Division of Urologic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA.
Harvard Medical School, Boston, MA, USA.
Curr Oncol Rep. 2021 Feb 9;23(2):24. doi: 10.1007/s11912-021-01018-w.
Clinically regional node-positive (cN+) urothelial carcinoma of the bladder requires a multi-modal management approach amidst growing recognition that it represents a spectrum of disease. Herein, we review the contemporary evidence for the natural history, evaluation, and management of clinically regional node-positive urothelial carcinoma of the bladder, highlighting recent changes in lymph node staging.
Despite advances in techniques, cross-sectional imaging remains relatively insensitive for the detection of lymph node metastases. Recent changes to nodal staging that distinguish between cN1, cN2-3, and non-regional lymph node metastases reflect an increasing understanding that node-positive disease is heterogeneous and its management must be individualized according to nodal staging. Systemic therapy remains the initial management strategy, either alone or in conjunction with radiotherapy, with choice and sequencing of agents extrapolated from studies of metastatic disease. Consolidative radical cystectomy is an option for patients with disease response to upfront systemic therapy, and several series demonstrate a subset of patients with favorable oncologic outcomes. The comparative effectiveness of radiotherapy and radical cystectomy as local therapy remains an important evidence gap. Future studies that identify predictive biomarkers will help inform optimal choice of systemic therapy. The management of clinically regional node-positive disease requires a multimodal approach comprising both systemic and local therapy, tailored to the patient and to disease response. While choice of systemic therapy will be informed by ongoing studies in patients with metastatic disease, including the elucidation of predictive biomarkers, the comparative effectiveness of local therapies remains an important evidence gap.
目前临床上认为区域淋巴结阳性（cN+）的膀胱癌是一种疾病谱，需要采取多模式管理方法。本文主要回顾了膀胱癌 cN+的自然病史、评估和管理的最新循证医学证据，重点讨论了淋巴结分期的最新变化。
尽管技术不断进步，但横断面成像对于检测淋巴结转移仍相对不敏感。最近对淋巴结分期的修改区分了 cN1、cN2-3 和非区域性淋巴结转移，这反映了人们越来越认识到阳性淋巴结疾病具有异质性，其管理必须根据淋巴结分期进行个体化。全身治疗仍然是初始治疗策略，无论是单独使用还是联合放疗，药物的选择和序贯可从转移性疾病的研究中推断出来。对于有疾病缓解的患者，巩固性根治性膀胱切除术是一种选择，有几项研究表明，部分患者具有良好的肿瘤学结局。放疗和根治性膀胱切除术作为局部治疗的疗效比较仍然是一个重要的证据空白。未来识别预测生物标志物的研究将有助于为最佳全身治疗选择提供信息。cN+疾病的管理需要包括全身治疗和局部治疗在内的多模式方法，针对患者和疾病反应进行个体化调整。尽管转移性疾病患者的正在进行的研究（包括对预测生物标志物的阐明）将为全身治疗选择提供信息，但局部治疗的疗效比较仍然是一个重要的证据空白。
