The George Washington University Medical Faculty Associates, Washington, DC.
The George Washington University Medical Faculty Associates, Washington, DC; The Brody School of Medicine at East Carolina University, Greenville, NC.
Clin Genitourin Cancer. 2022 Apr;20(2):e135-e139. doi: 10.1016/j.clgc.2021.11.011. Epub 2021 Dec 1.
Up to 14% of bladder urothelial carcinoma has variant histology (VH), which is associated with a higher incidence of occult regional lymph node metastasis. Neoadjuvant chemotherapy (NAC) is the gold-standard for resectable cT2-4 disease as it achieves pathologic complete response (pCR) in select patients at the time of radical cystectomy (RC). A landmark trial demonstrated chemosensitivity and pT0 status in the setting of VH. pT0N+ pathology in patients undergoing subsequent RC has prompted concerns about post-chemotherapy bladder preservation. We investigate how VH impacts pathologic primary site and nodal downstaging post-NAC. We queried the National Cancer Database for cT2-4N0M0 patients who underwent NAC and RC between 2004 and 2016. These patients were stratified into pure urothelial cell carcinoma (UCC) and VH. The rate of downstaging to ≤pT1 was analyzed, along with pN+ status. Overall survival was analyzed using the Kaplan-Meier method and multivariable Cox proportional hazards regression model. Multivariable models were adjusted for demographic and clinicopathologic variables. Of 5,335 patients, 92.1% were UCC and 7.9% VH. UCC was associated with better unadjusted survival and lower adjusted odds of being pN+ (aOR = 0.60, P < .001). Squamous cell, glandular, and sarcomatoid histologies were significantly associated with decreased adjusted odds of any pT downstage. Neuroendocrine histology (NE) trended towards increased adjusted odds of downstage to pT0N0. Patients with VH were more likely to harbor occult regional lymph node metastasis in the setting of intravesical pCR. NE had the highest pT0N0 rate, with potential implications on post-NAC bladder preservation. These findings reinforce the role of RC after NAC especially for VH.
多达 14%的膀胱尿路上皮癌具有变体组织学（VH），这与隐匿性区域淋巴结转移的发生率较高相关。新辅助化疗（NAC）是可切除 cT2-4 疾病的金标准，因为它在根治性膀胱切除术（RC）时可使选择的患者达到病理完全缓解（pCR）。一项具有里程碑意义的试验证明了 VH 背景下的化疗敏感性和 pT0 状态。在随后接受 RC 的患者中，pT0N+ 病理学引发了对化疗后膀胱保留的关注。我们研究了 VH 如何影响病理原发性肿瘤部位和淋巴结降期。我们从 2004 年至 2016 年期间在国家癌症数据库中查询了接受 NAC 和 RC 的 cT2-4N0M0 患者。这些患者被分为纯尿路上皮细胞癌（UCC）和 VH。分析了降期至≤pT1 的比率，以及 pN+状态。使用 Kaplan-Meier 方法和多变量 Cox 比例风险回归模型分析总生存期。多变量模型调整了人口统计学和临床病理变量。在 5335 名患者中，92.1%为 UCC，7.9%为 VH。UCC 与未经调整的生存更好和调整后的 pN+状态的几率较低相关（aOR=0.60，P<.001）。鳞状细胞、腺和肉瘤样组织学与任何 pT 降期的调整后几率降低显著相关。神经内分泌组织学（NE）趋势为 pT0N0 降期的调整后几率增加。在膀胱内 pCR 的情况下，VH 患者更有可能隐匿性区域淋巴结转移。NE 具有最高的 pT0N0 率，这对化疗后膀胱保留具有潜在影响。这些发现强调了 NAC 后 RC 的作用，特别是对于 VH。
