淋巴廓清術於上泌尿道泌尿上皮癌對臨床上淋巴結陰性患者的預後影響
謝享宸、裘坤元、程千里、王賢祥、陳卷書、李建儀、楊晨洸、林嘉彥
台中榮民總醫院 外科部 泌尿外科
The prognostic impact of lymph node dissection for upper urinary tract urothelial
carcinoma in patient with clinically node-negative disease
Hsiang-Chen Hsieh, Kun-Yuan Chiu, Chen-Li Cheng, Shian-Shiang Wang,
Chuan-Shu Chen, Jian-Ri Li, Chun-Kuang Yang, Chia-Yen Lin
Divisions of Urology, Department of Surgery, Taichung Veterans General Hospital, Taiwan
Purpose:
To evaluate the prognostic impact of lymph node dissection (LND) in patients underwent radical nephroureterectomy (RNU) with bladder cuff excision (BCE) for upper urinary tract urothelial carcinoma (UTUC) with clinically node-negative (cN0) disease.
Materials and Methods:
We retrospectively enrolled patients with UTUC and cN0 disease in a single tertiary referral center from 1989 to 2015. The patients were divided into three groups including patient with/without pathologically proved lymph node metastasis (pN1-3 and pN0) and patients without LND (pNx). The association between overall(OS)/disease free survival(DFS) and clinical characteristics were analyzed.
Results:
Totally 485 patients were enrolled to our study and divided into three groups (pN1-3, pN0, pNx with 17, 283 and 185 patients, respectively). The mean following duration was 4.2 years (range from 1.00-20.05). The significantly worse OS/DFS in the pN1-3 group (p<0.001, p<0.001) and worse OS in the pNx (p= 0.034) group comparing with pN0 group were noted. There was also a worse trend of pNx group
comparing to pN0 group in 5 years DFS (81.1% v.s 68.6%, p= 0.091). In univariate analysis, the age (HR= 1.03, p< 0.001), patients with pN1-3 (HR= 4.36, p< 0.001) and pNx (HR= 1.54, p= 0.038), DM (HR= 1.69, p= 0.018), CVA (HR= 2.50, p= 0.013), gastric ulcer (HR= 2.04, p= 0.004), pathological T2 (HR= 1.82, p= 0.037) and T3-T4 stage (HR= 2.91, p< 0.001), positive lymphovascular invasion (HR= 2.94, p < 0.001) and positive surgical margin (HR= 2.86, p= 0.002) were correlated to significantly worse OS. However, in the multivariate analysis, only age (HR= 1.03, p= 0.008), patients with node-positive disease (pN1-3, HR= 2.33, p= 0.039), gastric ulcer (HR= 2.24, p= 0.004) and pathological T3-T4 stage (HR= 2.08, P= 0.007) still significantly affected OS. After balancing the confounders, there is no significant difference of OS in pNx group comparing to pN0 group (HR1.16, p=0.530).
Conclusion:
In our study, pathological proved pN0 disease of UTUC patient had significant better OS and DFS comparing to patients with pathological proved lymph node metastasis disease and without lymph node dissection during RNU+BCE surgery. However, patient with pNx was not an independent prognostic factor of OS in multivariate analysis. The OS difference in OS may be resulted in multiple other confounding factors.