Impact of Surgical Margin and Extent of Lymphadenectomy on Oncologic Outcomes in Plasmacytoid Urothelial Carcinoma
Moffitt Cancer Center's Drs. Rohit Jain, Logan Zemp, Alice Yu, Michael Poch, Philippe Spiess, Scott Gilbert, Wade Sexton, Heather Huelster, G Daniel Grass, Kyle Rose, and Roger Li in the Department of Genitourinary Oncology, co-authored the publication entitled, "Impact of Surgical Margin and Extent of Lymphadenectomy on Oncologic Outcomes in Plasmacytoid Urothelial Carcinoma” which explores the guideline recommendations on template boundaries for pelvic lymph node dissection (PLND) in conventional urothelial carcinoma.
Some of the highlights include:
- Plasmacytoid urothelial carcinoma is best managed by complete surgical extirpation.
- Lymphadenectomy yielding ≥20 lymph nodes portends an improved overall survival.
- Adhering to specific lymphadenectomy templates does not affect survival outcomes.
- Achieving negative surgical margins is paramount in plasmacytoid bladder cancer.
The guideline recommendations disagree on template boundaries for pelvic lymph node dissection (PLND) in conventional urothelial carcinoma. Less is known about PLND in variant histology. They aimed to analyze the role of LND in plasmacytoid urothelial carcinoma (PUC).
A retrospective review of patients with cTanyNanyM0 PUC who underwent radical cystectomy (RC) with PLND was performed from 2012 to 2022. Lymph node count (LNC) was a surrogate for the extent of lymph node dissection and was dichotomized based on maximally selected rank statistics. Multivariable cox hazard regression analysis (MVA) for overall survival (OS) corrected for age, perioperative chemotherapy, soft tissue margin status, and stage ≥pT3 and/or pN+ was performed. Disease-free survival (DFS) and OS were estimated using Kaplan-Meier (KM) analysis.
The results showed 67 patients with a median age of 71, who were 79.1% male were included. Neoadjuvant and adjuvant chemotherapy was administered in 61.2% and 19.4% of patients, respectively. At RC, 70.1% were ≥pT3. Median LNC was 22 (IQR 14–27) with 43.3% of patients being pN+. The calculated optimal LNC cut point for DFS and OS was 19. Grouping by optimal (≥20) vs. suboptimal-LNC (<20), no significant clinicodemographic differences were found. Optimal-LNC provided improved DFS (P = 0.05) and OS (P = 0.02). Optimal-LNC (HR 0.47, 0.24–0.93 CI 95%, P = 0.03) and negative soft tissue margin (HR 0.38, 0.19–0.76 CI 95%, P = 0.01) were associated with improved OS on MVA. Receipt of perioperative chemotherapy did not improve OS (P = 0.46).
In PUC, complete surgical extirpation achieving negative soft tissue margins and removing ≥20 lymph should be prioritized if operative intervention is pursued.
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