Sorbonne University, GRC 5, Predictive Onco-Urology, APHP, Pitié-Salpêtrière Hospital, Urology, 75013, Paris, France.
Division of Urology, Geneva University Hospitals, Geneva, Switzerland.
Nat Rev Urol. 2024 Jun;21(6):339-356. doi: 10.1038/s41585-023-00842-y. Epub 2024 Jan 31.
Identification of clinically positive pelvic lymph node metastases (cN+) in patients with muscle-invasive bladder cancer is currently challenging, as the diagnostic accuracy of available imaging modalities is limited. Conventional CT is still considered the gold-standard approach to diagnose lymph node metastases in these patients. The development of innovative diagnostic methods including radiomics, artificial intelligence-based models and molecular biomarkers might offer new perspectives for the diagnosis of cN+ disease. With regard to the treatment of these patients, multimodal strategies are likely to provide the best oncological outcomes, especially using induction chemotherapy followed by radical cystectomy and pelvic lymph node dissection in responders to chemotherapy. Additionally, the use of adjuvant nivolumab has been shown to decrease the risk of recurrence in patients who still harbour ypT2-T4a and/or ypN+ disease after surgery. Alternatively, the use of avelumab maintenance therapy can be offered to patients with unresectable cN+ tumours who have at least stable disease after induction chemotherapy alone. Lastly, patients with cN+ tumours who are not responding to induction chemotherapy are potential candidates for receiving second-line treatment with pembrolizumab.
目前，在肌肉浸润性膀胱癌患者中，识别临床阳性盆腔淋巴结转移（cN+）具有挑战性，因为现有影像学方法的诊断准确性有限。传统 CT 仍然被认为是诊断这些患者淋巴结转移的金标准方法。包括放射组学、基于人工智能的模型和分子生物标志物在内的创新诊断方法的发展，可能为 cN+疾病的诊断提供新的视角。关于这些患者的治疗，多模式策略可能提供最佳的肿瘤学结果，特别是在对化疗有反应的患者中使用诱导化疗后行根治性膀胱切除术和盆腔淋巴结清扫术。此外，辅助使用纳武利尤单抗可降低手术后仍存在 ypT2-T4a 和/或 ypN+疾病患者复发的风险。或者，对于诱导化疗后仅疾病稳定的不可切除的 cN+肿瘤患者，可以提供avelumab 维持治疗。最后，对诱导化疗无反应的 cN+肿瘤患者可能是接受二线治疗（pembrolizumab）的潜在候选者。
