Long-term survival after combined modality treatment in metastatic bladder cancer patients presenting with supra-regional tumor positive lymph nodes only
Introduction
Bladder cancer patients with lymph node metastases outside the true pelvis (regional lymph nodes: the nodes below the bifurcation of the common iliac arteries) are classified within the TNM system as distant metastases. In general, patients with metastatic disease are treated with palliative intention. A small proportion of bladder cancer patients presents with supra-regional lymph node metastases only (positive para-aortic and/or para-caval lymph nodes) without synchronous hematogenic metastases. It has been our policy to treat these patients with platinum-based chemotherapy followed by surgical removal of all tumor-bearing sites in those patients showing no sign of progression after chemotherapy response evaluation. The purpose of this study was to assess the results of combination therapy with neoadjuvant chemotherapy and surgery in bladder cancer patients presenting with supra-regional metastases only.
Section snippets
Preoperative assessment and patient selection
Between 1987 and 2007, 394 patients with transitional cell carcinoma (TCC) were treated with cystectomy, regional and supra-regional lymph node dissection at the Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital. Fourteen patients presented with para-aortic/para-caval lymph node metastases without evidence of other distant metastases. Diagnostic workup consisted of physical examination, transurethral resection, chest X-ray and pelvic abdominal computerized tomography. All stages were
Chemotherapy
Classic MVAC was given to eight patients, five patients received HD-MVAC and one patient received GC.
Clinical and pathological response
In five patients there was a complete clinical response, in nine patients there was a partial response after neoadjuvant chemotherapy. After surgery, histopathological proof of complete remission in the bladder was confirmed in all five cases. One patient still had tumor in the pelvic lymph nodes; in four others no tumor was present after chemotherapy. No tumor could be detected in the bladder
Discussion
Patients presenting with tumor positive regional lymph nodes have a 5-year disease-specific survival of 20–40% after surgery alone depending on primary tumor stage and number of lymph nodes involved.2, 4
Conclusions
An attempt can be made to treat patients with supra-regional tumor positive lymph nodes without other distant metastases with combination therapy of chemotherapy and surgery. Patients achieving a partial or complete remission after chemotherapy could undergo subsequent surgery aiming at removing all cancer-bearing sites. In this series, 24% of patients survive 5 years after combination therapy.
Conflict of interest
There is no actual or potential conflict of interest in relation to this article.
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