J Urol Oncol > Volume 21(1); 2023 > Article
Kim, Ko, Kim, Kang, Jung, Park, Seo, Kim, Jeong, Kim, Choi, Nam, Ku, Joo, Jang, Yoon, Yun, Hong, and Oh: The Prognostic Impact of Angiolymphatic Invasion in Bladder Urothelial Carcinoma Patients Undergoing Radical Cystectomy
This article has been corrected. See "Declaration of Conflict of Interest for Editorial Board Members’ Articles" in Volume 22 on page 95.

Abstract

Purpose

The aim of this study was to investigate the association between angiolymphatic invasion (ALI) and bladder cancer in patients who underwent radical cystectomy (RC).

Materials and Methods

Multicenter retrospective data from 495 bladder cancer patients who underwent RC between 2007 and 2019 were enrolled in this study. Patients were stratified into 2 groups according to the presence of ALI. The effect of ALI was analyzed by the Kaplan-Meier method and Cox regression hazard models for patients’ cancer-specific survival (CSS), overall survival (OS), and recurrence-free survival (RFS).

Results

The median age of the 495 patients in the study was 65 years, with median and mean follow-up durations of 23.3 months and 37.1 months, respectively. ALI was present in 182 patients (36.8%). ALI was significantly associated with worse RFS as well as CSS and OS (p<0.001, p=0.012, and p=0.01, respectively). Adjusting for significant variables, a multivariate analysis showed that tumor stage (over T2) and ALI were independent predictors for CSS, whereas lymph node (LN) metastasis was not. Meanwhile, the adjusted multivariate analysis showed that tumor stage over T2, ALI, LN metastasis, and positive surgical margin were independent predictors for RFS. Otherwise, tumor grade (over grade 2) was not a significant predictor.

Conclusions

The presence of ALI was an independent predictor influencing both CSS and RFS.

INTRODUCTION

According to a report from the early 2000s, 10,246 cases of primary bladder cancer occurred in Korea from 1998 to 2002. Furthermore, based on the 2021 Korea National Cancer Incidence Database, bladder cancer is the cancer with the 10th highest burden of incidence and mortality in men [1].
Twenty-five percent of patients who are newly diagnosed with bladder cancer have muscle-invasive bladder cancer. The leading treatment for muscle-invasive bladder cancer or refractory high-grade non-muscle-invasive bladder cancer patients is generally radical cystectomy (RC) with extended bilateral lymphadenectomy. With pathological staging, this procedure can provide an exact evaluation of both bladder cancer and the regional lymph nodes (LNs). Several variables have been identified as significantly related to the disease-specific survival of bladder cancer. LN metastasis, in particular, has been considered as a predictor of bladder cancer-related survival [2,3]. Several studies have established variables that can be used to predict an adverse prognosis, such as age, tumor stage and LN density, which are used to calculate the COBRA (Cancer of the Bladder Risk Assessment) score [4]. Along with the prognostic value of factors related to the LNs, lymphovascular invasion and angiolymphatic invasion (ALI) remain a matter of debate. ALI has been identified as a poor prognostic factor for other solid tumors, such as upper urinary tract, prostate, liver, and colorectal cancer [5,6]. Based on the concept that angiolymphatic channels allow the dissemination of invading tumor cells, several articles have reported poor prosnosis for cases of bladder cancer in which RC or even transurethral resection was performed [7]. However, other studies have found ALI not to be significant in comparison to other variables [8] or less significant for urothelial bladder cancer than for squamous cell carcinoma of the bladder [9].
In this study, we aimed to evaluate the prognostic value of ALI in cases of bladder cancer treated with RC.

MATERIALS AND METHODS

1. Study Population

The retrospective, multicenter, full-scale survey study analyzed 495 patients who underwent robot-assisted radical bladder cystectomy between April 2007 and October 2019. The study was approved by the Institutional Review Board of Bundang Seoul National University Hospital (IRB no. 2019AN0102). Of the 495 patients, ALI was present in 182 patients and absent in 313 patients. The exclusion criteria were non-transitional cell carcinoma histology, a history of neoadjuvant therapy, and incomplete data. The surgical technique and the extent of lymphadenectomy (standard, extended, or limited) were decided based on the surgeon's discretion. Regional lymphadenectomy was also performed based on preoperative imaging or an intraoperative examination.

2. Data Collection and Pathologic Evaluation

Clinical and pathological information was also retrospectively obtained from individual medical records from corresponding hospitals for bladder cancer research (a total of 7 medical institutions). Staff pathologists from each institution examined all specimens according to the institutional protocol. The American Joint Committee on Cancer/TNM classification system was used for pathological staging, and the World Health Organization classification was used for pathological staging. The clinicopathologic data included age, sex, comorbidity, tumor stage, tumor grade, surgical margin, presence of ALI, perineural invasion, squamous or glandular metaplasia, and the presence of carcinoma in situ (CIS). ALI was defined as the presence of tumor cells within an arterial, venous, or lymphatic lumen. ALI presence was assessed using routine light microscopic examinations with hematoxylin and eosin staining.

3. Statistical Analyses

Descriptive statistics were calculated to evaluate any potential differences in the demographic data and health status of the subjects.
We divided the patients into ALI and non-ALI groups based on the primary tumor. Differences between these 2 groups were evaluated by the chi-square test for categorical variables and the independent t-test for continuous variables. The Kaplan-Meier method was used to calculate time-dependent outcomes, such as recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) and differences were assessed with the log-rank statistic. Univariate and multivariate survival analyses were performed with a Cox proportional-hazards regression model to evaluate the prognostic significance of the pathological variables. Statistical significance in this study was set at p<0.05. All analyses were performed with IBM SPSS Statistics ver. 22.0 (IBM Co., Armonk, NY, USA).

RESULTS

1. Baseline Characteristics of Patients

The baseline characteristics of all 495 patients in this study are shown in Table 1. Their median age was 65 years, and the median and mean follow-up durations were 23.3 months and 37.1 months, respectively (range, 0-134 months). Most patients were men (418 patients, 84%). ALI was present in 182 patients (36.8%). The baseline characteristics of the ALI-negative group were similar to those of the ALI-positive group (n=313, 63.2%)
Table 1.
Baseline characteristics and perioperative outcomes among 496 patients who underwent radical cystectomy according to angiolymphatic invasion
Characteristic All (n=495) Angiolymphatic invasion p-value
Yes (n=182) No (n=313)
Age (yr) 65.5±10.4 67.3±10.8 64.6±10.1 0.006*
BMI (kg/m2) 24.1±3.1 23.8±3.4 24.3±2.9 0.205
Sex 0.558
   Male 418 (84.4) 148 (81.3) 271 (86.6)
   Female 77 (15.6) 34 (18.7) 42 (13.4)
Smoking 0.913
   Never 259 (52.3) 91 (50.0) 168 (53.7)
   Former 176 (35.6) 65 (35.7) 111 (35.5)
   Current 60 (12.1) 26 (14.3) 34 (10.9)
ASA PS classification 0.006*
   I 154 (31.1) 41 (22.5) 113 (36.1)
   II 306 (61.8) 120 (65.9) 186 (59.4)
   III 35 (7.1) 21 (11.5) 14 (4.5)
Preoperative GFR 75.54 72.77 77.11 0.046*
Hydronephrosis 0.001*
   No 373 (75.4) 119 (65.4) 252 (80.5)
   Yes 122 (24.6) 63 (34.6) 61 (19.5)
DM 113 (22.8) 47 (25.8) 66 (21.1) 0.160
HTN 211 (42.6) 84 (46.2) 127 (40.6) 0.130
Perioperative outcomes
   Operation time (min) 434 424 440 0.236
   Estimated blood loss (mL) 524 527 522 0.913
   Transfusion rate 83 (16.8) 33 (18.1) 50 (16.0) 0.444
   Complications 298 (60.2) 105 (57.7) 193 (61.7) 0.657
      ≥Grade 3 104 (21.0) 32 (17.6) 72 (23.0) 0.210

Values are presented as mean±standard deviation or number (%).

BMI, body mass index; ASA PS, American Society of Anesthesiologists physical status; GFR, glomerular filtration rate; DM, diabetes mellitus; HTN, hypertension.

* p<0.05, statistically significant differences.

The patients with ALI were significantly older (67.3 years vs. 64.6 years, p=0.006), had lower American Society of Anesthesiologists (ASA) physical status classification grades (ASA I: 22.5% vs. 36.1%, p=0.006) and had a higher rate of hydronephrosis (34.6% vs. 19.5%, p=0.001) than the patients without ALI. There were no significant differences in other characteristics, such as body mass index, sex, smoking history, preoperative glomerular filtration rate, or preexisting comorbidities (diabetes mellitus or hypertension) (Table 1).

2. Perioperative and Pathological Outcomes

Among a total of 495 patients who underwent robotic RC, there was no significant difference in average operation time (424 minutes vs. 440 minutes, p=0.236). In estimated blood loss, no significant difference was found (527 vs. 522, p=0.913). The patients with ALI had a higher rate of transfusion (18.1% vs. 16.0%, p=0.444) and a lower complication rate (57.7% vs. 61.7%, p=0.657), but without statistical significance (Table 1).
In terms of the final pathologic outcomes, the presence of ALI was associated with a significantly higher T stage (T3 or T4) and a significantly lower T stage (Ta to T2) (p<0.001). Similar relationships were observed for higher tumor grade, such as grade III (74.6% vs. 50.6%, p<0.001) and higher rates of LN invasion (48.1% vs. 10.4%, p<0.001) in the patients with ALI. The ALI-positive group also showed significantly higher frequencies of perineural invasion (37.6% vs. 8.9%, p<0.001), squamous metaplasia (11.6% vs. 6.6%, p=0.010), and glandular metaplasia (7.7% vs. 2.3%, p=0.001). In contrast, CIS was significantly more common in the ALI-negative group (0.6% vs. 17.0%, p<0.001). No significant difference was found in the percentage of positive surgical margins between the 2 groups (4.4% vs. 2.7%, p=0.185).

3. CSS, OS, and RFS Outcomes

Disease recurrence was observed in 153 patients (30.9%), and 70 patients (14.1%) were dead at the time of final follow-up (except for those lost to follow-up). Recurrence was significantly more common in patients with ALI than in those without ALI (38.5% vs. 26.5%, p<0.001)
The most frequent site of recurrence was the LN, with 47 patients (29.9%), followed by lung (23.6%), bone (17.2%) and liver and neobladder/conduit (12.7%). Other sites of recurrence included the ureter (4.5%) and urethra (3.2%). There was a single incidence of kidney, ureter, and urethra recurrence in the ALI-positive group. LN recurrence was also the most frequent site of recurrence in the ALI-negative group, with 29 patients (34.1%), but in the ALI-positive group, the lung was the most frequent site of recurrence (20 patients, 27.8%). However, no statistically significant differences were observed in recurrence sites between the 2 groups, except for the liver (p=0.017) (Table 2).
Table 2.
Pathological and oncological outcomes according to presence of angiolymphatic invasion among patients who underwent radical cystectomy
Variable All (n=440) Angiolymphatic invasion p-value
Yes (n=181) No (n=259)
Pathological outcomes
   T stage <0.001*
      Ta 10 (2.3) 0 (0) 10 (3.9)
      T1 102 (23.2) 8 (4.4) 94 (36.3)
      T2 128 (29.1) 40 (22.1) 88 (34.0)
      T3 156 (35.5) 101 (55.8) 55 (21.2)
      T4 44 (10.0) 32 (17.7) 12 (4.6)
   Carcinoma in situ 45 (10.2) 1 (0.6) 44 (17.0) <0.001*
   Lymph node invasion 114 (25.9) 87 (48.1) 27 (10.4) <0.001*
   Grade <0.001*
      I 51 (11.6) 4 (2.2) 47 (18.1)
      II 70 (15.9) 16 (8.8) 54 (20.8)
      III 266 (60.5) 135 (74.6) 131 (50.6)
   Positive surgical margin 15 (3.4) 8 (4.4) 7 (2.7) 0.185
   Perineural invasion 91 (20.7) 68 (37.6) 23 (8.9) <0.001*
   Squamous metaplasia 38 (8.6) 21 (11.6) 17 (6.6) 0.010*
Oncological outcomes All (n=495) Yes (n=182) No (n=313)
   Recurrence 153 (30.9) 70 (38.5) 83 (26.5) <0.001*
   Recurrence site
      Neobladder/conduit 20 (12.7) 6 (8.3) 14 (16.5) 0.158
      Lymph node 47 (29.9) 18 (25.0) 29 (34.1) 0.293
      Lung 37 (23.6) 20 (27.8) 17 (20.0) 0.181
      Bone 27 (17.2) 14 (19.4) 13 (15.3) 0.427
      Liver 20 (12.7) 4 (5.6) 16 (18.8) 0.017*
      Other 63 (40.1) 30 (41.7) 33 (38.8) 0.524
   Cancer-specific mortality 39 (7.9) 19 (10.4) 20 (6.4) 0.012*
   Overall mortality 70 (14.1) 31 (17.0) 39 (12.5) 0.010*

Values are presented as number (%).

* p<0.05, statistically significant differences.

Of the 70 dead patients (14.1%), cancer-specific death was recorded in 39 patients. ALI was significantly related to lower RFS, CSS, and OS (p<0.001, p=0.012, and p=0.01, respectively).
The ALI-negative patients showed higher 5-year and 10-year OS, CSS, and RFS. The exact percentages are given in Fig. 1. The mean OS was 95.7 months in the ALI-positive group versus 109.3 months in the ALI-negative group, the mean CSS was 108.7 months in the ALI-positive group versus 120.3 months in the ALI-negative group, and the mean RFS was 65.9 months in the ALI-positive group versus 89.1 months in the ALI-negative group (Fig. 1).
Fig. 1.
Oncological outcomes (OS, CSS, and RFS) according to presence of angiolymphatic invasion among patients who underwent radical cystectomy. OS, overall survival; ALI, angiolymphatic invasion; RFS, recurrence-free survival; CSS, cancer-specific survival.
juo-21-1-79f1.jpg
Multivariate and univariate Cox proportional hazard models to predict bladder cancer recurrence and survival among all 495 patients in the study are shown in Table 3, with all variables calculated in the analysis. Tumor stage (over T2), ALI, and LN metastasis were all associated with bladder cancer-specific death in the univariate analysis. Adjusting for those significant variables, the multivariate analysis showed that tumor stage (over T2) and ALI were independent predictors of CSS (hazard ratio [HR], 1.632; 95% confidence interval [CI], 1.035-2.571, p=0.035; HR, 2.396; 95% CI, 1.256-4.571, p=0.008, respectively), while LN metastasis was not (p=0.209) (Table 3).
Table 3.
Uni- and multivariate Cox proportional hazard analysis among patients who underwent radical cystectomy for cancer-specific survival
Variable Univariate analysis Multivariate analysis
HR 95% CI p-value HR 95% CI p-value
Age 1.026 0.993-1.060 0.121 - - -
Sex, female vs. male 0.899 0.376-2.149 0.811 - - -
Body mass index 0.907 0.817-1.007 0.067 - - -
Tumor stage, ≥T2 or not 2.398 1.099-5.232 0.028* 1.632 1.035-2.571 0.035*
Tumor grade, ≥2 or not 1.652 0.638-4.276 0.301 - - -
CIS+ 0.962 0.340-2.720 0.942 - - -
Angiolymphatic invasion 2.253 1.191-4.260 0.012* 2.396 1.256-4.571 0.008*
LN+ 2.414 1.238-4.703 0.010* 1.647 0.757-3.583 0.209
Positive surgical margin 1.530 0.208-11.241 0.676 - - -
Preoperative GFR 0.997 0.983-1.011 0.639 - - -
Presence of preoperative DM 1.529 0.760-3.076 0.234 - - -
Presence of preoperative HTN 0.723 0.371-1.408 0.340 - - -
History of smoking 1.702 0.899-3.223 0.103 - - -

HR, hazard ratio; CI, confidence interval; CIS, carcinoma in situ; LN, lymph node; GFR, glomerular filtration rate; DM, diabetes mellitus; HTN, hypertension.

* p<0.05, statistically significant differences.

For RFS, tumor stage (over T2), tumor grade (over grade 2), ALI, LN metastasis, and a positive surgical margin showed significant associations in the univariate analysis. The adjusted multivariate analysis showed that tumor stage over T2, ALI, LN metastasis, and positive surgical margin were independent predictors of RFS. Tumor grade (over grade 2) was not a significant predictor (Table 4).
Table 4.
Uni- and multivariate Cox proportional hazard analysis among patients who underwent radical cystectomy for recurrence-free survival
Variable Univariate analysis Multivariate analysis
HR 95% CI p-value HR 95% CI p-value
Age 1.006 0.991-1.021 0.450 - - -
Sex, female vs. male 0.749 0.497-1.128 0.167 - - -
Body mass index 0.982 0.932-1.034 0.485 - - -
Tumor stage, ≥T2 or not 2.713 1.817-4.049 <0.001* 1.938 1.209-3.107 0.006*
Tumor grade, ≥2 or not 1.700 1.030-2.805 0.038* 1.087 0.580-2.037 0.794
CIS+ 0.780 0.442-1.378 0.393 - - -
Angiolymphatic invasion 1.875 1.361-2.582 <0.001* 1.717 1.071-2.753 0.025*
LN+ 2.702 1.939-3.765 <0.001* 1.837 1.254-2.692 0.002*
Positive surgical margin 2.910 1.425-5.943 0.003* 4.090 1.831-9.137 0.001*
Preoperative GFR 0.998 0.991-1.005 0.565 - - -
Presence of preoperative DM 1.003 0.682-1.475 0.988 - - -
Presence of preoperative HTN 0.805 0.579-1.118 0.195 - - -
History of smoking 1.074 0.782-1.474 0.660 - - -

HR, hazard ratio; CI, confidence interval; CIS, carcinoma in situ; LN, lymph node; GFR, glomerular filtration rate; DM, diabetes mellitus; HTN, hypertension.

* p<0.05, statistically significant differences.

DISCUSSION

Identifying prognostic factors associated with the survival and recurrence of bladder cancer is crucial for selecting among treatment options. Several guidelines include pathological stage, LN metastases, and tumor size as prognostic factors for survival and recurrence. However, the prognostic value of ALI for bladder cancer patients who have undergone RC remains a matter of debate. Some studies have shown that this pathological property was associated with worse survival outcomes [10-14], while others have reported discordant findings [8, 15-18]. A subgroup analysis showed that ALI was not correlated with lower RFS in Asian populations [19]. Canter et al. [20] demonstrated that ALI showed significance only in pT3 patients based on univariate analysis of OS, CSS, and RFS. In the multivariate analysis, ALI was also a significant predictor for worse OS and disease-specific survival (p<0.01 and p=0.007, respectively), but not for RFS (p=0.1). According to a multi-institutional retrospective study conducted by Lotan et al. [21], ALI showed significance for predicting survival and recurrence, specifically for LN-negative patients. They also reported that the prevalence of ALI was 9% in pT1 and 78% in pT4 disease. Our study also showed similar results for the prevalence of ALI (7.8% in pT1, 72.7% in pT4). Regarding the N stage, 72% of LN-positive patients had ALI, while only 26% of LN-negative patients had ALI. Similarly, our study showed that 76% of LN-positive patients were ALI-positive.
We retrospectively analyzed a multi-institutional database of patients who underwent RC to evaluate the influence of ALI on tumor survival and recurrence. ALI showed significant associations with poor OS, CSS, and RFS. The 5-year OS was 82.7% in patients without ALI and 75.7% in patients with ALI. The 10-year OS was 65.0% in patients without ALI and 58.9% in those with ALI. This aligns with other studies that reported lower 5-year or 10-year OS or CSS in patients with ALI [8,14]. Furthermore, in line with previous reports [19,21], ALI was pathologically found in 36% of specimens.
A multivariate analysis was also done to clarify whether ALI can serve as an independent prognostic factor for recurrence and survival. In our analysis, ALI was an independent predictor for both RFS and CSS in univariate analysis (p=0.025 and p=0.008, respectively). Other factors, such as tumor stage and LN metastasis, were also related to both RFS and CSS, and tumor grade and a positive surgical margin were also related to RFS in the univariate analysis. In the multivariate analysis, higher T stage, LN metastasis, ALI, and a positive surgical margin were significant factors associated with recurrence, while only higher T stage and ALI were significant factors associated with CSS. Bassi et al. [22] reported that tumor stage and LN metastasis (but not ALI) were valuable factors for predicting survival through a multivariate analysis. In contrast, Canter et al. [20] demonstrated that ALI-positive patients showed lower OS, CSS, and RFS in the univariate analysis (p<0.001), and only OS and CSS showed significance in the multivariate analysis (p<0.01 and p=0.007, respectively). As shown by the above summary, several studies have reported different findings for independent predictors of survival and recurrence depending on the analysis type.
In our study, ALI-positive patients had a tendency for recurrence in the LNs, followed by the lung, neobladder/conduit, bone, and liver. This pattern of recurrence or progression was previously shown by Elsayed et al. [23], where metastasis occurred most frequently in the LNs (5%) and lung (6%). However, given the limited number of studies on the relationship between ALI and the progression or recurrence site, further study would help analyze the relevance of ALI for local and distal recurrence patterns.
Several previous studies of patients with other urological cancers, such as penile and prostate cancer, have established a relationship between ALI in LN-positive patients and a poorer prognostic outcome [5]. As ALI is theoretically related to both the lymphatic and vascular systems, this pathological property can be strongly associated with cancer cell spread [24]. Based on this characteristic of ALI as an important prognostic factor, the TNM staging for some cancers includes ALI. This may facilitate more precise cancer staging and improved decision-making by physicians. There has also been some debate about including ALI in the TNM staging of bladder cancer, based on studies that showed ALI to have prognostic value for worse progression-free survival and OS in RC patients (pooled HRs of 1.57 and 1.59, respectively) [25,26]. However, due to the difficulty of assessing ALI at a morphological level and the rare clinical use of immunohistochemical markers that enable differentiating lymphatic and vascular invasion at the pathological level, ALI is not yet appropriate for inclusion into the TNM staging system [27,28].
This study has several limitations. First, as a retrospective study, there is a risk of inherent bias. As this was a multicenter study, the pathological reports from each center for ALI may have been different or the criteria of ALI may have changed during the 12-year follow-up period. It is important to propose absolute morphological criteria to define ALI as vascular invasion or lymphatic invasion or combined in a standardized manner.
Our study also did not assess the extent of pelvic LN dissection, which may have generated bias; however, previous reports have shown no difference in RFS, CSS, or OS between extended and limited PLND [29]. However, these results remain uncertain. Even though extended LND is considered a standard procedure for RC, differences in the extent of PLND might affect the outcomes. The bias incurred by this limitation may have influenced our results for the relationship between LN metastasis and CSS. Fewer than 10 nodes were dissected in 101 out of 440 cases, corresponding to the lowest nodal yield for determining surgical quality. This result demonstrates that an inappropriate PLND extent and deficiency of the nodal yield might have influenced the results, as a bias incurring a higher likelihood for false negatives. Additional information will be needed on how to define the range of PLND.
Finally, since therapeutic options have changed rapidly since the 2000s, our study's long follow-up may not have accurate implications for newly diagnosed patients. The follow-up period of this study marks a transition from the beginning to the middle of robotic surgery. The learning curve for surgery might have biased the outcomes. Regarding this limitation, future large-scale randomized prospective trials with stringent criteria will provide insights into the effects of ALI on patients’ prognoses.

CONCLUSIONS

In conclusion, the presence of ALI in bladder cancer patients who underwent RC was associated with significantly worse outcomes both in terms of survival and recurrence.
Furthermore, along with a high T stage, the presence of ALI was an independent predictor influencing both CSS and RFS. Future prospective studies should be performed to further validate our results.

NOTES

Conflicts of Interest

The authors have nothing to disclose.

Funding/Support

This work was supported by Grant No. 02-2021-0031 from the Seoul National University Bundang Hospital (SNUBH) Research Fund.

Author Contribution

Conceptualization: JHK, JJO; Data curation: JHK, YHK, JWK, SHK, SIJ, JSP, HKS, HJK, BCJ, THK, SYC, JKN, JYK, KJJ, WSJ, YEY, SJY, SHH, JJO; Formal analysis: JHK, JJO; Methodology: JHK; Project administration: JHK, JJO; Visualization: JHK; Writing - original draft: JHK, JJO; Writing - review & editing: JHK, JJO.

REFERENCES

1.Jung KW, Won YJ, Hong S, Kong HJ, Im JS, Seo HG. Prediction of cancer incidence and mortality in Korea, 2021. Cancer Res Treat 2021;53:316-22.
crossref pmid pmc pdf
2.May M, Herrmann E, Bolenz C, Tiemann A, Brookman-May S, Fritsche HM, et al. Lymph node density affects cancer-specific survival in patients with lymph node-positive urothelial bladder cancer following radical cystectomy. Eur Urol 2011;59:712-8.
crossref pmid
3.Stein JP, Cai J, Groshen S, Skinner DG. Risk factors for patients with pelvic lymph node metastases following radical cystectomy with en bloc pelvic lymphadenectomy: concept of lymph node density. J Urol 2003;170:35-41.
pmid
4.Colomer Gallardo A, Candela L, Buisan Rueda O, Freixa Sala R, Elias Cañavera J, Moschini M, et al. The Cancer of the Bladder Risk Assessment (COBRA) score accurately predicts cancer-specific survival after radical cystectomy: external validation and lymphovascular invasion assessment value to improve its performance. Clin Genitourin Cancer 2022;20:199-209.
crossref pmid
5.Ku JH, Byun SS, Jeong H, Kwak C, Kim HH, Lee SE. Lymphovascular invasion as a prognostic factor in the upper urinary tract urothelial carcinoma: a systematic review and meta-analysis. Eur J Cancer 2013;49:2665-80.
crossref pmid
6.Lee HY, Li CC, Huang CN, Ke HL, Li WM, Liang PI, et al. Prognostic significance of lymphovascular invasion in upper urinary tract urothelial carcinoma is influenced by tumor location. Ann Surg Oncol 2015;22:1392-400.
crossref pmid pdf
7.Yoneda K, Kamiya N, Utsumi T, Wakai K, Oka R, Endo T, et al. Impact of lymphovascular invasion on prognosis in the patients with bladder cancer-comparison of transurethral resection and radical cystectomy. Diagnostics (Basel) 2021;11:244.
crossref pmid pmc
8.Manoharan M, Katkoori D, Kishore TA, Jorda M, Luongo T, Soloway MS. Lymphovascular invasion in radical cystectomy specimen: is it an independent prognostic factor in patients without lymph node metastases? World J Urol 2010;28:233-7.
crossref pmid pdf
9.Spradling K, Lotan Y, Shokeir A, Abol-Enein H, Mosbah A, Morgan JB, et al. Lymphovascular invasion is associated with oncologic outcomes following radical cystectomy for squamous cell carcinoma of the urinary bladder. Urol Oncol 2016;34:417.e1-8.
crossref pmid
10.Leissner J, Koeppen C, Wolf HK. Prognostic significance of vascular and perineural invasion in urothelial bladder cancer treated with radical cystectomy. J Urol 2003;169:955-60.
crossref pmid
11.Lopez JI, Angulo JC. The prognostic significance of vascular invasion in stage T1 bladder cancer. Histopathology 1995;27:27-33.
crossref pmid
12.Fosså SD, Reitan JB, Ous S, Odegaard A, Loeb M. Prediction of tumour progression in superficial bladder carcinoma. Eur Urol 1985;11:1-5.
crossref pmid
13.Herrmann E, Stöter E, van Ophoven A, Bierer S, Bolenz C, Hertle L, et al. The prognostic impact of pelvic lymph node metastasis and lymphovascular invasion on bladder cancer. Int J Urol 2008;15:607-11.
crossref pmid
14.Quek ML, Stein JP, Nichols PW, Cai J, Miranda G, Groshen S, et al. Prognostic significance of lymphovascular invasion of bladder cancer treated with radical cystectomy. J Urol 2005;174:103-6.
crossref pmid
15.Cheng L, Neumann RM, Scherer BG, Weaver AL, Leibovich BC, Nehra A, et al. Tumor size predicts the survival of patients with pathologic stage T2 bladder carcinoma: a critical evaluation of the depth of muscle invasion. Cancer 1999;85:2638-47.
crossref pmid
16.Wishnow KI, Levinson AK, Johnson DE, Tenney DM, Grignon DJ, Ro JY, et al. Stage B (P2/3A/N0) transitional cell carcinoma of bladder highly curable by radical cystectomy. Urology 1992;39:12-6.
crossref pmid
17.Boileau MA, Johnson DE, Chan RC, Gonzales MO. Bladder carcinoma: results with preoperative radiation therapy and radical cystectomy. Urology 1980;16:569-76.
crossref pmid
18.Bell JT, Burney SW, Friedell GH. Blood vessel invasion in human bladder cancer. J Urol 1971;105:675-8.
crossref pmid
19.Kim H, Kim M, Kwak C, Kim HH, Ku JH. Prognostic significance of lymphovascular invasion in radical cystectomy on patients with bladder cancer: a systematic review and meta-analysis. PLoS One 2014;9:e89259.
crossref pmid pmc
20.Canter D, Guzzo T, Resnick M, Magerfleisch L, Sonnad S, Bergey M, et al. The presence of lymphovascular invasion in radical cystectomy specimens from patients with urothelial carcinoma portends a poor clinical prognosis. BJU Int 2008;102:952-7.
crossref pmid
21.Lotan Y, Gupta A, Shariat SF, Palapattu GS, Vazina A, Karakiewicz PI, et al. Lymphovascular invasion is independently associated with overall survival, cause-specific survival, and local and distant recurrence in patients with negative lymph nodes at radical cystectomy. J Clin Oncol 2005;23:6533-9.
crossref pmid
22.Bassi P, Ferrante GD, Piazza N, Spinadin R, Carando R, Pappagallo G, et al. Prognostic factors of outcome after radical cystectomy for bladder cancer: a retrospective study of a homogeneous patient cohort. J Urol 1999;161:1494-7.
crossref pmid
23.Elsayed AS, Gibson S, Jing Z, Wijburg C, Wagner AA, Mottrie A, et al. Rates and patterns of recurrences and survival outcomes after robot-assisted radical cystectomy: results from the international robotic cystectomy consortium. J Urol 2021;205:407-13.
crossref pmid
24.Pepper MS. Lymphangiogenesis and tumor metastasis: myth or reality? Clin Cancer Res 2001;7:462-8.
pmid
25.Mari A, Kimura S, Foerster B, Abufaraj M, D'Andrea D, Gust KM, et al. A systematic review and meta-analysis of lymphovascular invasion in patients treated with radical cystectomy for bladder cancer. Urol Oncol 2018;36:293-305.
crossref pmid
26.Kikuchi E, Margulis V, Karakiewicz PI, Roscigno M, Mikami S, Lotan Y, et al. Lymphovascular invasion predicts clinical outcomes in patients with node-negative upper tract urothelial carcinoma. J Clin Oncol 2009;27:612-8.
crossref pmid pmc
27.Verhoest G, Shariat SF, Chromecki TF, Raman JD, Margulis V, Novara G, et al. Predictive factors of recurrence and survival of upper tract urothelial carcinomas. World J Urol 2011;29:495-501.
crossref pmid pmc pdf
28.Godfrey MS, Badalato GM, Hruby GW, Razmjoo M, McKiernan JM. Prognostic indicators for upper tract urothelial carcinoma after radical nephroureterectomy: the impact of lymphovascular invasion. BJU Int 2012;110:798-803.
crossref pmid
29.Gschwend JE, Heck MM, Lehmann J, Rübben H, Albers P, Wolff JM, et al. Extended versus limited lymph node dissection in bladder cancer patients undergoing radical cystectomy: survival results from a prospective, randomized trial. Eur Urol 2019;75:604-11.
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ORCID iDs

Jin Hyuck Kim
https://orcid.org/0000-0002-8702-7008

Young Hwii Ko
https://orcid.org/0000-0002-9150-4292

Jong Wook Kim
https://orcid.org/0000-0003-2228-0640

Seok Ho Kang
https://orcid.org/0000-0002-1524-5233

Seung Il Jung
https://orcid.org/0000-0002-7166-8732

Jin Sung Park
https://orcid.org/0000-0001-6158-3359

Ho Kyung Seo
https://orcid.org/0000-0003-2601-1093

Hyung Joon Kim
https://orcid.org/0000-0003-3975-3045

Byong Chang Jeong
https://orcid.org/0000-0002-5399-2184

Tae-Hwan Kim
https://orcid.org/0000-0003-4924-4826

Se Young Choi
https://orcid.org/0000-0002-4615-0966

Jong Kil Nam
https://orcid.org/0000-0002-3424-2417

Ja Yoon Ku
https://orcid.org/0000-0003-3460-9386

Kwan Joong Joo
https://orcid.org/0000-0003-2352-4387

Won Sik Jang
https://orcid.org/0000-0002-9082-0381

Young Eun Yoon
https://orcid.org/0000-0001-8059-6649

Seok Joong Yun
https://orcid.org/0000-0001-7737-4746

Sung-Hoo Hong
https://orcid.org/0000-0002-1952-4010

Jong Jin Oh
https://orcid.org/0000-0003-0448-5992

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