EURURO Vol. 71 No. 4

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assume this will be addressed pre-operatively. However
there are no specific guidelines on how this is best achieved.
Recent reports have highlighted concerns regarding worse
oncological outcomes if patients are transfused peri-
operatively, as well as higher complication rates, risk of
transfusion reactions and the cost of blood products,
making avoidance of transfusion desirable .
Regarding muscle-invasive bladder cancer, there are
many opportunities to consider anaemia ‘‘upstream’’ of the
blood loss encountered at cystectomy. Patients at presen-
tation are often bleeding and anaemic before undergoing
and following trans-urethral resection of bladder tumour
(TURBT). The haemoglobin drop associated with TURBT has
been reported to be between 0.6–0.8 g/dl Patients may
then go onto have neo-adjuvant chemotherapy, also
contributing to anaemia in this population.
As highlighted by Frosessler et al, optimisation of
haemoglobin peri-operatively may influence patient recov-
ery. Should we restore haemoglobin levels post cystec-
tomy? How is this best achieved, as oral iron may not be
tolerated in patients whose bowels are still recovering after
reconstruction?
Given the promising results of this study and the drive to
reduce ABTs in cystectomy patients intravenous iron
administered in the peri-operative phase would appear to
warrant more investigation in the cystectomy population.
The results of the large scale (n = 500) PREVENTT random-
ised control trial, investigating the outcomes of pre-
operative intravenous iron therapy to treat anaemia in
major abdominal surgery , will be of great use to this
patient population.
Conflicts of interest: The authors have nothing to disclose.
References
[1] [44_TD$DIFF]
[46_TD$DIFF] [46_TD$DIFF] [47_TD$DIFF]
[3_TD$DIFF] .
[2] Xia L[50_TD$DIFF], Guzzo TJ. Preoperative [51_TD$DIFF]anemia and [52_TD$DIFF]low [53_TD$DIFF]hemoglobin [54_TD$DIFF]level [55_TD$DIFF]are
[57_TD$DIFF]associated [57_TD$DIFF]with [58_TD$DIFF]worse [59_TD$DIFF]clinical [60_TD$DIFF]outcomes in [61_TD$DIFF]patients [57_TD$DIFF]with [62_TD$DIFF]bladder
[64_TD$DIFF]cancer [64_TD$DIFF]undergoing [65_TD$DIFF]radical [66_TD$DIFF]cystectomy: [47_TD$DIFF]a [67_TD$DIFF]meta-[68_TD$DIFF]analysis. [69_TD$DIFF]Clin
[71_TD$DIFF]Genitourin Cancer[71_TD$DIFF]. [72_TD$DIFF]In [73_TD$DIFF]press. [74_TD$DIFF]
.
[3]
[68_TD$DIFF]
[4_TD$DIFF] .
[4]
[3_TD$DIFF]
[5]
.
Matthew J. Young, Aidan P. Noon*
Department of Urology, Royal Hallamshire Hospital,
Sheffield Teaching Hospitals[20_TD$DIFF], Sheffield, UK
*Corresponding author. Department of Urology, Royal Hallamshire
Hospital, Sheffield Teaching Hospitals, Glossop Road, Sheffield,
South Yorkshire, S10 2JF, UK.
E-mail address: (A.P. Noon).
# 2016 European Association of Urology.
Published by Elsevier B.V. All rights reserved.
Re: Detection of Micrometastases by Flow Cytometry
in Sentinel Lymph Nodes from Patients with Renal
Tumours
Hartana CA, Kinn J, Rosenblatt R, et al
Br J Cancer 2016;115:957–66
Experts’ summary:
Hartana et al [1] analysed isolated tumour cells (ITCs) and
micrometastases in lymph nodes (LNs) that receive direct
drainage from renal tumours. After sentinel nodes were har-
vested at surgery, half of each LN was processed for flow
cytometry. The single-cell suspensions obtained were stained
for cytokeratin 18, carbonic anhydrase IX, and cadherin 6. Of
five patients with pT2–3a tumours with pN0 according to
haematoxylin and eosin staining of the paired LN half, four
were restaged as pN1 according to the percentage of tumour
cells in flow cytometry analysis of LN suspensions that met the
volume definition of nodal micrometastasis of the Interna-
tional Union Against Cancer (UICC).
Experts’ comments:
Amajor limitation of this study is the processing of LN halves. It
cannot be excluded that the halves subjected to flow cytometry
may have contained micrometastases according to the UICC
definition (cluster of 0.2–2 mm) that may have been diagnosed
at microscopy. Conversely, the UICC regards clusters below this
cutoff as ITCs. Although the authors demonstrate that the ratio
of tumour cells to the total number of cells at flow cytometry
corresponds to the volume of nodal micrometastases, the
counts may represent multiple spatially distributed ITCs with-
out the potential to develop metastasis. Data from breast
cancer sentinel node studies suggest that patients with ITCs
in their sentinel nodes had lower recurrence rates and longer
overall survival (OS) compared to those with nodal microme-
tastases [2] . The method reported by Hartana et al would result
in significant nodal upstaging of renal tumours [1] . Implications
for recurrence and OS are currently unknown. A randomised
trial of nephrectomy with and without LN dissection reported
no significant differences in OS, time-to-progression, or local
recurrence between the arms [3]. Assuming that LN dissection
removes nodal micrometastasis and ITCs, the historic results of
this trial suggest that the high incidence of tumour cells at flow
cytometry may have no clinical impact. Nevertheless, the
method described by Hartana et al warrants further investiga-
tion in contemporary patient cohorts. Apparently, shedding of
tumour cells into the lymphatic system is a common event for
renal tumours. This may have implications for improved prog-
nosis assessment and may allow us to investigate and modu-
late immune effector dysfunctions that may be associated with
early metastasis, as has been suggested for other tumours
[4]. Understanding these mechanisms is important in view
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