Discordant Response in Pelvic Lymph Nodes and Cystectomy Specimens After Neoadjuvant Chemotherapy in Muscle-invasive Bladder Cancer.
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Antonelli Luca, Afferi Luca, Del Giudice Francesco, Bologna Eugenio, Esperto Francesco, Chierigo Francesco, Antonelli Alessandro, Tully Karl, Umari Paolo, Albisinni Simone, Mari Andrea, Pichler Renate, Claps Francesco, Teoh Jeremy Yuen-Chun, Roumiguié Mathieu, Schulz Gerald Bastian, Orecchia Luca, Soria Francesco, Roupret Morgan, Marcq Gautier, Poyet Cedric, Kulkarni Girish S, Rink Michael, Klatte Tobias, Campi Riccardo, Krajewski Wojciech, Mertens Laura, Culpan Meftun, Lavallée Luke T, Moschini Marco, Fankhauser Christian Daniel, EAU YAU urothelial carcinoma working group
Аннотация
OBJECTIVE: To evaluate the association between pathological response in the bladder and pelvic lymph node status after NAC in patients with MIBC undergoing radical cystectomy (RC) and PLND.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective, multi-institutional cohort study included 751 patients with MIBC treated with NAC followed by RC and PLND between 2000 and 2021 across 26 institutions.
INTERVENTION: Neoadjuvant chemotherapy followed by RC and PLND.
OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was residual lymph node involvement (ypN+). Multivariable logistic regression was used to identify factors associated with ypN+.
RESULTS AND LIMITATIONS: Overall, 175 patients (23%) achieved a complete pathological response in the bladder (ypT0), 102 (14%) were downstaged to non-muscle-invasive disease (ypTa/ypTis/ypT1), and 185 (25%) had residual lymph node involvement. On multivariable analysis, cN+ disease before NAC was associated with higher odds of ypN+ (OR 1.97, 95% CI 1.32-2.94), whereas ypT0 (OR 0.11, 95% CI 0.05-0.21) and ypTa/ypTis/ypT1 (OR 0.24, 95% CI 0.12-0.47) were associated with lower odds of ypN+. Notably, 5% of ypT0 and 10% of downstaged patients harboured residual lymph node metastases. Limitations include potential selection bias and centre-level variability in surgical and pathological assessment, which may affect the generalizability of the findings.
CONCLUSIONS: Current clinical and radiological variables cannot reliably exclude residual pelvic lymph node disease, even in patients achieving ypT0-1. Novel imaging techniques and liquid biomarkers require validation before bladder-sparing approaches can be safely expanded.