Presacral Nodes Research Articles

1908 NUMBER OF LYMPH NODES REMOVED DOES NOT INFLUENCE SURVIVAL IN STAGE N0 BLADDER CANCER AFTER COMPLETE EXTENDED LYMPHADENECTOMY

You have accessJournal of UrologyBladder Cancer: Metastatic Disease/Staging1 Apr 20121908 NUMBER OF LYMPH NODES REMOVED DOES NOT INFLUENCE SURVIVAL IN STAGE N0 BLADDER CANCER AFTER COMPLETE EXTENDED LYMPHADENECTOMY Matthew T. Johnson, Erinn M. Hade, Amanda N. Calhoun, Michael C. Gong, Debra L. Zynger, and Kamal S. Pohar Matthew T. JohnsonMatthew T. Johnson Columbus, OH More articles by this author , Erinn M. HadeErinn M. Hade Columbus, OH More articles by this author , Amanda N. CalhounAmanda N. Calhoun Columbus, OH More articles by this author , Michael C. GongMichael C. Gong Cleveland, OH More articles by this author , Debra L. ZyngerDebra L. Zynger Columbus, OH More articles by this author , and Kamal S. PoharKamal S. Pohar Columbus, OH More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.2064AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Number of lymph nodes (LN) removed is accepted as a surrogate of the extent and quality of lymphadenectomy at radical cystectomy (RC). Removing more LN was reported to provide therapeutic benefit in node negative (pN0) patients. However, studies are limited by including patients with different anatomic extent of LN removal. The reported therapeutic benefit may in fact be a staging benefit (Will Rogers phenomenon) or a reflection of inadequate LN removal in a given template. An extended lymphadenectomy (ELN) when properly performed has been shown to correctly stage pN0 patients. The aim of our study was to determine if the number of LN removed influenced disease free survival (DFS) or overall survival (OS) in pN0 patients undergoing ELN by strict surgical standards. METHODS The study included 100 patients with >cT2 bladder cancer who underwent an ELN between 03/2006-12/2010. 21 patients had lesser extent of LN removal (history of pelvic radiation or aortic graft) and were excluded. ELN included complete removal of presciatic, common iliac and presacral LN. Data was analyzed from a prospectively maintained database. Kaplan-Meier curves were used to describe the survival function of pN0 patients. Cox proportional hazards models were used to obtain adjusted estimates of the association between the number of LN removed and DFS or OS. The number of LN removed was modeled as both a continuous and a categorical variable. RESULTS Neoadjuvant chemotherapy (NAC) was received by 41% of the cohort. RC pathology was >T3 in 58%, lymphovascular invasion (LVI) in 32% and positive soft tissue surgical margin (STSM) in 7%. The mean number of LN removed was 37 (15-76) with 6% of patients having <20 LN removed, 94% >20, 69% >30, 38% >40 and 6% >50 LN removed. 23 patients recurred and 36 died of all causes after a median follow-up of 21.5 months. Positive STSM, LVI and >T3 at RC were important predictors of DFS and OS. When considered together, positive STSM and LVI were independently predictive of DFS; positive STSM, LVI and >pT3 were independently predictive of OS, adjusted for age. Total number of LN removed and use of NAC were not important predictors for either DFS or OS. CONCLUSIONS LN counts vary considerably between patients within the same ELN template. The number of LN removed does not influence DFS or OS in pN0 muscle invasive bladder cancer after a complete ELN. This may not be true for lesser extent of LN removal. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e769-e770 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Matthew T. Johnson Columbus, OH More articles by this author Erinn M. Hade Columbus, OH More articles by this author Amanda N. Calhoun Columbus, OH More articles by this author Michael C. Gong Cleveland, OH More articles by this author Debra L. Zynger Columbus, OH More articles by this author Kamal S. Pohar Columbus, OH More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Robot assisted autonomic nerve sparing extended lymphadenectomy including presacral, common iliac and lower paraaortic nodes in the part of radical hysterectomy

Robot assisted autonomic nerve sparing extended lymphadenectomy including presacral, common iliac and lower paraaortic nodes in the part of radical hysterectomy

Quality of Lymphadenectomy is Equivalent With Robotic and Open Cystectomy Using an Extended Template

Extended lymph node dissection for bladder cancer provides better staging, cancerous node removal and potentially survival. Minimally invasive techniques have been criticized about the ability to adequately perform extended lymph node dissection. We compared the extended lymph node dissection quality of robotic and open cystectomy by assessing node yield and positivity. We compared extended lymph node dissection in 120 open and 35 robotic cystectomy cases. Extended lymph node dissection included skeletonization of structures in each nodal group below the aortic bifurcation (common iliac, external iliac, obturator, hypogastric and presacral nodes). Nodes were processed identically but submitted as 1 or 2 packets for robotic cases and as 10 or more packets for open surgery cases. The mean±SD node count in the open group was 36.9±14.8 (range 11 to 87) and in the robotic group the mean yield was 37.5±13.2 (range 18 to 64). Only 12 of 120 open (10%) and 2 of 35 robotic (6%) cases had fewer than 20 nodes. A total of 36 open (30%) and 12 robotic (34%) cases were node positive. Open extended lymph node dissection identified 80% and 90% confidence of accurate staging as pN0 when obtaining 23 and 27 nodes, respectively. A node count of 23 or 27 was achieved in 87% and 77% of open cases, and in 91% and 83% of robotic cases, respectively. Of patients with open surgery 36% received neoadjuvant chemotherapy compared to 31% of those with robotic surgery. No difference was identified in the lymph node yield or the positive node rate when comparing open and robotic extended lymph node dissection. Local recurrence and survival data are needed to confirm whether the 2 techniques are oncologically equivalent.

Robot-Assisted Upper Para-Aortic Lymphadenectomy Techniques Using Only Three Robotic Arms

We would like to demonstrate robot-assisted upper para-aortic lymphadenectomy using only two robotic instrumental arms without changing the position of the patient. We utilize the supraumbilical port location which allows for greater access to the aortic lymph nodes. The right arm was placed 10 cm lateral 1 cm inferior to the endoscope. The left arm was placed 12 cm lateral and 2 cm inferior to the endoscope. A 12 mm sized assistant port was placed between the endoscope and left arm. After completing pelvic lymphadenectomy, presacral and bilateral lower para-aortic lymph nodes were dissected with ureters retracted laterally by the assistant.

Bladder Cancer Patterns of Pelvic Failure: Implications for Adjuvant Radiation Therapy

Bladder Cancer Patterns of Pelvic Failure: Implications for Adjuvant Radiation Therapy

Presacral and Retroperitoneal Lymph Node Involvement in Urothelial Bladder Cancer: Results of a Prospective Mapping Study

We evaluated the incidence of positive lymph nodes in the presacral and retroperitoneal regions in patients who underwent radical cystectomy and extended pelvic lymph node dissection for urothelial bladder cancer. As part of a prospective mapping study, 143 patients underwent radical cystectomy and extended pelvic lymph node dissection for urothelial bladder cancer between 2006 and 2010. Lymph nodes from 6 separate regions were labeled, including bilateral pelvic and common iliac, presacral and retroperitoneal. We evaluated pathological features, treatment outcomes and cancer specific survival in patients with or without lymph node positive disease in the presacral and retroperitoneal regions. A median of 37 lymph nodes (IQR 27-49) were removed. Overall 52 (36%) patients had positive lymph nodes, of whom 24 (46%) had metastatic disease in the presacral or retroperitoneal region. Four patients (3%) had an isolated solitary positive lymph node in these 2 templates. Two-year overall survival in patients without vs with presacral/retroperitoneal lymph node positive disease was 44% (95% CI 24-64) vs 25% (95% CI 5-45) (p = 0.11). In contrast, 2-year cancer specific survival in the 2 groups was 55% (95% CI 33-77) and 29% (95% CI 7-51), respectively (p = 0.02). A substantial proportion of patients have lymph node positive disease in the presacral and retroperitoneal regions, including some with isolated and/or solitary lymph node involvement. While the limited positive lymph node burden in these templates suggests a potential therapeutic role for extending the anatomical boundaries of lymph node dissection, patient survival was poor. Extended lymph node dissection provides important staging information but to our knowledge the therapeutic benefit has yet to be definitively proved.

Pure Laparoscopic Radical Cystectomy and Ileal Conduit Diversion: Report of Two Cases

Abstract Objective: To explore the technique and clinical efficacy of laparoscopic radical cystectomy and ileal conduit diversion for patients with muscle-invasive bladder cancer. Materials and Methods: Laparoscopic radical cystectomies and ileum conduit diversions were performed in two patients with muscle-invasive bladder cancer (T2b, N0, M0; high-grade papillary urothelial carcinoma). The mean age was 69. Patients were administered general anesthesia and placed in supine position. A small incision was made 4 cm above the umbilicus, and a Veress needle was inserted through the incision to establish the pneumoperitoneum. The patient was then placed at a 30-degree Trendelenburg incline, and a five-port transperitoneal approach was employed.1,2 The boundaries of extended pelvic lymph node dissection started from the bifurcation of common iliac vessel to the root of the inferior mesentery artery. The presacral nodes were also removed. The procedure of cystectomy, extended pelvic lymph node dissection, and i...

Lymph node metastasis mapping in extended lymphadenectomy to the level of the inferior mesenteric artery for bladder cancer

The aim of this study was to evaluate the distribution of lymph node metastasis in extended lymphadenectomy for patients with bladder cancer. We analyzed 31 patients who underwent extended lymphadenectomy at radical cystectomy for bladder cancer between April 2008 and February 2010. Specimens were evaluated as 14 separate packages from predesignated anatomical locations. The lymph node mapping was prospectively registered. The median lymph node count was 37 (range 19-68). Ten (32%) patients had lymph node metastasis. The positive rates at each lymph node site were 0% at the left internal iliac, 13% at the left obturator, 3.2% at the left external iliac, 6.5% at the right internal iliac, 10% at the right obturator, 16% at the right external iliac, 3.2% at the left common iliac, 3.2% at the right common iliac and 6.5% at the presacral node. No lymph node metastasis was detected in the Cloquet, paracaval, aortocaval or paraaortic nodes. One (3.2%) patient had a skip metastasis from the left obturator to the presacral node. Extended lymphadenectomy provides more accurate lymph node staging. We suggest that it is better to perform lymphadenectomy at least below the aortic bifurcation including the presacral node.

Lymphatic spread of nodal metastases in high‐risk prostate cancer: The ascending pathway from the pelvis to the retroperitoneum

The aim of this study was to map the nodal metastases distribution in patients with high-risk prostate cancer (PCa) treated with extended pelvic lymph node dissection (ePLND) and retroperitoneal lymph node dissection (rLND) at the time of radical prostatectomy (RP). This prospective mapping study included 19 patients with high-risk PCa (sharing at least two out of the three following parameters: PSA >20 ng/ml, cT3, biopsy Gleason score ≥8). All patients were treated with RP, ePLND (removal of the obturator, hypogastric, external iliac, presacral, and common iliac lymph nodes) and rLND (removal of para-aortal/para-caval and inter-aorto-caval lymph nodes) by a single surgeon. All patients signed an informed consent highlighting the absence of clinical data supporting the benefit of this surgical approach. Overall, 18 out of 19 patients (94.7%) had pelvic lymph node invasion. The most commonly affected pelvic nodal landing site was obturator (88.8%), followed by external iliac (83.3%), common iliac (77%), hypogastric (44.4%), and presacral (33.3%). Moreover, 14 (77.8%) patients also had involvement of retroperitoneal lymph nodes. Only patients with positive common iliac lymph nodes having at least five positive lower pelvic lymph nodes (n = 14), also had invariably positive retroperitoneal lymph nodes. No patients with negative common iliac lymph nodes had positive retroperitoneal lymph nodes. PCa lymphatic spread ascends from the pelvis up to the retroperitoneum invariably through common iliac lymph nodes. PCa lymphatic spread can be divided in two main levels: pelvic and common iliac plus retroperitoneal lymph nodes.

1981 QUALITY OF LYMPHADENECTOMY IS EQUIVALENT IN ROBOTIC AND OPEN CYSTECTOMY USING AN EXTENDED TEMPLATE

You have accessJournal of UrologyBladder Cancer: Metastatic Disease1 Apr 20111981 QUALITY OF LYMPHADENECTOMY IS EQUIVALENT IN ROBOTIC AND OPEN CYSTECTOMY USING AN EXTENDED TEMPLATE Ronney Abaza, Kamal Pohar, and Robert Bahnson Ronney AbazaRonney Abaza Columbus, OH More articles by this author , Kamal PoharKamal Pohar Columbus, OH More articles by this author , and Robert BahnsonRobert Bahnson Columbus, OH More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.2207AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Relative to lesser templates, extended lymph node dissection (eLND) more accurately assigns nodal stage, removes more positive lymph nodes, and may have greater survival benefit. Minimally-invasive techniques for radical cystectomy have been criticized due to concerns over ability to adequately perform eLND. We determined whether the quality of lymphadenectomy in robotic and open cystectomy is comparable using an extended template by assessing node yield and positivity. METHODS Extended lymph node dissection (eLND) was performed in 120 open and 35 robotic cystectomy patients by a dedicated open or dedicated robotic surgeon. Extended lymphadenectomy was strictly defined as thorough skeletonization of anatomical structures in each nodal group below the aortic bifurcation, including common iliac, external iliac, obturator, hypogastric, and presacral node chains. The hypogastric nodes included skeletonization of the triangle of Marcille (presciatic space). Lymph nodes were identified by palpation without fat clearing techniques or solvents. Nodes from robotic cases were extracted and submitted en bloc or as a maximum of two specimens while open surgery allowed nodes to be submitted as packets from each of the 5 nodal basins. RESULTS The mean lymph node count in the open group was 36.9 ± 14.8 (range, 11 to 87). Only 12 of 120 patients (10%) had a total node count of less than 20. In the robotic group, the mean node yield was 37.5 ± 13.2 (range, 18 to 64) with only 2 of 35 patients (6%) having less than 20 nodes. In the open group, 36 patients (30%) had lymph node metastasis, and in the robotic group, 11 patients (31%) had involved nodes. Open eLND identified 80% and 90% confidence of accurate staging as pN0 when 23 and 27 nodes were obtained, respectively. A total lymph node count of 23 or 27 was achieved in 104 (87%) and 92 (77%) of the open surgery patients and in 32 (91%) and 29 (83%) patients who had robotic surgery. Among open surgical patients, 36% of patients received neoadjuvant chemotherapy as compared with 31% in the robotic surgery group. CONCLUSIONS No difference was identified in the total number of lymph nodes removed and the number of node-positive patients when comparing open and robotic cystectomy with extended lymphadenectomy. Local recurrence and disease specific survival data will be required to confirm whether the two techniques are oncologically equivalent. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e793 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ronney Abaza Columbus, OH More articles by this author Kamal Pohar Columbus, OH More articles by this author Robert Bahnson Columbus, OH More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PET/CT-guided Percutaneous Biopsy of Abdominal Masses: Initial Experience

Purpose To develop a technique for guiding percutaneous biopsies of abdominal masses in a positron emission tomography (PET)/computed tomography (CT) scanner, and test its feasibility and safety in patients. Materials and Methods The authors conducted a prospective study in 12 patients who were in need of both a diagnostic 18F-fluoro-deoxy-D-glucose (FDG) PET/CT scan and a percutaneous biopsy of an abdominal mass, located in the liver ( n = 7), presacral soft tissue ( n = 2), lymph node ( n = 2), and kidney ( n = 1). After completion of the PET/CT scan, with the patient remaining on the table, a one-table-position PET/CT scan was obtained with a radiopaque grid in place, and the biopsy procedure was planned. Then, a biopsy needle was placed into the mass using one-table-position CT scan registered to the planning PET scan. Masses were sampled after confirming accurate positioning of the needle tips with a final one-table-position PET/CT scan. Negative results were confirmed independently with follow-up imaging. Results All biopsy procedures yielded diagnostic results; nine were positive for malignancy, and three were negative (fibrosis, steatosis, and Escherichia coli infection). One non–FDG-avid mass biopsy yielded a malignant result. Seven masses were either invisible or poorly depicted with unenhanced CT scan, and two masses contained FDG avidity in only a portion of the mass. There were no complications. Conclusions Although our data are preliminary, this initial experience suggests that abdominal masses can undergo successful biopsy in a PET/CT scanner. PET/CT guidance may be helpful when performing biopsy on FDG-avid masses that are either not visible with unenhanced CT or are FDG avid in only a portion.

Prolonged Chemoradiation in Locally Advanced Carcinoma of the Uterine Cervix

The aim of this phase II study was to evaluate response and toxicity of a prolonged chemoradiation regimen in patients with locally advanced cervical cancer. Three cycles of concomitant chemotherapy were used with cisplatin (20 mg/m², 2-hour intravenous infusion, days 1-4) and 5-fluorouracil (1000 mg/m², 24-hour continuous intravenous infusion, days 1-4) administered at weeks 1, 5, and 9 of radiotherapy. In combination, radiotherapy was delivered to a planning target volume (PTV) defined as the CTV (clinical target volume) plus 8 mm. The CTV was defined as follows: gross tumor volume, upper half of the vagina (if not involved) or the whole vagina (if clinically involved), uterus, obturator nodes, external iliac nodes, internal iliac nodes, and the presacral nodes (cranial to S2). The prescribed dose to the PTV was 50 Gy, 2 Gy/fraction (ICRU 62) delivered in 25 fractions with a 2-week break at 20Gy and 40 Gy (split-course technique). Early and late toxicity was assessed according to the RTOG and RTOG/EORTC toxicity scales. Perioperative toxicity was evaluated according to the Chassagne classification of surgical complications. A total of 25 patients were included in this study. Median age was 52 years (range, 28-69). Clinical stage was: IB2-II: 19 patients (76%), III-IVA: 6 patients (24%). All patients completed the prescribed dose of chemoradiation and were evaluated 4 weeks after the end of treatment. Complete and partial clinical local response was observed in 4 and 19 patients, respectively (totaling 92% of clinical responses). About 32% of patients experienced grade 3 to 4 toxicity, in particular, grade 3 or 4 hematological toxicity was observed in 7 patients and 1 patient developed grade 3 genitourinary toxicity. No patients developed grade 3 gastrointestinal toxicity or skin toxicity. Of total, 22 patients (88%) underwent radical hysterectomy. Seven patients (28%) showed a complete response (CR) to treatment, and 7 patients (28%) showed microscopic residual disease (μPR), totaling 14 patients (56%) complete/partial microscopic responses. Perioperative morbidity was higher than reported in historical controls especially in terms of tissue fibrosis (64%) and perioperative urinary toxicity (14%). Actuarial 2-year local control, disease-free survival, and overall survival were 65.5%, 61.8%, and 80.8%, respectively. A prolonged treatment with more chemotherapy courses does not improve tumor response and increases the risk of perioperative complication. This treatment regimen, considering the low incidence of acute gastrointestinal toxicity, might be tested in the adjuvant setting.

Curages ganglionnaires dans les cancers de prostate et de vessie : technique et indications

Lymphadenectomy for prostate or bladder cancer gives many informations concerning prognosis. Usually standard lymphadenectomy is made. However, extended lymphadenectomy with external, internal and common iliac and presacral lymphs nodes improves prognosis but has equally therapeutic benefit.

Metastatic Rectal Carcinoid on In-111 Octreotide SPECT-CT Imaging

A 65-year-old asymptomatic male who tested positive for fecal occult blood was found to have a rectal mass on colonoscopy. Staging workup included a CT scan of the abdomen which showed a neoplasm in the liver, with neuroendocrine features on fine needle aspiration. Planar 24 hours whole body In-111 octreotide scan showed a small focus of mildly increased activity in the lateral left lower chest, a very large focus of intense uptake in the liver, and 4 distinct foci of mild to moderately increased uptake in the lower abdomen and pelvis. SPECT-CT images localized these abnormalities to: focal uptake in the rectal wall thickening, 2 presacral lymph nodes, the liver mass, and multiple bone metastases (left ilium, L5 pedicle, and the left 6th rib). This rare case highlights the importance of SPECT-CT in staging carcinoid tumors with In-111 octreotide imaging.

Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up

Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up

Prospective Randomized Double-Blind Pilot Study of Site-Specific Consensus Atlas Implementation for Rectal Cancer Target Volume Delineation in the Cooperative Group Setting

Variations in target volume delineation represent a significant hurdle in clinical trials involving conformal radiotherapy. We sought to determine the effect of a consensus guideline-based visual atlas on contouring the target volumes. A representative case was contoured (Scan 1) by 14 physician observers and a reference expert with and without target volume delineation instructions derived from a proposed rectal cancer clinical trial involving conformal radiotherapy. The gross tumor volume (GTV), and two clinical target volumes (CTVA, including the internal iliac, presacral, and perirectal nodes, and CTVB, which included the external iliac nodes) were contoured. The observers were randomly assigned to receipt (Group A) or nonreceipt (Group B) of a consensus guideline and atlas for anorectal cancers and then instructed to recontour the same case/images (Scan 2). Observer variation was analyzed volumetrically using the conformation number (CN, where CN = 1 equals total agreement). Of 14 evaluable contour sets (1 expert and 7 Group A and 6 Group B observers), greater agreement was found for the GTV (mean CN, 0.75) than for the CTVs (mean CN, 0.46-0.65). Atlas exposure for Group A led to significantly increased interobserver agreement for CTVA (mean initial CN, 0.68, after atlas use, 0.76; p = .03) and increased agreement with the expert reference (initial mean CN, 0.58; after atlas use, 0.69; p = .02). For the GTV and CTVB, neither the interobserver nor the expert agreement was altered after atlas exposure. Consensus guideline atlas implementation resulted in a detectable difference in interobserver agreement and a greater approximation of expert volumes for the CTVA but not for the GTV or CTVB in the specified case. Visual atlas inclusion should be considered as a feature in future clinical trials incorporating conformal RT.

1031 FACTORS AFFECTING THE ADEQUACY OF LYMPH NODE YIELD IN EXTENDED PELVIC LYMPH NODE DISSECTION FOR UROTHELIAL BLADDER CANCER

You have accessJournal of UrologyBladder Cancer: Staging1 Apr 20101031 FACTORS AFFECTING THE ADEQUACY OF LYMPH NODE YIELD IN EXTENDED PELVIC LYMPH NODE DISSECTION FOR UROTHELIAL BLADDER CANCER Robert Freundlich, Lambros Stamatakis, Kumaran Sathyamoorthy, Anuja Mital, Guilherme Godoy, and Seth Lerner Robert FreundlichRobert Freundlich More articles by this author , Lambros StamatakisLambros Stamatakis More articles by this author , Kumaran SathyamoorthyKumaran Sathyamoorthy More articles by this author , Anuja MitalAnuja Mital More articles by this author , Guilherme GodoyGuilherme Godoy More articles by this author , and Seth LernerSeth Lerner More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.2066AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES An extended lymph node dissection has been suggested as a means to allow for improved staging and disease control in patients with urothelial carcinoma (UC) of the bladder. In order to better define an adequate lymph node dissection, the concept of a minimum number of lymph nodes has been advocated. We sought to analyze patient factors affecting the ability to obtain an adequate lymph node yield. METHODS An institutional, IRB approved database was used to identify patients who underwent radical cystectomy by a single surgeon at two hospitals for urothelial carcinoma of the bladder between 2004 and 2009. All patients received an extended pelvic lymph node dissection, defined as a superior boundary at or above the aortic bifurcation and including the presacral nodes. Factors studied included body mass index (BMI), age, gender, and hospital. An adequate lymph node count was defined as the removal of at least 25 lymph nodes, which has been shown to have a 75% probability of detecting one or more positive lymph nodes. Odds ratios for an adequate lymph node count were calculated by performing both a univariate and multivariate analysis using a binary logistic regression model. RESULTS 131 consecutive patients were included in the study. 110 patients were male, 21 were female. The mean age was 66.7 (range 41-89, SD 10.66) and the mean BMI was 27.6 (17.6-43.1, SD 4.82). An average of 33.7 (range 9-81, SD 13.62) lymph nodes were reported by the pathologist. An extended lymph node dissection on patients with a BMI of greater than 25 had a higher likelihood of yielding an adequate lymph node count than in patients with a BMI of less than 25 (OR 18.8, p<0.001). Age less than 65 was also associated with obtaining an adequate lymph node count (OR 3.57, p=0.047). Multivariate analysis showed that a BMI of at least 25 was an independent predictor of adequate lymph node count. CONCLUSIONS An adequate extended lymph node dissection can be performed in overweight and obese patients in spite of perceived technical difficulties, giving these patients the benefit of improved disease staging and localized cancer control. Houston, TX© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e401 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Robert Freundlich More articles by this author Lambros Stamatakis More articles by this author Kumaran Sathyamoorthy More articles by this author Anuja Mital More articles by this author Guilherme Godoy More articles by this author Seth Lerner More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Prostatic Lymphatic Drainage With Sentinel Nodes at the Ventral Abdominal Wall Visualized With SPECT/CT

Lymphatic drainage from the prostate is mainly directed towards pelvic sentinel lymph nodes, although presacral and para-aortic sentinel nodes have also been found with lymphatic mapping. In this case series, we describe direct lymphatic drainage towards the anterior abdominal wall in 3 patients with prostate cancer. In one patient, the sentinel node at the anterior abdominal wall contained metastasis. Sentinel node sampling provides the possibility to map all nodes on a direct drainage pathway, in contrast to regional pelvic nodal dissection with which some sentinel nodes may be missed.

Role of Pelvic Lymphadenectomy in the Treatment of Bladder Cancer: A Mini Review

Although radical cystectomy with pelvic lymph node dissection (PLND) is the standard treatment for muscle-invasive bladder cancer, the optimal extent of PLND and the minimum number of nodes that should be examined for pathology remain unclear. However, evidence is growing that extended PLND has additional diagnostic and therapeutic benefits relative to standard PLND. In particular, a more meticulous and extended PLND may improve the disease-free survival of node-negative patients because it removes undetected micrometastases. Indeed, some patients with positive nodes can be cured by surgery alone, even those with gross adenopathy. Increasing lines of evidence also suggest that the extent of the primary bladder tumor, the number of lymph nodes that are removed, and the lymph node tumor burden are important prognostic variables in patients undergoing cystectomy. Therefore, extended PLND may not only provide improved prognostic information, it may also have a clinically significant therapeutic benefit for both lymph node-positive and node-negative patients undergoing radical cystectomy. Although the absolute limits of PLND remain to be determined, evidence supports the notion that a more extended PLND should include the common iliac vessels and presacral lymph nodes at cystectomy. Such PLND should only be performed in patients who are appropriate surgical candidates. Prospective, randomized trials are needed to properly establish the extent of PLND that is required to generate these benefits.

How Do Commonly Performed Lymphadenectomy Templates Influence Bladder Cancer Nodal Stage?

Determining pathological nodal stage in patients with bladder cancer is important for prognosis. We determined how the extent of lymphadenectomy and the lymph node count influence accurate nodal staging. The study included 120 patients who underwent at least extended lymphadenectomy at radical cystectomy. Different anatomical templates for lymphadenectomy were evaluated for nodal staging accuracy. The cumulative percent was plotted to determine a lymph node count that confidently identified node positive cases. The mean +/- SD total lymph node count in the study population was 36.9 +/- 14.8 at extended lymphadenectomy. Of the patients 36 (30%) had lymph node metastasis, including 14 (39%) with metastasis involving the common iliac and/or presacral lymph nodes. Limited, standard and extended lymphadenectomy accurately identified 75%, 88.9% and 100% of node positive cases, respectively. Removing 23 and 27 lymph nodes provided 80% and 90% confidence, respectively, that a case was accurately staged as pN0. No patient had lymph node metastasis above the aortic bifurcation without nodal metastasis below the aortic bifurcation and none had a change in pN stage by extending lymphadenectomy above the aortic bifurcation. To accurately identify node positive and negative cases, and correctly assign pN stage in node positive cases it is necessary to perform extended lymphadenectomy. Identifying at least 23 to 27 lymph nodes on final pathological evaluation provides a high level of confidence that a case is correctly staged as node positive or negative.