Cancer-specific mortality following radical cystectomy for bladder cancer with lymph node involvement: impact of pathologic disease features and adjuvant chemotherapy

[Pathological pelvic lymph node involvement in muscle-invasive bladder cancer patients treated with radical cystectomy: A narrative review]

OBJECTIVE

To perform a narrative review of the contemporary literature on the diagnosis, prognosis and adjuvant management of muscle-invasive bladder cancer (MIBC) patients with pathological pelvic lymph node involvement (pN+) at radical cystectomy.

METHOD

A narrative review of the contemporary literature available on Medline was conducted to report studies evaluating the diagnosis, prognosis and/or adjuvant treatments for MIBC patients with pN+ disease at radical cystectomy.

RESULTS

Open or robotic extended pelvic lymph node dissection up to the crossing of the ureter with common iliac vessels can enhance the diagnosis of pN+ MIBC, especially using separate packages for the submission of a maximum number of lymph nodes. The main prognosis factors for pN+ patients are the number of positive and retrieved lymph nodes, lymph node density, extranodal extension as well as lymph node metastasis diameter. Adjuvant chemotherapy is likely to prolong overall survival in pN+ patients treated with radical cystectomy alone while adjuvant immunotherapy using nivolumab has been shown to decrease the risk of recurrence in all pN+ patients, especially those with ypN+ disease after neoadjuvant chemotherapy followed by radical cystectomy. However, few data are currently available on the role of adjuvant radiation therapy, which remains currently experimental for these patients.

CONCLUSION

Multiple parameters have been reported to impact the diagnosis and prognosis of patients with pN+ MIBC at radical cystectomy. Adjuvant management is currently based on chemotherapy and immunotherapy with preliminary data on radiation therapy.

The impact of treatment modality on survival in patients with clinical node-positive bladder cancer: results from a multicenter collaboration

PURPOSE

To assess the impact of perioperative chemotherapy on survival in cN+ BCa patients and analyze it according to the pN status.

METHODS

A retrospective analysis was conducted on 639 BCa patients with cTanyN1-3M0 BCa treated with radical cystectomy (RC) and bilateral lymph node dissection (LND) with or without perioperative chemotherapy in ten tertiary referral centers from 1990 to 2017. Selected cN+ patients received induction chemotherapy (IC), whereas adjuvant chemotherapy (ACT) was delivered to selected pN+ patients. Univariable and multivariable Cox regression analyses were used to predict overall mortality (OM) after surgery, adjusting for clinicopathological confounders. Kaplan-Meier analyses assessed OM according to the treatment modality.

RESULTS

Overall, 356 (56%) patients were treated with surgery alone, 155 (24%) with IC followed by surgery, and 128 (20%) with ACT following surgery. Over a median follow-up of 25 months, 316 deaths were recorded. At univariable analysis, patients treated with IC and surgery had lower OM both considering cN+ [hazard ratio (HR) 0.65, 95% confidence interval (CI) 0.49-0.87, p = 0.004] and cN+pN- patients (HR 0.61, 95% CI 0.37-0.99, p = 0.05) compared to those treated with surgery alone. cN+pN+ patients treated with ACT experienced lower OM compared to those treated with IC or surgery alone at multivariable analysis (HR 0.40, 95% CI 0.22-0.74, p = 0.003).

CONCLUSION

Patients with cTany cN+ cM0 BCa benefit more in terms of OS when treated with IC followed by RC + LND compared to RC + LND alone, regardless of LNMs at final histopathology examination. More data are needed to assess the role of ACT in the management of cN+ patients.

An EMT-related gene signature for the prognosis of human bladder cancer

The transition from non-muscle-invasive bladder cancer (NMIBC) to muscle-invasive bladder cancer (MIBC) is detrimental to bladder cancer (BLCA) patients. Here, we aimed to study the underlying mechanism of the subtype transition. Gene set variation analysis (GSVA) revealed the epithelial-mesenchymal transition (EMT) signalling pathway with the most positive correlation in this transition. Then, we built a LASSO Cox regression model of an EMT-related gene signature in BLCA. The patients with high risk scores had significantly worse overall survival (OS) and disease-free survival (DFS) than those with low risk scores. The EMT-related gene signature also performed favourably in the accuracy of prognosis and in the subtype survival analysis. Univariate and multivariate Cox regression analyses demonstrated that the EMT-related gene signature, pathological N stage and age were independent prognostic factors for predicting survival in BLCA patients. Furthermore, the predictive nomogram model was able to effectively predict the outcome of BLCA patients by appropriately stratifying the risk score. In conclusion, we developed a novel EMT-related gene signature that has tumour-promoting effects, acts as a negative independent prognostic factor and might facilitate personalized counselling and treatment in BLCA.

Adjuvant chemotherapy versus observation after radical cystectomy in patients with node-positive bladder cancer

This retrospective study compared adjuvant chemotherapy (AC) versus observation after radical cystectomy (RC) in patients with node-positive bladder cancer (pN+). Outcomes were reviewed in patients with pTanyN1-3M0 bladder cancer who underwent RC with or without AC between 1995 and 2017. Baseline characteristics between the two groups were controlled with inverse probability of treatment weighting (IPTW)-adjusted analyses. Of 281 enrolled patients, the 3-year IPTW-adjusted rates of overall survival was higher in the AC group than the RC group (46.4% vs. 33.7%, p = 0.024). AC was an independent predictor of overall survival (hazard ratio = 0.48; P < 0.0001). When patients were subdivided by lymph node density (LND), the 3-year overall survival rates were similar between the AC and RC groups in patients with LND < 9%, but higher in the AC group in patients with LND 9–25% (53.4% vs. 23.7%) and LND ≥ 25% (27.4% vs. 16.1%). The numbers needed to treat to prevent one death at 3 years were three and nine in patients with LND 9–25% and ≥25%, respectively. In conclusion, AC after RC was associated with improved overall survival in patients with node-positive bladder cancer. Patients with an intermediate nodal burden may benefit most from AC.

Use of Adjuvant Chemotherapy in Patients with Advanced Bladder Cancer after Neoadjuvant Chemotherapy

Objectives:

To compare the outcomes of adjuvant chemotherapy (AC) versus observation in patients with non-organ confined disease after neoadjuvant chemotherapy and radical cystectomy (RC).

Materials and methods:

Using the National Cancer Database, we identified patients who received NAC prior to RC and had advanced stage (pT3/4) or pathologically involved nodes (pN+) at the time of surgery from 2004–2013. We determined whether patients then received AC or were managed with observation only and used multivariable proportional hazards regression to estimate the impact of AC on overall survival.

Results:

Overall 34% (N = 705) of patients who received NAC and underwent RC were pT3/4 and/or pN+. Of these patients, 24% (N = 168) received subsequent chemotherapy and the rest were observed. Median survival for the entire cohort was 21 months (IQR 12–45). There was not a statistically significant difference in median survival between the AC and observation groups (23 months [IQR 14–46] versus 20 months [IQR 12–46], log-rank p = 0.52). On multivariate analysis there was no survival advantage for the AC cohort. Subgroup analysis of pN+ patients who received AC also did not show a survival advantage.

Conclusions:

Patients who are pT3/4 and/or pN+ after NAC and RC have a poor prognosis. The addition of AC does not seem to be beneficial. Further research should focus identifying patients who may benefit from additional chemotherapy.

Decreased Overall and Bladder Cancer-Specific Mortality with Adjuvant Chemotherapy After Radical Cystectomy: Multivariable Competing Risk Analysis

Adding chemotherapy to radical cystectomy (RC) may improve outcome. Neoadjuvant treatment is advocated by guidelines based on meta-analysis data but is severely underused in clinical practice. Adjuvant treatment of patients at risk could be an alternative. We analyzed a sample of 798 patients who underwent RC between 1993 and 2011 for high-risk superficial or muscle-invasive urothelial or undifferentiated bladder cancer, of which 23% received adjuvant cisplatin-based chemotherapy and %5 received neoadjuvant chemotherapy. The use of adjuvant chemotherapy was an independent predictor of decreased overall mortality (hazard ratio [HR]: 0.50; 95% confidence interval [CI], 0.38-0.66; p<0.0001) and bladder cancer-specific mortality (HR: 0.71; 95% CI, 0.52-0.97; p=0.0321), but it was not associated with competing mortality. Similar figures were obtained when analyzing the number of cisplatin-containing cycles administered or when restricting the analysis to patients with lymph node-positive or extravesical but lymph node-negative disease, suggesting a mortality-reducing treatment effect after adjusting for several patient- and tumor-related confounders. Future trials should directly compare the concepts of neoadjuvant and adjuvant application of chemotherapy in candidates for RC.

PATIENT SUMMARY

Adjuvant chemotherapy may decrease overall and bladder cancer-specific mortality after radical cystectomy (RC). Future trials should directly compare the concepts of neoadjuvant and adjuvant application of chemotherapy in candidates for RC.

Preoperative lymphocyte-monocyte and platelet-lymphocyte ratios as predictors of overall survival in patients with bladder cancer undergoing radical cystectomy

Although pretreatment neutrophil-lymphocyte ratio (NLR), lymphocyte-monocyte ratio (LMR), and platelet-lymphocyte ratio (PLR) are reportedly associated with clinical outcomes of many cancers, their roles in patients with bladder cancer (BCa) who undergo radical cystectomy (RC) have not been widely investigated. We analyzed relationships between preoperative NLR, LMR, PLR, and overall survival (OS) in 124 BCa patients undergoing RC. OS curves were drawn using the Kaplan-Meier method and evaluated using the log-rank test. Relationships between OS and potential confounding variables were determined using Cox's proportional hazard regression model. Decreased LMR was associated with shorter OS (P = 0.012); OS in the low PLR group was significantly longer than that in the high PLR group (P = 0.029), and NLR was not significantly associated with oncological outcomes. However, after adjusting for confounding variables, patients in the high-LMR group indicated >30% decreased mortality than the low-LMR group (hazard ratio 0.674; 95% confidence interval 0.412-0.890; P = 0.003), and PLR was not an independent predictor of OS. Our results show that preoperative LMR is a better prognostic factor in BCa patients undergoing RC, compared with NLR and PLR.