Occult Nodal Metastases in Patients Down-Staged to Nonmuscle Invasive Disease Following Neoadjuvant Chemotherapy

Nassiri, Nima; Ghodoussipour, Saum; Maas, Marissa; Nazemi, Azadeh; Asanad, Kian; Pearce, Shane M.; Bhanvadia, Sumeet; Djaladat, Hooman; Schuckman, Anne; Daneshmand, Siamak

doi:10.1016/j.urology.2020.03.021

Cited by 11 publications

(9 citation statements)

References 20 publications

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“…On the other hand, the number of patients with pN+ after RARC was comparable between the partial and no-responders groups (53.3% vs. 42.9%, respectively). This is in contrast with recent findings where the rates of occult nodal metastases in patients with downstaged no MIBC after NACT was approximately 5.4% [ 27 ]. In the absence of clinical predictors of clinical involvement, our data suggest that a large number of patients who would have otherwise been considered partial NACT responders still have a significant clinically undetected but pathologically proven burden of disease and may benefit an extended lymphadenectomy.…”

Section: Discussioncontrasting

confidence: 96%

“…Since in our series patients who achieved a partial response following NACT and non-responders showed comparable survival outcomes, these data suggest that the amount of rMIBC rather than the degree of downstaging following NACT is associated with subsequent survival outcomes. In analogy to previous ORC series, our study confirmed that patients with nodal metastatic disease after RARC have the same, worse, oncologic outcomes [ 27 ]. Thus, a critical evaluation of the response to NACT in patients with MIBC may be accurately predict the prognosis of the patients, or potentially the appropriate extent of the lymphadenectomy template.…”

Section: Discussionsupporting

confidence: 87%

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Impact of Clinical Response to Neoadjuvant Chemotherapy in the Era of Robot Assisted Radical Cystectomy: Results of a Single-Center Experience

Anceschi¹,

Brassetti²,

Tuderti³

et al. 2020

JCM

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Background: Response to neoadjuvant chemotherapy (NACT) has been proven to be an established prognostic factor after open radical cystectomy (ORC). We evaluated the impact of NACT on survival outcomes of a single-institution robotic radical cystectomy (RARC) series. Methods: From January 2012 to June 2020, 79 patients were identified. Baseline, demographic, perioperative, and pathologic data were described. Kaplan–Meier with the log-rank test was used to compare overall survival (OS) differences between complete, partial, and no-NACT responders, respectively. Univariable and multivariable regression analyses were performed to identify predictors of OS. Results: Complete, partial, and absent response to NACT were recorded in 43 (54.4%), 21 (19%), and 15 (26.6%) patients, respectively. A complete response to NACT displayed a trend toward significant higher OS (p = 0.03). In univariable analysis, significant predictors of lower OS were hypertension (HR 3.37; CI 95% 1.31–8.62; p = 0.01); advanced nodal involvement (HR 2.41; CI 95% 0.53–10.9; p < 0.001); and incomplete response to NACT (HR 0.41; CI 95% 0.18–0.95; p = 0.039). In multivariable analysis, the only independent predictor of worse OS was advanced pathologic N stages (HR 10.1; CI: 95% CI 2.3–44.3; p = 0.002). Conclusions: Complete response to NACT is associated with increased OS probability, but significant nodal residual disease remains the only independent predictor of OS after RARC.

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Section: Discussioncontrasting

confidence: 96%

Section: Discussionsupporting

confidence: 87%

Impact of Clinical Response to Neoadjuvant Chemotherapy in the Era of Robot Assisted Radical Cystectomy: Results of a Single-Center Experience

Anceschi¹,

Brassetti²,

Tuderti³

et al. 2020

JCM

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“…In line with these findings, pelvic and sentinel lymph node mapping studies in BC confirm that a limited versus an extended PLND does not capture all draining lymph nodes and thus might lead to a false negative 'pN0 status' [20,21]. It is, therefore, likely that the true prevalence of LNM in patients with a presumed 'pT0 status' before RC is higher than the 5% which was found in both the study of Nassiri et al [11] and our study. This assumption might favor the harm to benefit ratio to perform a diagnostic PLND.…”

Section: Discussionsupporting

confidence: 89%

“…However, 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 ]. In these patients, 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 ].…”

Section: Introductionmentioning

confidence: 99%

Occult lymph node metastases in patients without residual muscle-invasive bladder cancer at radical cystectomy with or without neoadjuvant chemotherapy: a nationwide study of 5417 patients

Hoogstraten¹,

Gennep

Kiemeney³

et al. 2021

World J Urol

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Purpose Little 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). Methods Patients 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. Results In 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. Conclusion Occult 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.

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“…The role of variant histology to stratify patients at risk in HGT1 bladder carcinomas remains uncertain due to the limited number of related studies. Most reports on HGT1 with variant histology are reporting on micropapillary carcinoma or, rarely, nested carcinoma [4,[7][8][9][10][11][12][13][14][15][16][17][18][19][20]. The fact that some pathologists do not recognize or report about one-half of cases with variant histology in their practice is an additional limitation; therefore, the risk associated with variant histology in HGT1 carcinomas might indeed be underrecognized [21,22].…”

Section: Introductionmentioning

confidence: 99%

T1 bladder carcinoma with variant histology: pathological features and clinical significance

et al. 2022

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The aim of the study was to stratify high-grade T1 (HGT1) bladder urothelial carcinoma into risk categories based on the presence of variant histology when compared to conventional urothelial carcinoma. The clinicopathological features of 104 HGT1 cases of urothelial carcinoma of the bladder with variant histology present in 34 (37%) were assessed. The endpoint of the study was disease-free survival and cancer-specific survival. Overall, variant histology was identified as a significant predictor of disease-free survival (P = 0.035). The presence of any specific variant histology (squamous, glandular, micropapillary, nested, microcystic, inverted growth, villous-like, basaloid, and lymphoepithelioma-like) was identified as a significant predictor of disease-free survival (P = 0.008) and cancer-specific survival (P = 0.0001) in HGT1 bladder cancer. Therefore, our results support including micropapillary HGT1 urothelial carcinoma within the aggressive high-risk category, as suggested by some recent clinical guidelines, but also favor nested, glandular, and basaloid to be placed in the high-risk category due to their potential of aggressive, life-threatening behavior and their limited response to bacillus Calmette-Guerin therapy. Conversely, the low-risk category would include urothelial carcinomas with squamous, inverted growth, or microcystic morphology, all with limited life-threatening potential and good response to current therapy. A very low-risk category would finally include patients whose tumors present villous-like or lymphoepithelioma-like morphology. In conclusion, our findings support the value of reporting the variant histology as a feature of variable aggressiveness in HGT1 urothelial carcinoma of the bladder.

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Occult Nodal Metastases in Patients Down-Staged to Nonmuscle Invasive Disease Following Neoadjuvant Chemotherapy

Cited by 11 publications

References 20 publications

Impact of Clinical Response to Neoadjuvant Chemotherapy in the Era of Robot Assisted Radical Cystectomy: Results of a Single-Center Experience

Impact of Clinical Response to Neoadjuvant Chemotherapy in the Era of Robot Assisted Radical Cystectomy: Results of a Single-Center Experience

Occult lymph node metastases in patients without residual muscle-invasive bladder cancer at radical cystectomy with or without neoadjuvant chemotherapy: a nationwide study of 5417 patients

T1 bladder carcinoma with variant histology: pathological features and clinical significance

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