根治性膀胱切除术中需清扫盆腔淋巴结最小数量的探讨

The minimum number of lymph nodes needed to be resected during radical cystectomy

目的 探讨膀胱癌患者行根治性膀胱切除术中,为获得最佳病理分期所需送检的最小淋巴结数量.方法 2008年1月至2015年1月行扩大盆腔淋巴结清扫＋全膀胱切除术且具备完整病理资料的膀胱癌患者197例,其中53例（26.9％）病理检查发现淋巴结阳性,男47例,女6例.年龄36～87岁,平均（63.9±11.1）岁.按解剖部位将盆腔淋巴结分为10区6组进行盆腔淋巴结清扫术：髂外组、闭孔组、髂内组、髂总组,每组左、右侧各为一个区域;骶前组为一个区域;肠系膜下动脉起始部以下、腹主动脉及腔静脉远端周围的腹膜后组为一个区域.分析膀胱切除标本中,各组区域清除的淋巴结数量、转移淋巴结（阳性淋巴结）数量,淋巴结转移率、淋巴结密度（lymph nodes density,LND）等.根据有淋巴结转移病例的LND,计算获得最佳病理分期所需最小清除淋巴结数量为1/LND.随访197例的肿瘤复发及生存情况.结果 本研究197例手术共清扫出淋巴结5 813枚,每例检出淋巴结数量平均为（29.4±11.9）枚.53例淋巴结阳性患者共清扫出淋巴结1 528枚,其中244枚为阳性（16.0％）,每例检出阳性淋巴结数量平均为（4.7±3.9）枚.各组区域清扫出的淋巴结百分率分别为髂内组23.8％（363/1 528）,闭孔组19.4％（296/1 528）,腹膜后组17.3％ （264/1 528）,髂总组16.4％（251/1 528）,髂外组16.0％（245/1 528）和骶前组7.1％ （109/1 528）;阳性淋巴结百分率分别为闭孔组27.5％ （67/244）,髂外组20.9％（51/244）,髂内组20.5％（50/244）,髂总组20.1％（49/244）,腹膜后组8.2％（20/244）和骶前组2.9％（7/244）.联合LND和UICC膀胱肿瘤（TNM分期）进行分析,N1、N2和N3分期需提供病理检查的最少淋巴结数量分别约为18（1/0.056）、11（1/0.195×2）和5（1/0.211）枚;M1分期为4（1/0.251）枚.平均真骨盆内淋巴引流区域和髂总区域分别提供18枚（至少11枚）和5枚淋巴结可获得N分期;远处区域（腹膜后）提供4枚淋巴结可获M1分期.129例获得随访,平均37.7个月,肿瘤复发33例（25.6％）,总生存率为87.6％ （113/129）.结论 在根治性膀胱切除标本中,要获得最佳的N和M分期分别需要清除20枚和27枚淋巴结.

Objective To evaluate the minimum number of lymph nodes （LN）required for optimal staging at radical cystectomy specimens analysis from patients with bladder cancer and to analyze the frequency of LN metastases among different anatomic regions.Methods From Jan.2008 to Jan.2015,a total of 197 patients underwent super-extended pelvic lymph nodes dissection were recruited,and their clinical data were reviewed,icluding 53cases（47male and 3 female patients） with positive LN.The superextended pelvic lymph nodes dissection were divided into 10 regions as well as 6 groups according to the anatomic sites,including the external iliac,internal iliac,obturator and bilateral common lilac lymph nodes,the presacral lymph nodes and above the aortic bifurcation lymph nodes.Particular attention was paid to the total number of LN examined,the number and location of LN with metastases （positive LN）,lymph node metastasis rate and lymph nodes density in the cystectomy specimen.According to the lymph node density （LND） of lymph node metastasis cases,minimum removal of lymph node number is 1/LND.The recurrence and survival was followed up.Results A total of 197 radical cystectomies with 8 513 LN were reviewed,including 53 （26.9 %） LNs positive cases,with 244 positive LN out of the 1 528 LNs （16.0%）.The average number of LN examined in each case was 29.4 ± 11.9,and the average number of positive LNs identified in each case was 4.7 ± 3.9.Among all of the LNs,the internal iliac/obturator LN were the most commonly submitted （23.8%/19.7%） and the external iliac /obturator LN were the highest number of positive LNs （20.9%/27.5%）.On average,for cases staged N1 and N2,there was one positive LN per 18 （1/0.056）and 11 （1/0.195 × 2）LN examined from the primary drainage LN,respectively.For N3 cases,one out of 5 （1/0.211）secondary drainage LN was found to be positive.Similarly,one out of 4（1/0.251） distant LN was found to be positive in cases with M1 staging.On average,23 LN（at least 16LN） including 18 （at least 11） primary drainage LN and five secondary drainage LN should be submitted for optimal N staging.For adequate M1 staging,an average of four distal LN should be evaluated.One hundred and twenty-nine cases were followed up for an average of 37.7 months,with tumor recurrence was 33 eases （25.6%）,overall survival 87.6% （113/129）.Conclusion A minimum of 20 and 27 LNs should be examined in radical cystectomy specimens in order to achieve accurate N and M staging.