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there are several aspects that have to be considered. First of
all, the cause of death was not reported. Indeed, this is a
relevant variable as patients with UCB have several
comorbidities that can inevitably bias OS. Further, there
is also a strong selection bias because of the
[5_TD$DIFF]
study design.
Preoperative chemotherapy was offered to younger and
probably fitter patients with lower clinical T and N stages.
Chemotherapy regimens, doses, and treatment duration
varied among institutions, but it was not possible to include
these data.
[6_TD$DIFF]
Finally, histological variants of UCB were not
considered in the analysis. This is
[7_TD$DIFF]
a relevant bias as
histological variants are associated with worse clinical and
oncological outcomes
[4]
as well as reduced response rates
to systemic therapy
[5]
. Nevertheless, on multivariable
analyses, patients treated with a multimodal approach had
best OS outcomes. As described in previous studies, patients
with a pathologic down-staging had the greatest survival
benefit
[6]
.
In conclusion, patients with cN+ and favorable tumor
biology may have a survival benefit if approached with a
multimodal treatment
[2_TD$DIFF]
consisting of surgery and preopera-
tive chemotherapy. Treatment can be curative in 25%
of patients. The biggest challenge remains patient selection
for the multimodal approach, specifically of those who
should undergo surgery after chemotherapy. Patient
selection may be improved by focusing on histologic
variants, molecular profiling of the tumor, and new
imaging technologies.
Conflicts of interest:
The authors have nothing to disclose.
References
[1]
Galsky MD, Stensland K, Sfakianos JP, et al. Comparative effective- ness of treatment strategies for bladder cancer with clinical evidence of regional lymph node involvement. J Clin Oncol 2016;34:2627–35.
[2]
Ho PL, Willis DL, Patil J, et al. Outcome of patients with clinically node-positive bladder cancer undergoing consolidative surgery after preoperative chemotherapy: The M.D. Anderson Cancer Cen- ter Experience. Urol Oncol 2016;34, 59.e1–8.[3]
Zargar-Shoshtari K, Zargar H, Lotan Y, et al. A multi-institutional analysis of outcomes of patients with clinically node positive urothelial bladder cancer treated with induction chemotherapy and radical cystectomy. J Urol 2016;195:53–9.
[4]
Rogers CG, Palapattu GS, Shariat SF, et al. Clinical outcomes follow- ing radical cystectomy for primary nontransitional cell carcinoma of the bladder compared to transitional cell carcinoma of the bladder. J Urol 2006;175:2048–53, discussion 2053.
[5]
Ghoneim IA, Miocinovic R, Stephenson AJ, et al. Neoadjuvant syste- mic therapy or early cystectomy?. single-center analysis of outcomes after therapy for patients with clinically localized micropapillary urothelial carcinoma of the bladder. Urology 2011;77:867–70.
[6]
Izquierdo L, Peri L, Leon P, et al. The role of cystectomy in elderly patients—a multicentre analysis. BJU Int 2015;116(Suppl 3):73–9.
David D’Andrea,
[1_TD$DIFF]
Shahrokh F. Shariat
*
[3_TD$DIFF]
Medical University of Vienna, Vienna, Austria
*Corresponding author. Medical University of Vienna,
[4_TD$DIFF]
Department of
Urology, Wa¨hringer Gu¨ rtel 18-20, Vienna 1090, Austria.
E-mail address:
sfshariat@gmail.com(
[1_TD$DIFF]
Shahrokh F. Shariat).
http://dx.doi.org/10.1016/j.eururo.2017.05.041#
2017 European Association of Urology.
Published by Elsevier B.V. All rights reserved.
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