Stein-膀胱癌淋巴清扫资料.ppt

The Role of Lymphadenectomy in Bladder Cancer John P.Stein,M.D.University of Southern California Keck School of Medicine,Norris Comprehensive Cancer Center,Los Angeles CA HIGH-GRADE,INVASIVE BLADDER CANCER Reality“Invasive bladder cancer is a lethal disease.”USC BLADDER CANCER EXPERIENCE Rationale for Cystectomy Best survival results Lowest local recurrence rates Improved morbidity and mortality Urinary reconstruction has improved quality of life(continent and orthotopic diversion)Equally effective forms of therapy have not emerged USC/NORRIS BLADDER CANCER EXPERIENCE Recurrence-Free Survival of 1054 Patients Stratified by Lymph Node Status (LN+vs.LN-)(6/71-12/97)0 5 10 15 Years from Cystectomy 0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00 Probability of Not Recurring LN+(n=244)LN-(n=810)P0.001 Incidence of Lymph Node Metastases at Cystectomy Author Years Total#Pts LN+Poulsen 90-97 191 50(26%)Vieweg 80-90 686 193(28%)Leissner 99-02 290 81(28%)Stein 71-97 1054 246(24%)Totals 2221 570(25%)Risk Factors for Lymph Node Metastases Following Radical Cystectomy:The Concept of Lymph Node Density John P.Stein,M.D.University of Southern California Keck School of Medicine,Norris Comprehensive Cancer Center,Los Angeles CA USC Radical Cystectomy Experience:Long-Term Results in 1,054 Patients J.Clin.Oncol.,19:666,2001.Radical cystectomy with BPLND 24%of patients LN+disease Risk factors include:p-stage#of LN involved Organ Confined(n=594)Extravesical(n=214)Lymph Node(+)(n=246)P 0.001 Probability of Not Recurring USC Radical Cystectomy Experience:Long-Term Results in 1,054 Patients J.Clin.Oncol.,19:666,2001.Radical cystectomy with BPLND 24%of patients LN+disease Risk factors include:p-stage#of LN involved USC Radical Cystectomy Experience:Long-Term Results in 1,054 Patients J.Clin.Oncol.,19:666,2001.Radical cystectomy with BPLND 24%of patients LN+disease Risk factors include:p-stage#of LN involved USC Radical Cystectomy Experience:Long-Term Results in 1,054 Patients J.Clin.Oncol.,19:666,2001.Radical cystectomy with BPLND 24%of patients LN+disease Risk factors include:p-stage#of LN involved Radical Cystectomy Extent of Lymphadenectomy Prognostic factors in LN-disease:Herr et al,J Urol,167 1298,2002 Poulsen et al,J Urol,160,2015,2002 Leissner et al,Br J Urol,85,817,2000 Radical Cystectomy Extent of Lymphadenectomy Prognostic factors in LN-disease:Herr et al,J Urol,167 1298,2002 Poulsen et al,J Urol,160,2015,2002 Leissner et al,Br J Urol,85,817,2000 Radical Cystectomy Extent of Lymphadenectomy Prognostic factors in LN-disease:Herr et al,J Urol,167 1298,2002 Poulsen et al,J Urol,160,2015,2002 Leissner et al,Br J Urol,85,817,2000 Radical Cystectomy Extent of Lymphadenectomy Prognostic factors in LN-disease:Herr et al,J Urol,167 1298,2002 Poulsen et al,J Urol,160,2015,2002 Leissner et al,Br J Urol,85,817,2000 Lymph Node Positive Bladder Cancer Lymph Node Density Novel concept#of involved LN/#of LN removed Accounts for:1.LN tumor burden 2.Extent of PLND USC/Norris Lymph Node Positive Bladder Cancer Experience Purpose 1.Evaluate the clinical outcomes and risk factors for patients with lymph node metastases following radical cystectomy.2.Evaluate the concept of lymph node density(#positive lymph nodes/#lymph nodes removed).USC/Norris Lymph Node Positive Bladder Cancer Experience Patients Time period:July 1971 Dec 1997 Total lymph node+:244(24%)244(24%)Gender:191 males(78%);53 females Age:median 66 years(range 36-90)Follow-up:median 10.1 years(range 0-26)USC BLADDER CANCER EXPERIENCE P-Stage and Lymph Node+Lymph Node StatusP-Stage(TNM)Total (%)Positive(%)Negative(%)P0,Pis,Pa,P1419(40)19(5)400(95)P2116(11)21(18)95(82)P3a133(13)35(27)98(73)P3b247(23)112(45)135(55)P4136(13)58(43)78(57)Totals1054244(24%)806(76%)19(5)21(18)35(27)112(45)58(43)244 (24%)Pelvic Iliac Lymphadenectomy Pelvic Iliac Lymphadenectomy Level of the inferior mesenteric artery Genitofemoral nerve Pelvic Iliac Lymphadenectomy Level of the inferior mesenteric artery Genitofemoral nerve Pelvic Iliac Lymphadenectomy Level of the inferior mesenteric artery Genitofemoral nerve Lymph node of Cloquet*Genitofemoral nerve Obturator fossa Genitofemoral nerve Pelvic Iliac Lymphadenectomy Lymph node of Cloquet*Level of the inferior mesenteric artery Obturator fossa Genitofemoral nerve Pelvic Iliac Lymphadenectomy Level of the inferior mesenteric artery Lymph node of Cloquet*Presacral lymph nodes USC/Norris Lymph Node Positive Bladder Cancer Experience Adjuvant Therapies Chemotherapy 139 patients(56%)Postop-126(52%)Preop-7(3%)Pre&Postop-6(2%)Radiation Therapy 37 patients(15%)Preop-26(11%)Postop-8(3%)Pre&Postop-3(1%)USC/Norris Lymph Node Positive Bladder Cancer Experience Lymph Nodes Median#of LN removed:30(range 1-96)Median#of LN involved:2 (range 1-63)1438480510152025303540455030%patients with LN removed3030 2 2 USC/Norris Lymph Node Positive Bladder Cancer Experience Morbidity and Mortality 2 perioperative deaths(1%)66 early complications(27%)No complication directly rela