Long-term survival after combined modality treatment in metastatic bladder cancer patients presenting with supra-regional tumor positive lymph nodes only

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Abstract

Aims

To evaluate if combined treatment should be offered to bladder cancer patients presenting with supra-regional lymph node metastases only and a clinical complete or partial response after chemotherapy.

Patients and methods

We identified 14 patients with supra-regional lymph node metastases out of 394 patients with transitional cell carcinoma (TCC) treated in our institute with cystectomy and regional and supra-regional lymph node dissection between 1987 and 2007. Prior to cystectomy, neoadjuvant chemotherapy had been given. The patients received a total of four cycles of platinum-based chemotherapy.

Results

Five patients had a CR, nine patients had a PR after neoadjuvant chemotherapy. Histopathological proof of complete response in the bladder was confirmed in all five cases. One of these five patients had a CR in the bladder but pelvic lymph nodes still contained vital tumor. Five patients had no tumor in the lymph nodes, whereas four had tumor in the lymph nodes. Eleven patients died due to bladder cancer, seven of them within 1 year after cystectomy. The 3- and 5-year disease-specific survival rates were 36% (95% CI: 10–60%) and 24% (95% CI: 0–49%). Mean follow-up was 2.5 years.

Conclusions

Combination therapy consisting of neoadjuvant chemotherapy and surgery in selected patients with tumor positive supra-regional lymph nodes only can result in durable long-term survival rates (24% 5-year survival). Response evaluation after neoadjuvant chemotherapy might play a decisive role in the selection of patients undergoing subsequent surgical removal of all known tumor sites.

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.

References (9)

There are more references available in the full text version of this article.

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