Mp77-14 Can Pre-Operative Ct Identify Positive Lymph Nodes in Patients With Upper Tract Urothelial Carcinoma?

Yee, Alyssa; Cha, Eugene; Sfakianos, John P.; Kim, Philip; Friedman, Fara; Sternberg, Itay; Coleman, Jonathan

doi:10.1016/j.juro.2014.02.2477

Cited by 8 publications

(6 citation statements)

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“…Due to lack of sensitivity of preoperative CT scans to identify pN1 17 this limits the clinical usefulness of our results since the extent of LND had oncological impact only in pN1 patients. Predefined standardized templates could be the best solution as proposed by Kondo et al in two studies 9,18 , further discussed below.…”

Section: Discussionmentioning

confidence: 96%

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Prognostic value of lymph node yield during nephroureterectomy for upper tract urothelial carcinoma

Winer

Vertosick

Ghanaat

et al. 2017

Urologic Oncology: Seminars and Original Investigations

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Introduction Lymph node dissection (LND) performed during radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) remains controversial and difficult to evaluate. The aim of this study was to investigate whether removal of more lymph nodes during RNU is safe and improves oncologic outcomes. Methods We evaluated 422 patients who underwent RNU with concomitant LND for UTUC between 1976 and 2015, assessing for an association between total nodes removed, recurrence-free (RFS) and cancer-specific survival (CSS) using Cox proportional hazards models. We also investigated the relationship between nodal yield and peri-operative metrics and inter-surgeon variability using linear regression. Results In our cohort of 442 patients, 239 developed recurrences and 94 patients died from disease. Median follow-up among survivors was 3.7 years (IQR 1.2, 7.4). The median nodal yield was 9 (IQR 4, 16). Among patients with node positive disease (pN1), we observed a significant improvement in RFS (HR 0.84 per 5 nodes removed, p=0.039) and a non-significant improvement in CSS with an increase in the nodal yield (HR 0.90 per 5 nodes removed, p=0.2). There was no evidence of an association between node yield and OR time, EBL or 30 day complications on multivariable analysis. There was significant heterogeneity between surgeons regarding the extent of lymph node dissection (p<0.0001). Conclusions We found that a more extensive node dissection may improve oncologic outcomes in a subset of high-risk patients without significantly increasing OR time or serious complications. Additionally we identified considerable inter-surgeon heterogeneity with regards to the extent of lymph node dissection furthering the notion of surgeon variability as a non-standardized factor.

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Section: Discussionmentioning

confidence: 96%

“…Currently preoperative staging of the regional LNs in patients with UTUC is limited in accuracy 17 , therefore studies have suggested that template directed LND may be more important than absolute number of nodes removed. Kondo et al evaluated 109 patients with clinically node negative disease who underwent RNU and LND.…”

Section: Discussionmentioning

confidence: 99%

Prognostic value of lymph node yield during nephroureterectomy for upper tract urothelial carcinoma

Winer

Vertosick

Ghanaat

et al. 2017

Urologic Oncology: Seminars and Original Investigations

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“…noted that imaging studies can miss almost 50% of lymph node spread [24]. This finding may contradict the traditional indication of lymphadenectomy performed for enlargement of lymph nodes on preoperative imaging only, thereby reinforcing the role of template-based dissection.…”

Section: Patterns Of Spread and Recommended Templates For Lymphadenecmentioning

confidence: 99%

Current Status of Lymphadenectomy During Radical Nephroureterectomy for Upper Tract Urothelial Cancer—Yes, No or Maybe?

Tamhankar

Patil

Ahluwalia

et al. 2018

Indian J Surg Oncol

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While pelvic lymphadenectomy during radical cystectomy for bladder cancer is a well-established standard of care, the same does not hold true for upper tract urothelial carcinoma (UTUC). Indeed, a template-based lymphadenectomy is rarely, if ever, performed in conjunction with radical nephroureterectomy at most centres across the globe. While multiple studies have explored the staging and therapeutic role of lymphadenectomy in cases of UTUC, there remain large gaps in our understanding of the indications, extent and safety of this procedure as an adjunct to nephroureterectomy. This article elucidates the current knowledge on outcomes, benefits and complications of template-based lymphadenectomy during radical nephroureterectomy for UTUC. We also explore the current evidence-based guidelines on this controversial topic.

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“…The low median LN yield and high rate of positivity in the LNs sampled suggests that the attitude toward LND during RNU at the majority of centers is that of a staging procedure, with selective removal of suspicious LNs (“node plucking”) being performed without interest in extending the dissection template in the setting of positivity. Given that standard cross‐sectional imaging has limited accuracy in predicting pathologic LN positivity in patients with UTUC, LND has long been the gold standard for LN staging, which is a key determinant of prognosis . The adequacy of sampling is a central issue in surgical LN staging and the question of the number and location of LNs required for adequate staging is highly relevant.…”

Section: Discussionmentioning

confidence: 99%

Association between lymph node yield and survival among patients undergoing radical nephroureterectomy for urothelial carcinoma of the upper tract

Zareba

Rosenzweig

Winer

et al. 2017

Cancer

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Background Prior studies examining the value of lymph node dissection (LND) in patients with urothelial carcinoma of the upper urinary tract (UTUC) have produced conflicting results. The objective of this study was to assess the relationship between lymph node (LN) yield and survival among patients undergoing radical nephroureterectomy (RNU). Methods The National Cancer Data Base was used to identify patients with non-metastatic UTUC who were treated with RNU between 2004 and 2012. The association between LN yield and overall survival (OS) was assessed using Cox proportional hazards regression, with adjustment for patient, tumor and facility characteristics. Results Of the 14,472 patients, 2,926 (20%) underwent LND. Median yield was two LN (IQR 1, 6). Among the entire cohort and the LN-negative (pN0) subgroup, higher LN yield was associated with lower all-cause mortality (multivariable HR 0.94 per five LN removed, 95% CI 0.89, 1.00, p=0.034 for the entire cohort; HR 0.86, 95% CI 0.79, 0.94, p=0.001 for the pN0 subgroup). Among LN-positive (pN+) patients, there was no association between total LN yield and OS; however, positive and negative LN counts were independent predictors of OS (HR 1.27 per five positive LN, 95% CI 1.16, 1.39, p<0.001; HR 0.90 per five negative LN, 95% CI 0.82, 1.00, p=0.049). Conclusions In this large, contemporary cohort of patients with UTUC, LND was found to be used infrequently despite evidence that higher LN yield is associated with lower all-cause mortality.

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Mp77-14 Can Pre-Operative Ct Identify Positive Lymph Nodes in Patients With Upper Tract Urothelial Carcinoma?

Cited by 8 publications

References 0 publications

Prognostic value of lymph node yield during nephroureterectomy for upper tract urothelial carcinoma

Prognostic value of lymph node yield during nephroureterectomy for upper tract urothelial carcinoma

Current Status of Lymphadenectomy During Radical Nephroureterectomy for Upper Tract Urothelial Cancer—Yes, No or Maybe?

Association between lymph node yield and survival among patients undergoing radical nephroureterectomy for urothelial carcinoma of the upper tract

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