What is the prognosis following radical cystectomy with nodal disease?

Updated: Nov 27, 2016
  • Author: Michael Christopher Large, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
  • Print
Answer

In most large series, the incidence of lymph node metastases at the time of cystectomy ranged from 20%-30%; patients with positive nodes have a 5-year survival rate of 20%-35%. Of patients with nodal disease, survival depends on numerous factors, such as the following:

  • Extent of the primary bladder disease

  • Extent of nodal metastases (N1, N2, N3)

  • Total number of lymph nodes (diseased plus disease-free) removed [18]

  • Lymph node density (total number of positive lymph nodes divided by total lymph nodes removed)

A cure rate of up to 45% can be achieved in patients with nodal disease and a tumor confined to bladder (pT2 or less), whereas lower cure rates (15%-30%) are achieved in patients with nodal disease and an extravesical primary tumor.

N1 disease carries a 5-year survival rate of 26%-44%, N2 disease carries a 5-year survival rate of 22%-26%, and those with N3 disease rarely survive longer than 5 years.

The survival rate has also been correlated to the total number of lymph nodes removed, regardless of the number of diseased nodes; this is likely a result of more accurate pathologic staging and the removal of micrometastases not visualized pathologically. In one large study, patients with both node-negative and node-positive disease had an increased survival rate if the total number of lymph nodes removed was greater than 9. [18] Another recent study that analyzed lymph node dissection data from 1,121 patients undergoing cystectomy showed that, regardless of lymph node status, as more lymph nodes were resected, overall survival improved. Survival probability never plateaued at a specific lymph node threshold but continued to improve as more nodes were removed. This finding implies that more extensive lymph node dissections may result in improved long-term survival. [29]

Another prognostic tool is the lymph node ratio, or density, defined as the total number of positive lymph nodes divided by total lymph nodes removed. A cutpoint of 20% has been used to risk-stratify patients with positive lymph nodes. In a large Memorial Sloan Kettering Cancer Center and University of Southern California series, patients with a lymph node ratio of less than 20% had 5-year survival rates of 45%-64%, whereas those with a lymph node ratio of more than 20% had 5-year survival rates of 6%-18%.

When disease is limited to the prostatic urethra or prostatic ducts, the prognosis is similar to that in patients without prostatic involvement. Patients with urethral CIS, ductal prostatic involvement, and stromal prostatic involvement have 5-year survival rates of 74%, 67%, and 36%, respectively.

Other prognostic factors that have been independently associated with outcome following cystectomy include extracapsular extension of pelvic lymph node metastases, [30] Ki67 expression, [31] and lymphovascular invasion. [32] Recurrence after cystectomy almost uniformly results in cancer-specific mortality.


Did this answer your question?
Additional feedback? (Optional)
Thank you for your feedback!