Department of Urology, Mayo Clinic, Rochester, MN, USA; Department of Urology, Urological Research Institute, Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy.
Department of Urology, Mayo Clinic, Rochester, MN, USA.
Eur Urol Focus. 2018 Mar;4(2):245-251. doi: 10.1016/j.euf.2016.11.005. Epub 2016 Nov 23.
BACKGROUND: Data regarding clinical node metastases (cN+) in patients undergoing radical cystectomy (RC) are scarce. OBJECTIVE: To evaluate the performance of conventional imaging in detecting cN+ and analyze the impact of cN+ on survival among patients treated with RC without neoadjuvant chemotherapy (NAC). DESIGN, SETTING, AND PARTICIPANTS: Data from three independent centers of consecutive patients with bladder cancer treated with RC without NAC were analyzed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: cN+ was defined as pelvic nodes >8mm or abdominal nodes >10mm in maximum short-axis diameter as detected via preoperative computed tomography or magnetic resonance imaging. Performance characteristics were evaluated considering pN+ disease as the reference standard. Multivariable Cox regression analyses were performed for prediction of survival. RESULTS AND LIMITATIONS: Overall, 196 patients (7.1%) had cN+ disease before RC and pN+ status was confirmed for 122 of them (62.2%). cN+ status in the overall population had sensitivity of 18% and specificity of 96% with a calculated area under the curve of 57%. The median follow-up was 108 mo. On multivariable analyses, cN+pN+ (hazard ratio [HR] 1.84, 95% confidence interval [CI] 1.26-2.68) and cN-pN+ (HR 2.36, 95% CI 1.90-2.92) were predictors of CSM (both p<0.001). Conversely, cN+pN- status was not associated with worse survival outcomes (p > 0.2). CONCLUSIONS: Our study confirms the poor accuracy of conventional preoperative imaging in assessing nodal disease status. cN status had no independent impact on survival when all confounders were evaluated, and potentially curative treatments should not be withheld on the basis of clinical nodal status alone. PATIENT SUMMARY: The accuracy of conventional imaging techniques for detection of pathologic lymph node-positive disease before radical cystectomy for bladder cancer is suboptimal. The presence of clinical lymph node positivity on preoperative imaging is not an independent predictor of oncologic outcomes, and if the node invasion is not confirmed at radical cystectomy, these patients may have good long-term outcomes.
背景：根治性膀胱切除术（RC）患者的临床淋巴结转移（cN+）数据很少。
目的：评估常规影像学在检测 cN+中的作用，并分析 cN+对未接受新辅助化疗（NAC）的 RC 治疗患者生存的影响。
设计、地点和参与者：对来自三个独立中心的连续接受 RC 治疗且未接受 NAC 的膀胱癌患者的数据进行了分析。
观察指标和统计分析：cN+定义为术前 CT 或 MRI 检测到的盆腔淋巴结>8mm 或腹部淋巴结>10mm 最大短轴直径。以 pN+疾病为参考标准评估性能特征。进行多变量 Cox 回归分析以预测生存。
结果和局限性：总体而言，196 例（7.1%）患者在 RC 前存在 cN+疾病，其中 122 例（62.2%）患者的 pN+状态得到证实。总体人群中 cN+状态的敏感性为 18%，特异性为 96%，曲线下面积为 57%。中位随访时间为 108 个月。多变量分析显示，cN+pN+（风险比[HR]1.84，95%置信区间[CI]1.26-2.68）和 cN-pN+（HR 2.36，95%CI 1.90-2.92）是 CSM 的预测因素（均<0.001）。相反，cN+pN-状态与较差的生存结局无关（p>0.2）。
结论：我们的研究证实了常规术前影像学在评估淋巴结疾病状态方面的准确性较差。在评估所有混杂因素后，cN 状态对生存结果没有独立影响，并且不能仅基于临床淋巴结状态拒绝潜在的治愈性治疗。
患者总结：用于检测膀胱癌 RC 前病理淋巴结阳性疾病的常规成像技术的准确性并不理想。术前影像学上存在临床淋巴结阳性并不独立预测肿瘤学结局，如果在 RC 时未确认淋巴结侵犯，这些患者可能有良好的长期结局。
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