Is Lymph Node Dissection Necessary During Radical Nephroureterectomy for Clinically Node-Negative Upper Tract Urothelial Carcinoma? A Multi-Institutional Study

Hsiang-Ying Lee; Chao-Hsiang Chang; Chi-Ping Huang; Chih-Chin Yu; Chi-Wen Lo; Shiu-Dong Chung; Wei-Che Wu; I-Hsuan Alan Chen; Jen-Tai Lin; Yuan-Hong Jiang; Yu-Khun Lee; Thomas Y Hsueh; Allen W Chiu; Yung-Tai Chen; Chang-Min Lin; Yao-Chou Tsai; Wei-Chieh Chen; Bing-Juin Chiang; Hsu-Che Huang; Chung-Hsin Chen; Chao-Yuan Huang; Chia-Chang Wu; Wei Yu Lin; Jen-Shu Tseng; Hung-Lung Ke; Hsin-Chih Yeh

doi:10.3389/fonc.2022.791620

Is Lymph Node Dissection Necessary During Radical Nephroureterectomy for Clinically Node-Negative Upper Tract Urothelial Carcinoma? A Multi-Institutional Study

Front Oncol. 2022 Apr 29:12:791620. doi: 10.3389/fonc.2022.791620. eCollection 2022.

Authors

Hsiang-Ying Lee^{1

2

3

4}, Chao-Hsiang Chang^{5

6}, Chi-Ping Huang^{5

6}, Chih-Chin Yu^{7

8}, Chi-Wen Lo⁷, Shiu-Dong Chung^{9

10}, Wei-Che Wu^{10

11}, I-Hsuan Alan Chen¹², Jen-Tai Lin¹², Yuan-Hong Jiang¹³, Yu-Khun Lee¹³, Thomas Y Hsueh^{14

15}, Allen W Chiu¹⁶, Yung-Tai Chen¹⁷, Chang-Min Lin¹⁷, Yao-Chou Tsai^{18

19}, Wei-Chieh Chen¹⁹, Bing-Juin Chiang^{20

21

22}, Hsu-Che Huang^{21

22}, Chung-Hsin Chen²³, Chao-Yuan Huang²³, Chia-Chang Wu^{18

24

25}, Wei Yu Lin^{26

27

28}, Jen-Shu Tseng^{29

30

31}, Hung-Lung Ke^{1

2

3

4}, Hsin-Chih Yeh^{1

2

3

4}

Affiliations

¹ Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
² Department of Urology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
³ Department of Urology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan.
⁴ Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
⁵ Department of Urology, China Medical University and Hospital, Taichung, Taiwan.
⁶ School of Medicine, China Medical University, Taichung, Taiwan.
⁷ Division of Urology, Department of Surgery, Taipei Tzu Chi Hospital, The Buddhist Medical Foundation, New Taipei City, Taiwan.
⁸ School of Medicine, Buddhist Tzu Chi University, Hualien, Taiwan.
⁹ Graduate Program in Biomedical Informatics, College of Informatics, Yuan-Ze University, Chung-Li, Taiwan.
¹⁰ Division of Urology, Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan.
¹¹ Institute of Biomedical Engineering, National Taiwan University, Taipei, Taiwan.
¹² Division of Urology, Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.
¹³ Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan.
¹⁴ Division of Urology, Department of Surgery, Taipei City Hospital Renai Branch, Taipei, Taiwan.
¹⁵ Department of Urology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
¹⁶ College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
¹⁷ Department of Urology, Taiwan Adventist Hospital, Taipei, Taiwan.
¹⁸ Department of Urology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
¹⁹ Department of Urology, Taipei Medical University Hospital, Taipei, Taiwan.
²⁰ College of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan.
²¹ Department of Urology, Cardinal Tien Hospital, New Taipei City, Taiwan.
²² Department of Life Science, College of Science, National Taiwan Normal University, Taipei, Taiwan.
²³ Department of Urology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.
²⁴ Department of Urology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.
²⁵ TMU Research Center of Urology and Kidney (TMU-RCUK), Taipei Medical University, Taipei, Taiwan.
²⁶ Division of Urology, Department of Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan.
²⁷ Department of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
²⁸ Department of Medicine, Chang Gung University, Taoyuan, Taiwan.
²⁹ Department of Urology, MacKay Memorial Hospital, Taipei, Taiwan.
³⁰ Department of Urology, Mackay Medical College, New Taipei City, Taiwan.
³¹ Institute of Biomedical Informatics, National Yang Ming Chiao Tung University, Taipei, Taiwan.

Abstract

Purpose: This study aimed to compare the oncological outcomes of patients with upper tract urothelial carcinoma (UTUC) without clinical lymph node metastasis (cN0) undergoing lymph node dissection (LND) during radical nephroureterectomy (NU).

Methods: From the updated data of the Taiwan UTUC Collaboration Group, a total of 2726 UTUC patients were identified. We only include patients with ≥ pT2 stage and enrolled 658 patients. The Kaplan-Meier estimator and Cox proportional hazards model were used to analyze overall survival (OS), cancer-specific survival (CSS), disease-free survival (DFS), and bladder recurrence-free survival (BRFS) in LND (+) and LND (-) groups.

Results: A total of 658 patients were included and 463 patients without receiving LND and 195 patients receiving LND. From both univariate and multivariate survival analysis, there are no significant difference between LND (+) and LND (-) group in survival rate. In LND (+) group, 18.5% patients have pathological LN metastasis. After analyzing pN+ subgroup, it revealed worse CSS (p = 0.010) and DFS (p < 0.001) compared with pN0 patients.

Conclusions: We found no significant survival benefit related to LND in cN0 stage, ≥ pT2 stage UTUC, irrespective of the number of LNs removed, although pN+ affected cancer prognosis. However, from the result of pN (+) subgroup of LND (+) cohort analysis, it may be reasonable to not perform LND in patients with cT2N0 stage due to low positive predictive value of pN (+). In addition, performing LND may be considered for ureter cancer, which tends to cause lymphatic and hematogenous tumor spreading. Further large prospective studies are needed to validate our findings.

Keywords: clinical lymph node negative; lymph node dissection; muscle-invasive stage; pathological lymph node positive; upper tract urothelial carcinoma.