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Purpose <p>Preoperative chemotherapy (POC) combined with radical cystectomy (RC) is the standard treatment for clinically node-negative (cN0) bladder cancer (BC), but its role in clinically node-positive (cN+) disease remains uncertain. We investigated whether POC + RC improves outcomes in cN+ patients by assessing whether the survival gap between cN0 and cN+ patients is smaller than that historically observed in RC-only cohorts. We also evaluated whether radiographic nodal response predicts prognosis.</p> Materials and methods <p>We retrospectively analyzed patients with T2-4N0M0 or T1-4N + M0 BC who underwent POC + RC at our institution between 1999 and 2019. Recurrence-free survival (RFS) and cancer-specific survival (CSS) were compared between the cN0 and cN+ groups using Cox regression analysis. The hazard ratios (HRs) for cN+/cN0 survival in our cohort were then compared to published HRs from the largest RC-only series, adjusted for clinical rather than pathological nodal staging (non-inferiority margins: HR 2.19 for RFS, HR 2.39 for CSS).</p> Results <p>Among 142 patients (73 cN0, 69 cN+), 5-year RFS was 68% in both groups. The HR for recurrence in cN+ versus cN0 patients was 1.10 (95% Confidence interval [CI] 0.67–1.80), significantly lower than the RC-only benchmark (HR 2.19), demonstrating non-inferiority and suggesting the benefit of POC in cN+ disease. For CSS, 5-year rates were 80% (cN0) and 70% (cN+); the HR was 1.64 (95% CI 0.92–2.92), not significantly lower than the RC-only margin (HR 2.39). Among 72 cN+ patients with radiographic nodal assessment, complete or stable nodal response predicted superior RFS and CSS (<i>p</i> &lt; 0.001 for both). Pathological downstaging (<i>p</i> = 0.03) and mean lymph node density (<i>p</i> = 0.043) were also significantly better in clinical responders.</p> Conclusion <p>Compared with RC alone, POC + RC narrows the survival gap between cN+ and cN0 patients, supporting its use in cN+ disease. Radiographic nodal response is a robust preoperative predictor of survival and may inform treatment decisions.</p>

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Effectiveness of preoperative chemotherapy and radical cystectomy in clinically node-positive and node-negative bladder cancer patients

  • 期刊论文

  • 发表日期：

    2026年4月19日

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  • Murat Akand,
  • Thomas Van Weyenbergh,
  • Lisa Moris,
  • Tim Muilwijk,
  • Simon Bulteel,
  • Tomas Gajdos,
  • Frank Van der Aa,
  • Wouter Everaerts,
  • Hendrik Van Poppel,
  • Maarten Albersen,
  • Steven Joniau

摘要

Purpose

Preoperative chemotherapy (POC) combined with radical cystectomy (RC) is the standard treatment for clinically node-negative (cN0) bladder cancer (BC), but its role in clinically node-positive (cN+) disease remains uncertain. We investigated whether POC + RC improves outcomes in cN+ patients by assessing whether the survival gap between cN0 and cN+ patients is smaller than that historically observed in RC-only cohorts. We also evaluated whether radiographic nodal response predicts prognosis.

Materials and methods

We retrospectively analyzed patients with T2-4N0M0 or T1-4N + M0 BC who underwent POC + RC at our institution between 1999 and 2019. Recurrence-free survival (RFS) and cancer-specific survival (CSS) were compared between the cN0 and cN+ groups using Cox regression analysis. The hazard ratios (HRs) for cN+/cN0 survival in our cohort were then compared to published HRs from the largest RC-only series, adjusted for clinical rather than pathological nodal staging (non-inferiority margins: HR 2.19 for RFS, HR 2.39 for CSS).

Results

Among 142 patients (73 cN0, 69 cN+), 5-year RFS was 68% in both groups. The HR for recurrence in cN+ versus cN0 patients was 1.10 (95% Confidence interval [CI] 0.67–1.80), significantly lower than the RC-only benchmark (HR 2.19), demonstrating non-inferiority and suggesting the benefit of POC in cN+ disease. For CSS, 5-year rates were 80% (cN0) and 70% (cN+); the HR was 1.64 (95% CI 0.92–2.92), not significantly lower than the RC-only margin (HR 2.39). Among 72 cN+ patients with radiographic nodal assessment, complete or stable nodal response predicted superior RFS and CSS (p < 0.001 for both). Pathological downstaging (p = 0.03) and mean lymph node density (p = 0.043) were also significantly better in clinical responders.

Conclusion

Compared with RC alone, POC + RC narrows the survival gap between cN+ and cN0 patients, supporting its use in cN+ disease. Radiographic nodal response is a robust preoperative predictor of survival and may inform treatment decisions.