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Impact of the Extent of Lymph Node Dissection on Survival Outcomes in Clinically Lymph Node-Positive Bladder Cancer - Beyond the Abstract

Radical cystectomy (RC) with bilateral pelvic lymph node dissection (PLND) stands as the established treatment for muscle-invasive bladder cancer (BCa).1 Despite this, the impact of the extent of PLND on oncologic outcomes remains a topic of debate. Two recent randomized controlled trials (NCT01215071, NCT01224665) failed to demonstrate an advantage in recurrence-free/disease-free survival for performing an extended PLND (ePLND) over standard PLND (sPLND) in patients with clinically node-negative or cT2-T4a N0-2 BCa.2,3

In this retrospective multicenter study, we investigated whether performing an ePLND at the time of RC would impact the anatomic distribution of recurrences, recurrence-free (RFS), and overall survival (OS) compared to sPLND in cTany N1-3 M0 BCa.4 PLND templates were defined according to the EAU guideline recommendation. Perioperative treatment with platin-based combination chemotherapy was allowed. To account for differences between template groups, propensity score matching was performed.

A total of 510 patients were matched, with 41% receiving induction chemotherapy. In the ePLND group, significantly more lymph nodes were removed compared to sPLND (median lymph nodes removed 24 vs. 16; p<0.001). Among pN0 patients, 33% did not receive induction chemotherapy. The median time to recurrence was 8 months (IQR 4-15), with approximately 30% of patients experiencing distant disease recurrence and 13% locoregional disease recurrence. With a median follow-up of alive patients of 30 months (IQR 13-51), we found no benefit in RFS or OS for performing an ePLND at the time of RC in clinically lymph node-positive (cN+) BCa patients, as confirmed through uni- and multivariable analyses. This finding persisted when patients were stratified according to the induction chemotherapy status.

In summary, performing an ePLND did not improve RFS or OS compared to performing a sPLND in cN+ patients. cN+ BCa is a highly heterogeneous disease associated with a significant staging bias.

This was a study from the CLIPOLY (Clinically Positive Lymph Nodes) study group.

Written by: Markus von Deimling1,2 and Shahrokh F. Shariat1,3-7 on behalf of the CLIPOLY study group collaborators

  1. Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
  2. Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
  3. Department of Urology, University of Texas Southwestern, Dallas, Texas, USA
  4. Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan
  5. Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria
  6. Department of Urology, Weill Cornell Medical College, New York, New York, USA
  7. Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
References:

  1. Witjes JA, Bruins HM, Cathomas R, et al: European Association of Urology Guidelines on Muscle-invasive and Metastatic Bladder Cancer: Summary of the 2020 Guidelines. Eur. Urol. 2021; 79: 82–104.
  2. Gschwend JE, Heck MM, Lehmann J, et al: Extended Versus Limited Lymph Node Dissection in Bladder Cancer Patients Undergoing Radical Cystectomy: Survival Results from a Prospective, Randomized Trial. Eur. Urol. 2019; 75: 604–611.
  3. Lerner SP, Tangen C, Svatek RS, et al: SWOG S1011: A phase III surgical trial to evaluate the benefit of a standard versus an extended lymphadenectomy performed at time of radical cystectomy for muscle invasive urothelial cancer. J. Clin. Oncol. 2023; 41: 4508–4508.
  4. von Deimling M, Furrer M, Mertens LS, et al: Impact of the Extent of Lymph Node Dissection on Survival Outcomes in Clinically Lymph Node-Positive Bladder Cancer. BJU Int. 2023; 136. Available at: http://www.ncbi.nlm.nih.gov/pubmed/37904652. 
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