Introduction:

S1011 trial showed no benefits of extended lymphadenectomy (ELND) compared to standard LND (SLND) in patients with muscle-invasive bladder cancer (MIBC) undergoing radical cystectomy (RC). Debate still exists regarding the role of ELND in selected patients. We aim to investigate the impact of level of nodal metastasis (N+) on outcomes and rate of skip nodal metastases.

Methods:

Using our IRB approved perspective institutional database, we identified patients with cT2-4aN0M0 urothelial cancer who underwent RC and super-extended LND +/- neoadjuvant chemotherapy (NAC) between 2002 and 2023. Level of LNs were divided into 3 levels (Figure 1): level 1 – external/internal iliac, and obturator LNs (SLND); level 2 - common iliac, pre-sciatic, and pre-sacral LNs (ELND); level 3 - paraaortic and paracaval LNs (ELND) The cohort was stratified into three groups based on the highest level of N+. Skip N+ was defined as having level 2 or 3 N+ without having lower-level positive nodes.

Results:

A total of 738 patients were included and N+ was seen in 159 (21.5%) patients. Among patients with N+, 100 (62.9%) had highest/only N+ at level 1, 22 (13.8%) had highest N+ at level 2, and 37 (23.3%) had highest N+ at level 3 (Figure 2). Only 7 (4.4%) patients had skip N+ including 3 (1.9%) skip level 2 and 4 (2.5%) skip level 3. Two-year (2-y) recurrence free survival (RFS) for node negative, level 1, level 2, and level 3 N+ was 81%, 52%, 36%, and 23%, respectively and 2-y overall survival (OS) were 82%, 60%, 49%, and 27%, respectively. For patients with level 1 N+ who did not receive peri-operative chemotherapy (n=38), 2-y RFS was 45% and 2-y OS was 43%. However, for patients with higher level (2-3) N+ who did not receive peri-operative chemotherapy (n=16), 14 (88%) died within 2 years and 10 (63%) died within 1 year.

Conclusion:

The therapeutic benefit of ELND is very small for patients with higher level of N+ due to the poor prognosis without chemotherapy. The incidence of skip N+ is low and diagnostic benefit of ELND may also be limited. The role of ELND in the post-S1011 era may be very limited and further prospective studies are needed to identify if any MIBC patients benefit from ELND.

Funding: N/A