Zusammenfassung
Fragestellung: Im Gegensatz zur operativen Therapie vieler solider Tumoren existieren für die pelvine Lymphadenektomie bei der radikalen Zystektomie keine Richtlinien oder Standards. Die wenigen Literaturdaten über den therapeutischen Nutzen der Lymphadenektomie und deren Einfluss auf die Tumorklassifikation sind widersprüchlich.
Methodik: Retrospektiv wurden die Daten von 484 konsekutiven Patienten evaluiert, die zwischen 1986 und 1999 mit kurativer Zielsetzung radikal zystektomiert worden sind. Die Gesamtanzahl der entfernten Lymphknoten wurde mit der histopathologischen Klassifikation, Operateur und Pathologen sowie dem weiteren Krankheitsverlauf der Patienten korreliert.
Ergebnisse: Das mittlere Alter der Patienten betrug bei der Zystektomie 62,7 Jahre, 321 Patienten konnten nachbeobachtet werden. Im Mittel wurden 14,3 Lymphknoten entfernt (1-46).
Die Anzahl der entfernten Lymphknoten korrelierte signifikant mit den verschiedenen Operateuren, jedoch nicht mit den auswertenden Pathologen. Wurden mehr als 15 Lymphknoten entfernt, war die Prognose bei Patienten mit pT2- und pT3-Tumoren und bei Patienten ohne Lymphknotenmetastasen signifikant besser. In der multivariaten Analyse hatten die pT-Kategorie (p < 0,01), Lymphknotenstatus (p < 0,01) und Anzahl der entfernten Lymphknoten (p = 0,04) einen Einfluss auf die Prognose.
Schlussfolgerung: Eine radikalere Lymphadenektomie verbesserte in unserem retrospektiv untersuchten Kollektiv signifikant die Prognose und stellte damit eine potenziell kurative Maßnahme dar. Auf dem Boden dieser Ergebnisse müssen prospektive Untersuchungen klären, wo der Standard für die pelvine Lymphadenektomie liegt und welchen Überlebensvorteil die radikale Chirurgie für den Patienten
bietet.
Abstract
Objective: In contrast to other carcinomas such as breast or colon cancer, there are no guidelines regarding the number and location of lymph nodes to be removed during radical surgery in patients with invasive bladder carcinoma. The therapeutic effect of pelvic lymphadenectomy and its influence on tumour staging has not been documented yet.
Methods: Here we present an evaluation of pelvic lymph nodes from 484 patients who underwent radical cystectomy with curative intention between 1986 and 1999. The number of lymph nodes was correlated with the depth of invasion of the primary tumour, occurrence of nodal metastases, clinical outcome, the operating surgeon, and the pathologist.
Results: There were 484 patients with a mean age of 62.7 years. Clinical follow up was available from 321 patients with a mean follow up period of 35.9 months. The average number of
lymph nodes removed was 14.3 (range: 1-46). The number of lymph nodes removed varied significantly between different surgeons and did not correlate with the pathologists. There was a significant correlation between the number of lymph nodes removed and the tumour-free survival in pT2 or pT3 tumours and in patients without lymph node metastases. Multivariate analysis revealed that pT-category (p < 0.01), pN-category (p < 0.01), and the total number of lymph nodes removed (p = 0.04) were the most important factors affecting survival.
Conclusion: The more extensive lymphadenectomy significantly improved the prognosis of patients with invasive bladder cancer and therefore, represents a potentially curative procedure. The results indicate a need for a standardised lymph node dissection.
Schlüsselwörter
Pelvine Lymphadenektomie - Radikale Zystektomie - Blasenkarzinom - Prognose
Key words
Pelvic lymphadenectomy - Radical cystectomy - Bladder cancer - Prognosis
Literatur
-
1
Benedetti-Panici P, Scambia G, Baiocchi G, Greggi S, Mancuso S.
Technique and feasibility of radical para-aortic and pelvic lymphadenectomy for gynecologic malignancies: a prospective study.
Int J Gynecol Cancer.
1991;
1
33-40
-
2
Bonenkamp J J, Hermans J, Sasako M, van de Velde C J. Dutch Gastric Cancer Group .
Extended lymph-node dissection for gastric cancer.
N Engl J Med.
1999;
340
908-914
-
3
Bunt A MG, Hogendoorn P CW, van de Velde C JH, Bruijn J A, Hermans J.
Lymph node staging standards in gastric cancer.
J Clin Oncol.
1995;
13
2309-2316
-
4
Caplin S, Cerottini J P, Bosman F T, Constanda M T, Givel J C.
For patients with Dukes' B (TNM Stage II) colorectal carcinoma, examination of six or fewer lymph nodes is related to poor prognosis.
Cancer.
1998;
83
666-672
-
5
Cuschieri A, Weeden S, Fielding J, Bancewicz J, Craven J, Joypaul V, Sydes M, Fayers P. Surgical Co-operative Group .
Patient survival after D1 and D2 resections for gastric cancer: long-term results of the MRC randomized surgical trial.
Br J Cancer.
1999;
79
1522-1530
-
6
Friedberg V, Beck T.
Ergebnisse operativer Therapie des Zervixkarzinoms im Stadium II b.
Geburtshilfe Frauenheilkd.
1989;
49
782-86
-
7
Hermanek P, Giedl J, Dworak O.
Two programs for examination of regional lymph nodes in colorectal carcinoma with regard to the new pN classification.
Pathol Res Pract.
1989;
185
867-873
-
8
Hermanek P, Wiebelt H, Riedl S.
Studiengruppe kolorektales Karzinom: Langzeitergebnisse der chirurgischen Therapie des Colonkarzinoms. Ergebnisse der Studiengruppe kolorektales Karzinom.
Chirurg.
1994;
65
287-297
-
9
Höckel M, Konerding M A, Heußel C P.
Liposuction-assisted nerve-sparing extended radical hysterectomy: oncologic rationale, surgical anatomy, and feasibility study.
Am J Obstet Gynecol.
1998;
178
971-976
-
10
Holmäng S, Hedelin H, Borghede G, Johansson S L.
Long-term followup of a bladder carcinoma cohort: questionable value of radical radiotherapy.
J Urol.
1997;
157
1642-1646
-
11
Jeffers M D, O'Dowd G M, Mulcahy H, Stagg M, O'Donoghue D P, Toner M.
The prognostic significance of immunohistochemically detected lymph node micrometastases in colorectal carcinoma.
J Pathol.
1994;
172
183-187
-
12
Kaplan E L, Meier P.
Nonparametric estimation from incomplete observation.
J Am Stat Assoc.
1958;
53
457-481
-
13
Leissner J, Hohenfellner R, Thüroff J W, Wolf H K.
Lymphadenectomy in patients with transitional cell cancer of the urinary bladder - significance for staging and prognosis.
BJU Int.
2000;
85
817-823
-
14
Lerner S P, Skinner D G, Lieskovsky G, Boyd S D, Groshen S L.
The rationale for en bloc pelvic lymph node dissection for bladder cancer patients with nodal metastases: long-term results.
J Urol.
1993;
149
758-765
-
15
Mathiesen O, Carl J, Bonderup O, Panduro J.
Axillary sampling and the risk of erroneous staging of breast cancer.
Acta Oncol.
1990;
29
721-725
-
16
Peto R, Pike M C.
Design and analysis of randomized clinical trials requiring prolonged observations of each patient.
Br J Cancer.
1977;
35
1-39
-
17
Porter G, Soskolone C, Yakimets W, Newman S.
Surgeon-related factors and outcome in rectal cancer.
Ann Surg.
1998;
227
157-167
-
18
Poulsen A L, Horn T, Steven K.
Radical cystectomy: extending the limits of pelvic lymph node dissection improves survival for patients with bladder cancer confined to the bladder wall.
J Urol.
1998;
160
2015-2020
-
19
Schumpelick V, Willis S, Kasperk R.
Moderne Operationsverfahren des Rektumkarzinoms: Sind adjuvante Therapiemaßnahmen notwendig?.
Dt Ärztbl.
2000;
97
1138-1146
-
20
Scott K W, Grace R H, Gibbons P.
Five-year follow-up study of the fat clearance technique in colorectal carcinoma.
Dis Colon Rectum.
1994;
37
126-128
-
21
Skinner D G.
Management of invasive bladder cancer: a meticulous pelvic node dissection can make a difference.
J Urol.
1982;
128
34-36
-
22
Stackl W, Baierlein M, Albrecht W.
Bladder preservation in muscle-invasive bladder cancer.
Br J Urol.
1998;
82
357-360
-
23
Stein J P, Lieskovsky G, Cote R, Groshen S, Feng A, Boyd S, Skinner E, Bochner B, Thangathurai D, Mukhail M, Raghavav D, Skinner D G.
Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1 054 patients.
J Clin Oncol.
2001;
19
666-675
-
24
Sternberg C N, Calabro F.
Chemotherapy and management of bladder tumours.
BJU Int.
2000;
85
559-610
-
25
Stöckle M, Meyenburg W, Welleck S, Voges G E, Gertenbach U, Thüroff J W, Huber C, Hohenfellner R.
Advanced bladder cancer (stages pT3b, pT4a, pN1 and pN2): improved survival after radical cystectomy and 3 adjuvant cycles of chemotherapy. Results of a controlled prospective study.
J Urol.
1992;
148
302-307
-
26 Tajiama A, Kameyama S, Kawabe K, Aso Y, Ishikawa A. What is the role of pelvic lymph node dissection in bladder cancer?. In: Donehue JP (ed). Lymph node surgery in urology. Isis Medical Media 1995; 43-50
-
27 Wittekind C, Wagner G. TNM-Klassifikation maligner Tumoren. Wittekind C, Wagner G (Hrsg). 5. Auflage. Springer, Berlin, Heidelberg, New York 1997
-
28
van Lancker M, Goor C, Sacre R, Lamote J, van Belle S, De Coene N, Roelstraete A, Storme G.
Patterns of axillary lymph node metastasis in breast cancer.
Am J Clin Oncol.
1995;
18
267-272
-
29
Vieweg J, Gschwend J E, Herr H W, Fair W R.
Pelvic lymph node dissection can be curative in patients with node positive bladder cancer.
J Urol.
1999;
161
449-454
-
30
Zincke H, Patterson D E, Utz D C.
Pelvic lymphadenectomy and radical cystectomy for transitional cell carcinoma of the bladder with pelvic nodal disease.
Br J Urol.
1985;
57
156-159
Dr. J. Leißner
Urologische Universitätsklinik
Otto-von-Guericke-Universität
Leipziger Straße 44
39120 Magdeburg
Phone: 03 91/6 71 50 37
Email: joachim.leissner@medizin.uni-magdeburg.de
