The study cohort consisted of 67 patients, of whom 79.1% were male, and the median age was 71 years. Most patients (56.7%) had ≥ cT3 disease without clinical nodal metastases (92.5%). Approximately 61% and 19% of patients received neoadjuvant and adjuvant chemotherapy, respectively. At the final radical cystectomy, 70.1% of patients had ≥ pT3, 43.3% were pathologically node-positive, and 29.9% had positive soft tissue margins. Pathologic downstaging (<pT2) in response to neoadjuvant chemotherapy occurred in 13.4% of patients. The unadjusted hazard ratio (HR) for soft tissue margin status and overall survival (OS) was 4.0 when a positive margin was detected (p < 0.01). A negative surgical margin was associated with a median OS of 27 months, while a positive margin was associated with a median OS of 2 months (p < 0.01).
The median lymph node yield among patients was 22, and 19 lymph nodes were determined to be the optimal cut-off for lymph node count. Median disease-free survival (DFS) was 15 months for patients with a lymph node count ≥ 20 (optimal-LNC) and 5 months for patients with lymph node count < 20 (suboptimal-LNC) (p = 0.05). Median OS was 29 months among optimal-LNC patients and 10 months among suboptimal-LNC patients (p = 0.02). Patients who achieved two surgical milestones, negative surgical margin and examining 20 or more lymph nodes, had higher DFS and OS than patients who did not (p < 0.01). In multivariate analysis for OS, variables associated with improved OS were negative surgical margin (HR 0.38, 0.19−0.76 CI 95%, p = 0.01) and optimal-LNC (HR 0.47, 0.24−0.93 CI 95%, p = 0.03).
Overall, patients with PUC who underwent radical cystectomy and lymph node dissection with 20 or more lymph nodes excised had better clinical outcomes. Aggressive surgical resection may also improve clinical outcomes, as surgical margins also impacted survival. Importantly, specific lymphadenectomy templates did not have a significant impact on survival.
Written by: Bishoy M. Faltas, MD, Director of Bladder Cancer Research, Englander Institute for Precision Medicine, Weill Cornell Medicine
Reference:
- Davaro F, Davaro E, Rose K, et al. Impact of surgical margin and extent of lymphadenectomy on oncologic outcomes in plasmacytoid urothelial carcinoma [published online ahead of print, 2023 Mar 21]. Urol Oncol. 2023;S1078-1439(23)00077-7.