Pelvic lymph node dissection can be curative in patients with node positive bladder cancer

Purpose: We analyze outcome in a large cohort of patients with bladder cancer metastatic to the regional lymph nodes using disease specific survival as the end point. Materials and Methods: To identify predictors for outcome a large series of 193 consecutive patients with regional lymph node metastases operated on from 1980 to 1990 at Memorial Sloan-Kettering Cancer Center was retrospectively analyzed. Results: Among various clinical and pathological parameters, univariate and multivariate analyses identified only P (p = 0.0001) and N categories (p = 0.0006) as parameters predicting disease specific survival. In patients who received chemotherapy or irradiation either as part of a nonrandomized clinical protocol or on an ad hoc basis no beneficial impact on disease specific survival could be demonstrated. Survival was also not affected by pathological grade and other histological parameters, since pathological features in patients with node positive bladder cancer are uniformly shifted towards high grade lesions with vascular or lymphatic invasion and a solid appearance on histological analysis. Conclusions: Nodal metastases carry a poor prognosis despite pelvic lymphadenectomy and radical cystectomy. Nevertheless, some node positive cases with otherwise localized bladder cancer and/or low N category appear to benefit from surgery. Our findings of improved outcome in some individuals with node positive disease should be considered in the design of clinical trials evaluating the effects of adjuvant or neoadjuvant treatment strategies, and emphasize the importance of randomized studies to assess the results of these approaches.