Impact of surgical margin and extent of lymphadenectomy on oncologic outcomes in plasmacytoid urothelial carcinoma

Facundo Davaro; Elizabeth Davaro; Kyle Rose; Prithvi Murthy; Heather Huelster; Shreyas Naidu; Lucia Camperlengo; George Daniel Grass; Aram Vosoughi; Vaibhav Chumbalkar; Rohit K Jain; Logan Zemp; Alice Yu; Michael A Poch; Philippe E Spiess; Scott M Gilbert; Wade J Sexton; Roger Li

doi:10.1016/j.urolonc.2023.02.003

Impact of surgical margin and extent of lymphadenectomy on oncologic outcomes in plasmacytoid urothelial carcinoma

Urol Oncol. 2023 Sep;41(9):389.e7-389.e13. doi: 10.1016/j.urolonc.2023.02.003. Epub 2023 Mar 22.

Authors

Facundo Davaro¹, Elizabeth Davaro², Kyle Rose¹, Prithvi Murthy¹, Heather Huelster¹, Shreyas Naidu³, Lucia Camperlengo¹, George Daniel Grass⁴, Aram Vosoughi², Vaibhav Chumbalkar², Rohit K Jain¹, Logan Zemp¹, Alice Yu¹, Michael A Poch¹, Philippe E Spiess¹, Scott M Gilbert¹, Wade J Sexton¹, Roger Li⁵

Affiliations

¹ Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL.
² Department of Pathology, H. Lee Moffitt Cancer Center, Tampa, FL.
³ Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL; Department of Immunology, H. Lee Moffitt Cancer Center, Tampa, FL.
⁴ Department of Radiation Oncology, H. Lee Moffitt Cancer center, Tampa, FL.
⁵ Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL. Electronic address: Roger.Li@moffitt.org.

PMID: 36959058
DOI: 10.1016/j.urolonc.2023.02.003

Abstract

Objective: Guideline recommendations disagree on template boundaries for pelvic lymph node dissection (PLND) in conventional urothelial carcinoma. Less is known about PLND in variant histology. We aimed to analyze the role of LND in plasmacytoid urothelial carcinoma (PUC).

Methods: 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 extent of lymph node dissection and 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.

Results: Sixty-seven patients with median age of 71, who were 79.1% male were included. Neoadjuvant and adjuvant chemotherapy were 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+. 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) was associated with improved OS on MVA. Receipt of perioperative chemotherapy did not improve OS (P = 0.46).

Conclusion: In PUC, complete surgical extirpation achieving negative soft tissue margins and removing ≥20 lymph should be prioritized if operative intervention is pursued.

Keywords: Lymphadenectomy; Plasmacytoid urothelial carcinoma; Radical cystectomy; Surgical Margin; Variant histology.

MeSH terms

Carcinoma, Transitional Cell* / pathology
Cystectomy
Female
Humans
Lymph Node Excision
Lymph Nodes / pathology
Lymph Nodes / surgery
Male
Margins of Excision
Retrospective Studies
Urinary Bladder Neoplasms* / drug therapy
Urinary Bladder Neoplasms* / pathology
Urinary Bladder Neoplasms* / surgery