A Thorough Pelvic Lymph Node Dissection in Presence of Positive Margins Associated With Better Clinical Outcomes in Radical Cystectomy Patients - 07/08/11

Doi : 10.1016/j.urology.2009.01.024

Daniel Canter ^a,^⁎ , Thomas J. Guzzo ^a, Matthew J. Resnick ^a, Meredith R. Bergey ^b, Seema S. Sonnad ^b, John Tomaszewski ^c, Keith VanArsdalen ^a, S. Bruce Malkowicz ^a
^a Department of Surgery, Division of Urology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
^c Department of Pathology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
^b Department of Surgery, Division of Outcomes Research, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania

Reprint requests: Daniel Canter, M.D., Department of Surgery, Division of Urology, Hospital of the University of Pennsylvania, 9 Penn Tower, 3400 Spruce Street, Philadelphia, PA 19104

Résumé

Objectives

To evaluate the effect of positive surgical margins in patients with muscle-invasive transitional cell carcinoma of the bladder on survival.

Methods

A retrospective evaluation of a prospectively maintained radical cystectomy database consisting of the data from 344 patients was performed. Cox regression analysis was done, and Kaplan-Meier tables were developed to evaluate the contribution of this finding to clinical outcomes.

Results

A total of 304 (88.4%) patients had negative surgical margins in the radical cystectomy specimen, and 40 (11.6%) had positive surgical margins. On univariate analysis, positive surgical margins conferred a significant risk of poorer clinical outcomes. The 5-year overall (OS) and disease-specific survival (DSS) rate was 9% and 18% for patients with positive margins compared with 48% and 65% for patients with negative margins, respectively. The multivariate analysis demonstrated a significant independent risk of decreased recurrence-free survival, DSS, and OS for patients with positive surgical margins. The corresponding hazard ratios were 2.29 (95% confidence interval 1.54-3.41, P < .001), 1.71 (95% confidence interval 1.15-2.56, P < .009), and 1.70 (95% confidence interval 1.23-2.34, P < .001). Despite these findings, patients with positive margins and node-negative disease experienced improved DSS and recurrence-free survival (P = .001 P and = .009, respectively) if >15 lymph nodes were removed during surgery.

Conclusions

The presence of positive surgical margins in the pathologic specimen confers a significant independent risk of reduced recurrence-free survival, DSS, and overall survival. Nevertheless, patients with positive surgical margins will still benefit from a meticulous pelvic lymph node dissection.

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