The impact of primary stage on survival in patients with lymph node positive bladder cancer

Contemporary series indicate that survival of cystectomy candidates with node positive bladder cancer is favorable when the primary tumor is confined to the bladder wall and lymph node involvement is minimal. However, these series lack node negative controls with a similar tumor stage to determine accurately the true impact of pelvic lymphadenectomy and radical cystectomy on survival.

We retrospectively analyzed disease specific survival in 686 consecutive cystectomy candidates of whom 193 (28.1%) had node positive disease at radical cystectomy. To correct for bias towards higher P category in the node positive group we subdivided groups into organ and nonorgan confined categories to compare outcome between node negative and node positive cases.

The frequency of organ confined disease in node positive cases was 22.8% compared to 59.2% in node negative cases. Although when analyzing the entire group disease specific survival was significantly decreased in node positive cases, after correction for P stage we found no statistically significant differences in survival between N0 and N1 cases in the organ confined group (p = 0.4267). Differences between N0 and N1 cases in nonorgan confined disease were statistically significant (p = 0.0276). Significance levels were more pronounced when cases with N2 or N3 categories were compared with node negative cases. Comparison of survival between node negative and N2 or N3 in either group revealed significant differences indicating limited impact of surgery alone at this disease stage.

Patients with N1 disease seem to benefit from pelvic lymphadenectomy and radical cystectomy as evidenced by similar outcome in those with node negative disease and similar P stage of the primary tumor. However, the observed benefit rapidly disappears when more than 1 lymph node is involved and additional therapy other than surgery seems appropriate.