Larré, Y. Neuzillet, H. Botto, M. Hitier, J. Rigaud, J. Crew, E. Xylinas, L. Salomon, J. N. Cornu, F. Iborra, D. Champetier, F. Rozet, V. Flamand, C. Bastide, L. Cormier, X. Durand, P. Lunardi, P. Rischmann, F. X. Nouhaud, S. Ferlicot, J. J. Patard, A. P. Floch, J. Irani, B. Peyronnet, K. Bensalah, L. Poissonnier, P. Grès, S. Droupy, J. Casenave, H. Wallerand, M. Soulié and C. Pfister; Bladder Cancer Committee of the French National Association of Urology Academic Department of Urology of la Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris VI, Paris, France Ann Surg Oncol 2011; 18: 3833–3838.
Purpose: To assess the postsurgical survival of patients with urothelial carcinoma of the bladder with pT0 tumor at pathologic examination of cystectomy specimens. Methods: A multi-institutional, retrospective database was analyzed with data from 4758 radical cystectomy (RC) patients who underwent RC without neoadjuvant chemotherapy and who were diagnosed with pT0 on the basis of the pathologic specimen. Survival curves were estimated. A multivariate Cox model was used to evaluate the association between prognosis factors and disease recurrence or survival. Results: Overall, 258 patients (5.4%) were included in the study. The median age was 64 years. At last resection, 171 tumors were invasive (at least pT2), and 87 were not. Median follow-up was 51 months. At multivariate analysis, initial location of the tumor and absence of lymphadenectomy were associated with tumor recurrence (P ⫽ 0.03 and P ⫽ 0.005, respectively) and specific mortality (P ⫽ 0.005 and 0.001, respectively). The main limitation of the study is its retrospective design, which is due to the rarity of this situation. Cancer-specific and recurrence-free survival rates were 89 and 85%, respectively, at 5 years and 82 and 80%, respectively, at 10 years. Conclusions: Despite acceptable oncological outcomes, patients with a pT0 tumor at the time of RC are still at risk of recurrence and progression and should not be considered to be entirely cured. In this population, stringent follow-up according to current recommendations should be effective. Editorial Comment: An aggressive transurethral tumor resection can eliminate the local tumor as evidenced by the pT0 status in up to 10% of cystectomy specimens that were not exposed to neoadjuvant chemotherapy. Despite the local tumor eradication, micrometastases at surgery are present in at least 18% of cases that subsequently demonstrate distant recurrences. David P. Wood, M.D.
Re: Identifying Additional Lymph Nodes in Radical Cystectomy Lymphadenectomy Specimens J. Gordetsky, E. Scosyrev, H. Rashid, G. Wu, C. Silvers, D. Golijanin, E. M. Messing and J. L. Yao Department of Pathology, University of Rochester, Rochester, New York Mod Pathol 2012; 25: 140 –144.
Lymph node count has prognostic implications in bladder cancer patients who are treated with radical cystectomy. Lymph nodes that are too small to identify grossly can easily be missed, potentially leading to missed nodal metastases and inaccurate nodal counts, resulting in inaccurate prognoses.
BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY
We investigated whether there is a benefit to submitting the entire lymph node packet for histological examination to identify additional lymph nodes. We prospectively assessed 61 pelvic lymphadenectomy specimens in 14 consecutive patients undergoing radical cystectomy. The specimens were placed in Carnoy’s solution overnight, then analyzed for lymph nodes. The residual tissue was entirely submitted to assess for additional lymph nodes. In 61 specimens, we identified 391 lymph nodes, ranging from 4 – 44 nodes per patient. We identified 238 (61%) lymph nodes with standard techniques and 153 (39%) lymph nodes in submitted residual tissue. The number of additional lymph nodes found in the residual tissue ranged from 0 to 26 (0 –75%) per patient. These lymph nodes ranged in size from 0.05 to 1 cm. All additional lymph nodes were negative for metastatic disease. Submitting the entire specimen for histological examination allowed for identification of more lymph nodes in radical cystectomy pelvic lymphadenectomy specimens. However, as none of the additional lymph nodes contained metastatic disease, it is unclear if there is a clinical benefit in evaluating lymph nodes that are neither visible nor palpable in lymphadenectomy specimens. Editorial Comment: The debate regarding the extent of lymph node dissection and positive lymph node density will continue until the current SWOG (Southwest Oncology Group) randomized trial is completed. As noted in this article, VERY careful examination of the lymph node packet can identify 39% more lymph nodes compared to standard evaluation. Interestingly none of the additional lymph nodes identified were cancerous, although there were only 4 cancerous lymph nodes among the entire 391 nodes removed. It seems the veracity of the pathologist in identifying lymph nodes is critical and can skew the results of nomograms that use lymph node density. David P. Wood, M.D.
Re: Quality of Care in Patients with Bladder Cancer: A Case Report? K. Chamie, C. S. Saigal, J. Lai, J. M. Hanley, C. M. Setodji, B. R. Konety and M. S. Litwin; Urologic Diseases in America Project Department of Urology, Health Services Research Group, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California Cancer 2012; 118: 1412–1421.
Background: Although there is level I evidence demonstrating the superiority of intravesical therapy in patients with bladder cancer, surveillance strategies are primarily founded on expert opinion. The authors examined compliance with surveillance and treatment strategies and the pursuant impact on survival in patients with high-grade disease. Methods: Using linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data, the authors identified subjects with a diagnosis of high-grade, non-muscle-invasive disease between 1992 and 2002 who survived 2 years and did not undergo definitive treatment during that time. Nonlinear mixed-effects regression analyses was used to examine compliance with surveillance and treatment strategies. After adjusting for confounders using a propensity score-weighted approach, the authors determined whether individual and comprehensive strategies during the initial 2 years after diagnosis were associated with survival after 2 years. Results: Of 4790 subjects, only 1 received all the recommended measures. Although mean utilization for most measures significantly increased after 1997, only compliance with an induction course of bacillus Calmette-Guerin (BCG) increased (13% to 20%; P ⬍.001). On multivariate analysis, compliance with ⱖ 4 cystoscopies, ⱖ 4 cytologies, and BCG instillation was found to be lower among octogenarians and higher among those with undifferentiated, Tis, and T1 tumors, and among those individuals diagnosed after 1997. Subjects compliant with these measures had a lower hazard of mortality (hazard ratio, 0.41; 95% confidence interval, 0.18 – 0.93) than those who received ⬍ 4 cystoscopies, ⬍ 4 cytologies, and no BCG. Conclusion: There was a statistically significant survival advantage found among those who received at least half of the recommended care. Improving compliance with these process-of-care measures via systematic quality improvement initiatives serves as the primary target to meliorate bladder cancer care.
73
BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY
Bladder, Penis and Urethral Cancer, and Basic Principles of Oncology Re: Oncologic Outcomes and Survival in pT0 Tumors After Radical Cystectomy in Patients Without Neoadjuvant Chemotherapy: Results from a Large Multicentre Collaborative Study M. Rouprêt, S. J. Drouin, S. Larré, Y. Neuzillet, H. Botto, M. Hitier, J. Rigaud, J. Crew, E. Xylinas, L. Salomon, J. N. Cornu, F. Iborra, D. Champetier, F. Rozet, V. Flamand, C. Bastide, L. Cormier, X. Durand, P. Lunardi, P. Rischmann, F. X. Nouhaud, S. Ferlicot, J. J. Patard, A. P. Floch, J. Irani, B. Peyronnet, K. Bensalah, L. Poissonnier, P. Grès, S. Droupy, J. Casenave, H. Wallerand, M. Soulié and C. Pfister; Bladder Cancer Committee of the French National Association of Urology Academic Department of Urology of la Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, University Paris VI, Paris, France Ann Surg Oncol 2011; 18: 3833–3838.
Purpose: To assess the postsurgical survival of patients with urothelial carcinoma of the bladder with pT0 tumor at pathologic examination of cystectomy specimens. Methods: A multi-institutional, retrospective database was analyzed with data from 4758 radical cystectomy (RC) patients who underwent RC without neoadjuvant chemotherapy and who were diagnosed with pT0 on the basis of the pathologic specimen. Survival curves were estimated. A multivariate Cox model was used to evaluate the association between prognosis factors and disease recurrence or survival. Results: Overall, 258 patients (5.4%) were included in the study. The median age was 64 years. At last resection, 171 tumors were invasive (at least pT2), and 87 were not. Median follow-up was 51 months. At multivariate analysis, initial location of the tumor and absence of lymphadenectomy were associated with tumor recurrence (P ⫽ 0.03 and P ⫽ 0.005, respectively) and specific mortality (P ⫽ 0.005 and 0.001, respectively). The main limitation of the study is its retrospective design, which is due to the rarity of this situation. Cancer-specific and recurrence-free survival rates were 89 and 85%, respectively, at 5 years and 82 and 80%, respectively, at 10 years. Conclusions: Despite acceptable oncological outcomes, patients with a pT0 tumor at the time of RC are still at risk of recurrence and progression and should not be considered to be entirely cured. In this population, stringent follow-up according to current recommendations should be effective. Editorial Comment: An aggressive transurethral tumor resection can eliminate the local tumor as evidenced by the pT0 status in up to 10% of cystectomy specimens that were not exposed to neoadjuvant chemotherapy. Despite the local tumor eradication, micrometastases at surgery are present in at least 18% of cases that subsequently demonstrate distant recurrences. David P. Wood, M.D.
Re: Identifying Additional Lymph Nodes in Radical Cystectomy Lymphadenectomy Specimens J. Gordetsky, E. Scosyrev, H. Rashid, G. Wu, C. Silvers, D. Golijanin, E. M. Messing and J. L. Yao Department of Pathology, University of Rochester, Rochester, New York Mod Pathol 2012; 25: 140 –144.
Lymph node count has prognostic implications in bladder cancer patients who are treated with radical cystectomy. Lymph nodes that are too small to identify grossly can easily be missed, potentially leading to missed nodal metastases and inaccurate nodal counts, resulting in inaccurate prognoses.
BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY
We investigated whether there is a benefit to submitting the entire lymph node packet for histological examination to identify additional lymph nodes. We prospectively assessed 61 pelvic lymphadenectomy specimens in 14 consecutive patients undergoing radical cystectomy. The specimens were placed in Carnoy’s solution overnight, then analyzed for lymph nodes. The residual tissue was entirely submitted to assess for additional lymph nodes. In 61 specimens, we identified 391 lymph nodes, ranging from 4 – 44 nodes per patient. We identified 238 (61%) lymph nodes with standard techniques and 153 (39%) lymph nodes in submitted residual tissue. The number of additional lymph nodes found in the residual tissue ranged from 0 to 26 (0 –75%) per patient. These lymph nodes ranged in size from 0.05 to 1 cm. All additional lymph nodes were negative for metastatic disease. Submitting the entire specimen for histological examination allowed for identification of more lymph nodes in radical cystectomy pelvic lymphadenectomy specimens. However, as none of the additional lymph nodes contained metastatic disease, it is unclear if there is a clinical benefit in evaluating lymph nodes that are neither visible nor palpable in lymphadenectomy specimens. Editorial Comment: The debate regarding the extent of lymph node dissection and positive lymph node density will continue until the current SWOG (Southwest Oncology Group) randomized trial is completed. As noted in this article, VERY careful examination of the lymph node packet can identify 39% more lymph nodes compared to standard evaluation. Interestingly none of the additional lymph nodes identified were cancerous, although there were only 4 cancerous lymph nodes among the entire 391 nodes removed. It seems the veracity of the pathologist in identifying lymph nodes is critical and can skew the results of nomograms that use lymph node density. David P. Wood, M.D.
Re: Quality of Care in Patients with Bladder Cancer: A Case Report? K. Chamie, C. S. Saigal, J. Lai, J. M. Hanley, C. M. Setodji, B. R. Konety and M. S. Litwin; Urologic Diseases in America Project Department of Urology, Health Services Research Group, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California Cancer 2012; 118: 1412–1421.
Background: Although there is level I evidence demonstrating the superiority of intravesical therapy in patients with bladder cancer, surveillance strategies are primarily founded on expert opinion. The authors examined compliance with surveillance and treatment strategies and the pursuant impact on survival in patients with high-grade disease. Methods: Using linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data, the authors identified subjects with a diagnosis of high-grade, non-muscle-invasive disease between 1992 and 2002 who survived 2 years and did not undergo definitive treatment during that time. Nonlinear mixed-effects regression analyses was used to examine compliance with surveillance and treatment strategies. After adjusting for confounders using a propensity score-weighted approach, the authors determined whether individual and comprehensive strategies during the initial 2 years after diagnosis were associated with survival after 2 years. Results: Of 4790 subjects, only 1 received all the recommended measures. Although mean utilization for most measures significantly increased after 1997, only compliance with an induction course of bacillus Calmette-Guerin (BCG) increased (13% to 20%; P ⬍.001). On multivariate analysis, compliance with ⱖ 4 cystoscopies, ⱖ 4 cytologies, and BCG instillation was found to be lower among octogenarians and higher among those with undifferentiated, Tis, and T1 tumors, and among those individuals diagnosed after 1997. Subjects compliant with these measures had a lower hazard of mortality (hazard ratio, 0.41; 95% confidence interval, 0.18 – 0.93) than those who received ⬍ 4 cystoscopies, ⬍ 4 cytologies, and no BCG. Conclusion: There was a statistically significant survival advantage found among those who received at least half of the recommended care. Improving compliance with these process-of-care measures via systematic quality improvement initiatives serves as the primary target to meliorate bladder cancer care.
73