Log Odds of Positive Lymph Nodes (LODDS) as an Independent Predictor of Overall Survival Following Radical Cystectomy in Urothelial Bladder Cancer: Time to Rethink Conventional Node Staging

Published:December 06, 2022DOI:



      Radical cystectomy (RC) with lymph node dissection is the mainstay of treatment for patients with muscle-invasive bladder cancer (MIBC) and high risk non-MIBC. The American Joint Committee on Cancer's (AJCC) node staging and lymph node ratio (LNR) systems are used in estimating prognosis; however, they do not directly factor in negative dissected nodes. In this study, we evaluated the log odds of positive lymph nodes (LODDS), a novel measure of nodal involvement, as a predictor of survival.

      Patients and methods

      Eighty-three patients who underwent RC were retrospectively included and their demographic and clinical data were collected. Kaplan-Meier curve and Cox regression were used for survival analyses.


      Median number of dissected lymph nodes was 13 (range 3-45). ROC curve analysis indicated −0.92 as the optimal LODDS cutoff. LODDS > −0.92 was associated with higher T stage, lymphovascular invasion, and significantly worse overall survival (OS) (mean OS 18.6 vs. 45.1 months, P-value < .001). Furthermore, we evaluated AJCC node staging, LNR, and LODDS in three separate multivariable Cox regression models. Among 3 different measures of nodal disease burden, only LODDS was an independent predictor of OS (HR 2.71, 95% CI 1.28-5.73, P = .009).


      Our results show that LODDS is an independent predictor of OS and outperforms AJCC node staging and LNR in forecasting prognosis among patients with urothelial bladder cancer who undergo RC.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Clinical Genitourinary Cancer
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bray F
        • Ferlay J
        • Soerjomataram I
        • Siegel RL
        • Torre LA
        • Jemal A.
        Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.
        Cancer J Clin. 2018; 68: 394-424
        • Ebrahimi H
        • Amini E
        • Pishgar F
        • et al.
        Global, Regional and National Burden of Bladder Cancer, 1990 to 2016: results from the GBD Study 2016.
        J Urol. 2019; 201: 893-901
        • Quek ML
        • Sanderson KM
        • Daneshmand S
        • Stein JP.
        The importance of an extended lymphadenectomy in the management of high-grade invasive bladder cancer.
        Expert Rev Anticancer Ther. 2004; 4: 1007-1016
        • Samani RE
        • Shirkhoda M
        • Hadji M
        • et al.
        The prognostic value of lymph node ratio in survival of head-and-neck squamous cell carcinoma.
        J Res Med Sci. 2018; : 23:35
        • Stein JP
        • Lieskovsky G
        • Cote R
        • et al.
        Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1,054 patients.
        J Clin Oncol. 2001; 19: 666-675
        • Amin MB
        • Edge SB.
        AJCC cancer staging manual.
        springer, 2017
        • Vinh-Hung V
        • Verschraegen C
        • Promish DI
        • et al.
        Ratios of involved nodes in early breast cancer.
        Breast Cancer Res. 2004; 6: R680-R688
        • Jin S
        • Wang J
        • Shen Y
        • et al.
        Comparison of different lymph node staging schemes in prostate cancer patients with lymph node metastasis.
        Int Urol Nephrol. 2020; 52: 87-95
        • Zhou W
        • Huang C
        • Yuan N.
        Prognostic nomograms based on log odds of positive lymph nodes for patients with renal cell carcinoma: a retrospective cohort study.
        Int J Surg. 2018; 60: 28-40
        • Persiani R
        • Cananzi FC
        • Biondi A
        • et al.
        Log odds of positive lymph nodes in colon cancer: a meaningful ratio-based lymph node classification system.
        World J Surg. 2012; 36: 667-674
        • Kouka M
        • Al-Ahmar E
        • Büntzel J
        • et al.
        The log odds of positive neck lymph nodes is a superior lymph node predictor for overall survival in head and neck cancer: a population-based analysis in Germany.
        Eur Arch Otorhinolaryngol. 2021; 279: 3587-3595
        • Wen J
        • Ye F
        • He X
        • et al.
        Development and validation of a prognostic nomogram based on the log odds of positive lymph nodes (LODDS) for breast cancer.
        Oncotarget. 2016; 7: 21046
        • Bao X
        • Chen F
        • Qiu Y
        • Shi B
        • Lin L
        • He B.
        Log odds of positive lymph nodes is not superior to the number of positive lymph nodes in predicting overall survival in patients with oral squamous cell carcinomas.
        J Oral Maxillofac Surg. 2020; 78: 305-312
        • Gu P
        • Deng J
        • Sun Z
        • et al.
        Superiority of log odds of positive lymph nodes (LODDS) for prognostic prediction after gastric cancer surgery: a multi-institutional analysis of 7620 patients in China.
        Surg Today. 2021; 51: 101-110
        • Batra A
        • Kong S
        • Hannouf MB
        • Cheung WY.
        A population-based study to evaluate the associations of nodal stage, lymph node ratio and log odds of positive lymph nodes with survival in patients with small bowel adenocarcinoma.
        Curr Oncol. 2022; 29: 1298-1308
        • Huang B
        • Chen C
        • Ni M
        • Mo S
        • Cai G
        • Cai S.
        Log odds of positive lymph nodes is a superior prognostic indicator in stage III rectal cancer patients: a retrospective analysis of 17,632 patients in the SEER database.
        Int J Surg. 2016; 32: 24-30
        • Iyer V
        • Kumar K
        • Hallikeri K
        • Desai AK
        • Kumar N
        • Natarajan S.
        Log odds of positive lymph nodes as an independent predictor of overall survival in oral squamous cell carcinoma.
        J Oral Maxillofac Pathol. 2020; 24: 576
        • Li Y
        • Wu G
        • Zhang Y
        • et al.
        Log odds of positive lymph nodes as a novel prognostic predictor for colorectal cancer: a systematic review and meta-analysis.
        BMC Cancer. 2022; 22: 290
        • Ye G
        • Chen Z
        • Wang L
        • et al.
        Log odds of positive lymph nodes predicts survival in patients treated with neoadjuvant therapy followed by esophagectomy.
        J Surg Oncol. 2020; 121: 1074-1083
        • Yildiz MM
        • Petersen I
        • Eigendorff E
        • Schlattmann P
        • Guntinas-Lichius O.
        Which is the most suitable lymph node predictor for overall survival after primary surgery of head and neck cancer: pN, the number or the ratio of positive lymph nodes, or log odds?.
        J Cancer Res Clin Oncol. 2016; 142: 885-893
        • Jin S
        • Wang B
        • Zhu Y
        • et al.
        Log odds could better predict survival in muscle-invasive bladder cancer patients compared with pn and lymph node ratio.
        J Cancer. 2019; 10: 249-256
        • Morgan TM
        • Barocas DA
        • Penson DF
        • et al.
        Lymph node yield at radical cystectomy predicts mortality in node-negative and not node-positive patients.
        Urology. 2012; 80: 632-640
        • Herr HW.
        Superiority of ratio based lymph node staging for bladder cancer.
        J Urol. 2003; 169: 943-945
        • May M
        • Herrmann E
        • Bolenz C
        • 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: 712-718
        • Lee D
        • Yoo S
        • You D
        • et al.
        Lymph node density vs. the American Joint Committee on Cancer TNM nodal staging system in node-positive bladder cancer in patients undergoing extended or super-extended pelvic lymphadenectomy.
        Urol Oncol. 2017; 35 (Elsevier151.e151-151.e157)
        • Salari A
        • Nili F
        • Jalaeefar AM
        • Shirkhoda M.
        Lymph node ratio: is it an independent prognostic factor for stage III cutaneous melanoma?.
        Asian Pacific J Cancer Prevent. 2018; 19: 3623
        • Ke B
        • Song X-N
        • Liu N
        • Zhang R-P
        • Wang C-L
        • Liang H.
        Prognostic value of the lymph node ratio in stage III gastric cancer patients undergoing radical resection.
        PloS One. 2014; 9: e96455
        • Dings PJ
        • Elferink MA
        • Strobbe LJ
        • de Wilt JH.
        The prognostic value of lymph node ratio in node-positive breast cancer: a Dutch nationwide population-based study.
        Ann Surg Oncol. 2013; 20: 2607-2614
        • Salari A
        • Saeedi E
        • Hadji M
        • Jalaeefar A
        • Zendehdel K
        • Shirkhoda M.
        The role of lymph node ratio in predicting survival in patients with esophageal squamous cell carcinoma.
        J Iranian Med Council. 2021; 4: 296-302