Abstract
PurposeLittle is known about the prevalence of occult lymph node metastases (LNM) in muscle-invasive bladder cancer (MIBC) patients with pathological downstaging of the primary tumor. We aimed to estimate the prevalence of occult LNM in patients without residual MIBC at radical cystectomy (RC) with or without neoadjuvant chemotherapy (NAC) or neoadjuvant radiotherapy (NAR), and to assess overall survival (OS).MethodsPatients with cT2-T4aN0M0 urothelial MIBC who underwent RC plus pelvic lymph node dissection (PLND) with curative intent between January 1995–December 2013 (retrospective Netherlands Cancer Registry (NCR) cohort) and November 2017–October 2019 (prospective NCR-BlaZIB cohort (acronym in Dutch: BlaaskankerZorg In Beeld; in English: Insight into bladder cancer care)) were identified from the nationwide NCR. The prevalence of occult LNM was calculated and OS of patients with <(y)pT2N0 vs. <(y)pT2N+ disease was estimated by the Kaplan–Meier method.ResultsIn total, 4657 patients from the NCR cohort and 760 patients from the NCR-BlaZIB cohort were included. Of 1374 patients downstaged to <(y)pT2, 4.3% (N = 59) had occult LNM 4.1% (N = 49) of patients with cT2-disease and 5.6% (N = 10) with cT3-4a-disease. This was 4.0% (N = 44) in patients without NAC or NAR, 4.5% (N = 10) in patients with NAC, and 13.5% (N = 5) in patients with NAR but number of patients treated with NAR and downstaged disease was small. The prevalence of <(y)pT2N+ disease was 4.2% (N = 48) in the NCR cohort and 4.6% (N = 11) in the NCR-BlaZIB cohort. For patients with <(y)pT2N+ and <(y)pT2N0, median OS was 3.5 years (95% CI 2.5–8.9) versus 12.9 years (95% CI 11.7–14.0), respectively.ConclusionOccult LNM were found in 4.3% of patients with cT2-4aN0M0 MIBC with (near-) complete downstaging of the primary tumor following RC plus PLND. This was regardless of NAC or clinical T-stage. Patients with occult LNM showed considerable worse survival. These results can help in counseling patients for bladder-sparing treatments.
Highlights
The standard treatment for clinically node-negative muscleinvasive bladder cancer (MIBC) is radical cystectomy (RC) and pelvic lymph node dissection (PLND) with cisplatinbased neoadjuvant chemotherapy (NAC) in fit patients [1]
Patients diagnosed with cT2-4aN0M0 urothelial bladder carcinoma (BC) who underwent RC plus PLND with or without NAC or neoadjuvant radiotherapy (NAR), between January 1st 1995 and December 31st 2013 and between November 1st 2017 and October 31st 2019 were selected from the Netherlands Cancer Registry (NCR)
The NCR-BlaZIB cohort consisted of patients included in the ongoing Dutch nationwide population-based prospective BlaZIB study (BlaaskankerZorg In Beeld, translation: Insight into Bladder Cancer Care) [12], which is embedded in the NCR
Summary
The standard treatment for clinically node-negative muscleinvasive bladder cancer (MIBC) is radical cystectomy (RC) and pelvic lymph node dissection (PLND) with cisplatinbased neoadjuvant chemotherapy (NAC) in fit patients [1]. A clinical complete response after TUR-only or TUR combined with systemic chemotherapy cannot reliably be concluded based on a combination of Re-TUR, negative cytology and cross-sectional imaging. These diagnostics are often performed in daily practice in attempting to confirm a so called “pT0-status” in patients who prefer bladder preservation [3, 4, 9, 10]. PLND for the assessment of nodal invasion is not routinely performed and the prevalence of occult metastatic disease and the potential role of PLND in this particular group has not been clearly demonstrated [11]
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