EURURO Vol. 72 No. 3

474 476

although lack of power because of low accrual might have
impacted the outcomes [4].
Finally, the current UC immunotherapy revolution is
likely to impact the management of patients with UTUC.
Ongoing UC clinical trials in the adjuvant setting are
including UTUC patients to receive either atezolizumab
(NCT02450331) or nivolumab (NCT02632409), but there
are no studies of preoperative immunotherapy available to
date. The latter would be more favorably supported by the
Young Academic Urologists group of the European Associa-
tion of Urology. The possibility of delivering short
neoadjuvant courses of effective treatments before RNU
has the potential for revitalized collaboration between
surgical and clinical oncology disciplines. It is a shared
opinion that the neoadjuvant platform has potential to
enhance our knowledge of the effect of immune checkpoint
inhibitors because of the opportunity to access tissue at
different time points. The rationale for clinical trials in the
UTUC population is supported by different underlying
biology in UTUC compared to UC of bladder origin. Such
differences may be mirrored by mechanisms of response
and development of resistance to immune checkpoint
inhibitor therapy [5].
In conclusion, we agree with the authors that despite the
inherent shortcomings and limitations, the study findings
to date should be considered to enhance patient counseling
and to inform post-RNU management of pT3–pT4 and/or
pN+ UTUC pending results fromdedicated clinical trials and,
most importantly, revisited management of UTUC via a
multidisciplinary approach from the early stages of the
disease.
Conflicts of interest: The authors have nothing to disclose.
References
[1]
[2]
.
[3]
[4]
[5]
Evanguelos Xylinasa,*, Andrea Necchib
on behalf of the Young Academic Urologists Urothelial Carcinoma Group
of the European Association of Urology
a Department of Urology, Cochin Hospital, Assistance Publique Hoˆpitaux de
Paris, Paris Descartes University, Paris, France
b Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei
Tumori, Milan, Italy
*Corresponding author. Department of Urology, Cochin Hospital,
Assistance Publique Hoˆpitaux de Paris, Paris Descartes University,
2 Rue Charles Tellier, Paris 75016, France.
E-mail address: (E. Xylinas).
# 2017 European Association of Urology.
Published by Elsevier B.V. All rights reserved.
Re: Comparative Effectiveness of Treatment Strategies
for Bladder Cancer with Clinical Evidence of Regional
Lymph Node Involvement
Galsky MD, Stensland K, Sfakianos JP, et al
J Clin Oncol 2016;34:2627–35
Experts’ summary:
This retrospective study [1] investigated the effect of different
treatment approaches for clinically node positive (cN+)
urothelial carcinoma of the bladder (UCB) on overall survival.
Data were retrieved from the National Cancer Data Base and
included 1739 patients. Exclusion criteria were missing data
regarding the timing or administration of chemotherapy,
contraindications to chemotherapy due to patient comorbid-
ities (defined by National Cancer Data Base coding), receipt of
single-agent chemotherapy or radiation, initiation of first
treatment 6 mo after clinical staging, or age 85 yr. In
essence, the authors show that patients treated with cystec-
tomy and preoperative chemotherapy had the best 5-yr sur-
vival rates (31%, 95% confidence interval: 25–38%),
particularly those who had a down-staging after systemic
treatment.
Experts’ comments:
Patients with cN+ UCB have a poor prognosis. Treatment is
usually palliative. According to the European Association of
Urology guidelines, patients should receive cisplatin-based
chemotherapy as first-line treatment (level of evidence 1b,
recommendation Grade A).
If these patients can be approached with multimodal
curative intent has still not been elucidated. There are few
retrospective studies that provide limited evidence. Ho et al
[2] achieved a 66% 5-yr cancer-specific survival in patients
with downstaging to pN0 after preoperative chemotherapy.
However, 29% of the patients with radiologic complete
response were pN+ at the time of cystectomy and had a 5-yr
cancer-specific survival rate of only 12%. Similar results
were obtained by Zargar-Shoshtari et al [3]. Patients that
achieved a pN0 status after chemotherapy had better
outcomes than those with pN+. Nevertheless, there was no
statistically significant difference in terms of overall
survival (OS) in cN1 versus cN2–3. Importantly, the cut-
off of 15 lymph nodes harvested during lymphadenectomy
predicted OS.
Although the present article represents the largest series
addressing survival outcomes for patients with cN+ UCB,
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