Current Opinion in Urology Eprint - June 2011 - (Page 110)
Extended lymph node dissection: bladder, kidney
Pascal Zehnder and Mihir Desai
USC Institute of Urology, Keck School of Medicine, Los Angeles, California, USA Correspondence to Mihir Desai, MD, 1441 Eastlake Ave, Suite 7416, Los Angeles, CA 90033, USA Tel: +1 323 865 3700; e-mail: adityadesai2003@gmail.com Current Opinion in Urology 2011, 21:110–114
Purpose of review To present recent advances in the field of lymph node dissection (LND) in the context of bladder cancer, upper urinary tract urothelial carcinoma and renal cell carcinoma with focus on dissection extent. Recent findings A recent Technetium-based lymph node mapping study has provided several observations to help guide the scientific practice of LND during radical cystectomy. Only 8–10% of primary lymphatic landing sites were located above the uretero-iliac crossing. In contrast, considerable lymph nodes were found in the fossa of Marcille and the internal iliac region. Intraoperative frozen sections are unlikely to abbreviate the LND procedure. Total nodal yield is influenced by numerous factors and may not represent the ideal surrogate for adequacy of LND. The lymphatic drainage of the upper urinary tract is less predictive. For upper urinary tract urothelial cancer, conflicting data question even the staging benefit. In contrast, the results from the sole prospective randomized trial evaluating the value of LND in renal cell carcinoma cannot be generalized because of the limited inclusion of patients with higher stage disease. Summary In invasive bladder cancer, meticulous extended LND offers both a prognostic and therapeutic benefit. However, the proximal boundaries of the LND template remain undefined. For upper urinary tract urothelial cancer there is a need to define a standardized approach (indication, template) in view of directing patients properly to adjuvant therapies and consecutively evaluate both prognostic and therapeutic value of LND. Similarly, the need for standardization accounts for renal cell carcinoma. Keywords bladder cancer, extended lymph node dissection, renal cell carcinoma, upper urinary tract urothelial carcinoma
Curr Opin Urol 21:110–114 ß 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 0963-0643
Introduction
Oncologic surgery requires radicalism with respect to resection of the primary tumor and the primary echelon of lymphatic drainage. Initially deployed for breast and colon cancer, loco-regional lymph node dissection (LND) has become an integral part of most oncologic urological procedures. LND improves postoperative staging accuracy. However, there still exist a variety of controversies in regard of the prognostic and therapeutic benefit for the various genitourinary cancers in part due to the lack of prospective randomized trials. Our review provides recent advances in the field of LND in the course of bladder cancer, upper urinary tract urothelial cancer and kidney cancer surgical treatments, particularly focusing on the extent of dissection.
Bladder cancer
Annually over 65 000 individuals are newly diagnosed with bladder cancer in the USA. Of those undergoing
0963-0643 ß 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
radical surgery, approximately 25% were found to have unexpected nodal involvement. Another 20–30% of occult microscopic metastases are missed on conventional histologic analysis [1]. Since LND for bladder cancer was firmly established in 1982 [2], there is growing retrospective evidence that an extended LND is beneficial from both a prognostic and therapeutic standpoint [3–6]. Despite the overwhelming data on the overall benefit of LND controversy exists over the exact dissection boundaries. Roth et al. [7] performed a Technetium-based mapping study to define the patterns of lymphatic drainage of the urinary bladder. After injection of a nanocolloid into the nontumor-bearing side of the bladder in 60 consecutive cystectomy candidates, they identified a median of 24 primary lymphatic landing sites per patient. Of those, only 8–10% of sites were located above the uretero-iliac crossing and the majority (11%) of the total of 15% of common iliac lymph nodes detected was found distal to the uretero-iliac junction vs. 4% proximal of it. None of the patients revealed so-called exclusive extrapelvic radioactive lymph nodes. In view of the relatively
DOI:10.1097/MOU.0b013e3283430abd
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Table of Contents for the Digital Edition of Current Opinion in Urology Eprint - June 2011
Current Opinion in Urology Eprint - June 2011
Contents
Extended Lymph Node Dissection: Blabber, Kidney
Robotic-Assisted Laparoscopic Prostatectomy: A Critical Analysis of Its Impact on Urinary Continence
A Critical Analysis of the Long-Term Impact of Brachytherapy for Prostate Cancer: A Review of the Recent Literature
Contemporary Role of Radiation Therapy in the Adjuvant or Salvage Setting Following Radical Prostatectomy
Current Opinion in Urology Eprint - June 2011
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