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Published on: October 30, 2013
Is there a therapeutic role for post-chemotherapy retroperitoneal lymph node dissection in metastatic transitional
Paul Sweeney1, Randall Millikan, Machelle Donat
1Department of Urology, University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
Purpose:
We identified a subset of patients with bladder cancer (transitional cell carcinoma) and regional nodal metastasis to the retroperitoneal lymph nodes without detectable systemic dissemination. While the majority of these patients respond initially to chemotherapy, most have disease relapse at the same site within a year. We report the results of a phase II study exploring the potential benefit of retroperitoneal lymph node dissection in patients with transitional cell carcinoma of the bladder in whom disease has shown a significant response to chemotherapy.
Materials And Methods:
A total of 11 patients with biopsy proven metastatic transitional cell carcinoma in the retroperitoneal lymph nodes and no evidence of visceral metastatic disease in whom disease showed a significant response to chemotherapy underwent complete bilateral retroperitoneal lymph node dissection. The end point of study was disease specific survival, calculated from the time of retroperitoneal lymph node dissection to death from transitional cell carcinoma of the bladder.
Results:
Four patients underwent delayed retroperitoneal lymph node dissection. Seven patients underwent concurrent cystectomy, and pelvic and retroperitoneal lymph node dissection. There was no perioperative mortality. Nine patients had evidence of residual disease in the retroperitoneal nodes. Seven patients have recurrence outside of the original surgical field with a median time to recurrence of 7 months and 6 died at a median time to death of 8 months (range 5 to 14). One patient with retrocrural recurrence attained a complete response to salvage chemotherapy and remained disease-free 57 months after retroperitoneal lymph node dissection. For all 11 patients median disease specific and recurrence-free survival rates were 14 and 7 months, respectively. Four-year disease specific and recurrence-free survival rates were 36% and 27%, respectively. We stratified the patients based on the number of involved lymph nodes at retroperitoneal lymph node dissection and noted that viable tumor in no more than 2 lymph nodes correlated with greater disease specific and recurrence-free survival (p = 0.006 and 0.01, respectively).
Conclusions:
Retroperitoneal lymph node dissection can be safely performed for metastatic transitional cell carcinoma. Retroperitoneal lymph node dissection has curative potential, particularly in patients with viable tumor in no more than 2 lymph nodes after chemotherapy.
Insights
Retroperitoneal lymph node dissection (RLND) shows curative potential for bladder cancer patients with metastatic retroperitoneal lymph nodes after chemotherapy. Optimal outcomes are seen in patients with limited residual disease post-chemotherapy.
Area of Science:
- Urology
- Surgical Oncology
- Medical Oncology
Background:
- Bladder cancer (transitional cell carcinoma) with retroperitoneal nodal metastasis often relapses after chemotherapy.
- Systemic dissemination is absent in this specific patient subset.
- Chemotherapy response is typically transient, necessitating further treatment exploration.
Purpose of the Study:
- To evaluate the efficacy of retroperitoneal lymph node dissection (RLND) in patients with transitional cell carcinoma of the bladder and metastatic retroperitoneal lymph nodes.
- To assess the safety and survival outcomes of RLND following chemotherapy response.
- To identify patient subgroups who may benefit most from RLND.
Main Methods:
- A phase II study involving 11 patients with biopsy-proven metastatic transitional cell carcinoma in retroperitoneal lymph nodes and no visceral disease.
- All patients showed significant response to chemotherapy before undergoing complete bilateral retroperitoneal lymph node dissection.
- Disease-specific survival was the primary endpoint, calculated from RLND to death from bladder cancer.
Main Results:
- No perioperative mortality was observed.
- Nine patients had residual disease in retroperitoneal nodes; seven experienced recurrence outside the surgical field.
- Median disease-specific survival was 14 months, and recurrence-free survival was 7 months, with 4-year survival rates of 36% and 27%, respectively.
- Fewer than 2 positive lymph nodes post-chemotherapy correlated with improved survival (p=0.006).
Conclusions:
- Retroperitoneal lymph node dissection (RLND) is a safe procedure for metastatic transitional cell carcinoma.
- RLND offers curative potential, especially for patients with limited viable tumor (≤2 lymph nodes) after chemotherapy.
- This surgical approach provides a survival benefit for select bladder cancer patients with advanced nodal disease.
