Old friends, new ways: revisiting extended lymphadenectomy and neoadjuvant chemotherapy to improve outcomes

Standard therapy for muscle-invasive bladder cancer is radical cystectomy and pelvic-lymph-node dissection. Because 50% of patients will die at 5 years as a result of micrometastases, improvements have been sought to increase the survival rates. Two specific approaches include administration of neoadjuvant chemotherapy or extending the boundaries of the lymph-node dissection. We reviewed the current literature to define present trends and studies that involve these adjunct treatments.

The benefits of extended lymphadenectomy have been demonstrated by several groups. These include mapping nodal metastatic sites and defining the requisite number of nodes removed to optimize survival. Though not universal, it is frequently concluded that increasing the number of nodes removed improves survival without worse morbidity. Neoadjuvant chemotherapy has been proposed to eliminate occult cancer cells outside the margins of resection. Results have been variable and modest, though emerging data from the Southwest Oncology Group may further support such an approach and improve organ preservation.

Extended lymphadenectomy has consistently shown benefit with minimal morbidity and should be considered--especially in cystectomy patients that are T3. The results from neoadjuvant chemotherapy are more modest. Further studies await further elucidation to confirm this.