Extranodal extension in node-positive bladder cancer: the continuing controversy

OBJECTIVE To examine whether extranodal extension (ENE) has an impact on the outcome of node-positive patients who underwent radical cystectomy for bladder cancer. PATIENTS AND METHODS Of 543 consecutive patients who underwent radical cystectomy for urothelial carcinoma of the bladder between 1990 and 2007, 112 patients with lymph node metastasis detected on histological examination were evaluated with regard to recurrence-free survival (RFS) and disease-specific survival (DSS) based on ENE status. RESULTS The overall 5-year RFS and DSS rates were 22.3% and 33.8%, respectively. ENE was observed in 41 (36.6%) of the 112 patients. The presence of ENE was associated with advanced pathological nodal status (P = 0.004), more positive lymph nodes (P = 0.006), and higher lymph node density (P < 0.001). The incidence of positive ENE increased with large positive lymph node diameter (P < 0.001). Multivariate analysis showed that lymph node density (hazard ratio (HR) = 2.39, 95% CI 1.09-5.24, P = 0.029; and HR = 3.13, 1.43-6.84, P = 0.004) and use of adjuvant chemotherapy (HR = 1.80, 1.02-3.20, P = 0.041; and HR = 2.07, 1.13-3.79, P = 0.018) were significant predictors of RFS and DSS, respectively. After adjustment for other prognostic factors, ENE was not significantly related to RFS (P = 0.825) and DSS (P = 0.961) by multivariate analysis. CONCLUSIONS The presence of ENE was not an independent prognostic factor in node-positive patients after radical cystectomy for bladder cancer. Additional prospective studies are needed to determine the independent prognostic role of ENE.