Clinical Scenario: Clinical Pelvic Nodal Metastases After Complete Response to Chemotherapy

52-Year-old man with T2 N1 M0 urothelial carcinoma who undergoes platinum-based chemotherapy with complete response
  • Adam C. ReeseEmail author
  • Mark Schoenberg


Pelvic lymph node metastases are an adverse prognostic factor in patients with urothelial carcinoma of the bladder. Nonetheless, a substantial percentage of these patients will exhibit a clinical response to chemotherapy, with resolution of lymphadenopathy on post-chemotherapy imaging studies. The management of these patients is complex, as many will have persistent micrometastatic disease at the time of radical cystectomy despite an apparent response to chemotherapy, illustrating the limitations of our current imaging modalities. Furthermore, the rate of response to chemotherapy for pelvic lymph node metastases may differ from the response rate of primary tumors, and the response to chemotherapy is highly variable among individuals.

The role of radical cystectomy in this setting remains unclear. The literature suggests that pathological evaluation of the bladder and regional lymph nodes after radical cystectomy is the only way to truly assess response to chemotherapy. Thus, surgery is the most effective manner of staging these patients, and pathology after radical cystectomy is strongly correlated with patient prognosis. However, the independent contribution of surgery, above and beyond that of chemotherapy, in improving survival for patients with pelvic nodal metastases remains unclear.


Urinary bladder neoplasms Chemotherapy Cystectomy Lymph nodes Neoplasm metastasis 


  1. 1.
    Dimopoulos MA, Finn L, Logothetis CJ. Pattern of failure and survival of patients with metastatic urothelial tumors relapsing after cis-platinum-based chemotherapy. J Urol. 1994;151:598.PubMedGoogle Scholar
  2. 2.
    Sternberg CN, Yagoda A, Scher HI, et al. Methotrexate, vinblastine, doxorubicin, and cisplatin for advanced transitional cell carcinoma of the urothelium. Efficacy and patterns of response and relapse. Cancer. 1989;64:2448.PubMedCrossRefGoogle Scholar
  3. 3.
    von der Maase H, Hansen SW, Roberts JT, et al. Gemcitabine and cisplatin versus methotrexate, vinblastine, doxorubicin, and cisplatin in advanced or metastatic bladder cancer: results of a large, randomized, multinational, multicenter, phase III study. J Clin Oncol. 2000;18:3068.PubMedGoogle Scholar
  4. 4.
    Meijer RP, Nieuwenhuijzen JA, Meinhardt W, et al. Response to induction chemotherapy and surgery in non-organ confined bladder cancer: a single institution experience. Eur J Surg Oncol. 2013;39:365.PubMedCrossRefGoogle Scholar
  5. 5.
    Nieuwenhuijzen JA, Bex A, Meinhardt W, et al. Neoadjuvant methotrexate, vinblastine, doxorubicin and cisplatin for histologically proven lymph node positive bladder cancer. J Urol. 2005;174:80.PubMedCrossRefGoogle Scholar
  6. 6.
    Eisenhauer EA, Therasse P, Bogaerts J, et al. New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer. 2009;45:228.PubMedCrossRefGoogle Scholar
  7. 7.
    Paik ML, Scolieri MJ, Brown SL, et al. Limitations of computerized tomography in staging invasive bladder cancer before radical cystectomy. J Urol. 2000;163:1693.PubMedCrossRefGoogle Scholar
  8. 8.
    Herr HW. Routine CT scan in cystectomy patients: does it change management? Urology. 1996;47:324.PubMedCrossRefGoogle Scholar
  9. 9.
    Schrier BP, Peters M, Barentsz JO, et al. Evaluation of chemotherapy with magnetic resonance imaging in patients with regionally metastatic or unresectable bladder cancer. Eur Urol. 2006;49:698.PubMedCrossRefGoogle Scholar
  10. 10.
    Jensen TK, Holt P, Gerke O, et al. Preoperative lymph-node staging of invasive urothelial bladder cancer with 18F-fluorodeoxyglucose positron emission tomography/computed axial tomography and magnetic resonance imaging: correlation with histopathology. Scand J Urol Nephrol. 2011;45:122.PubMedCrossRefGoogle Scholar
  11. 11.
    Swinnen G, Maes A, Pottel H, et al. FDG-PET/CT for the preoperative lymph node staging of invasive bladder cancer. Eur Urol. 2010;57:641.PubMedCrossRefGoogle Scholar
  12. 12.
    Drieskens O, Oyen R, Van Poppel H, et al. FDG-PET for preoperative staging of bladder cancer. Eur J Nucl Med Mol Imaging. 2005;32:1412.PubMedCrossRefGoogle Scholar
  13. 13.
    Kibel AS, Dehdashti F, Katz MD, et al. Prospective study of [18F]fluorodeoxyglucose positron emission tomography/computed tomography for staging of muscle-invasive bladder carcinoma. J Clin Oncol. 2009;27:4314.PubMedCentralPubMedCrossRefGoogle Scholar
  14. 14.
    Grossman HB, Natale RB, Tangen CM, et al. Neoadjuvant chemotherapy plus cystectomy compared with cystectomy alone for locally advanced bladder cancer. N Engl J Med. 2003;349:859.PubMedCrossRefGoogle Scholar
  15. 15.
    Sonpavde G, Goldman BH, Speights VO, et al. Quality of pathologic response and surgery correlate with survival for patients with completely resected bladder cancer after neoadjuvant chemotherapy. Cancer. 2009;115:4104.PubMedCentralPubMedCrossRefGoogle Scholar
  16. 16.
    Stein JP, Lieskovsky G, Cote R, et al. Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1,054 patients. J Clin Oncol. 2001;19:666.PubMedGoogle Scholar
  17. 17.
    Ploeg M, Kiemeney LA, Smits GA, et al. Discrepancy between clinical staging through bimanual palpation and pathological staging after cystectomy. Urol Oncol. 2012;30:247.PubMedCrossRefGoogle Scholar
  18. 18.
    Weight CJ, Garcia JA, Hansel DE, et al. Lack of pathologic down-staging with neoadjuvant chemotherapy for muscle-invasive urothelial carcinoma of the bladder: a contemporary series. Cancer. 2009;115:792.PubMedCrossRefGoogle Scholar
  19. 19.
    Kaag MG, Milowsky MI, Dalbagni G, et al. Regional lymph node status in patients with bladder cancer found to be pathological stage T0 at radical cystectomy following systemic chemotherapy. BJU Int. 2011;108:E272.PubMedCrossRefGoogle Scholar
  20. 20.
    Efstathiou JA, Spiegel DY, Shipley WU, et al. Long-term outcomes of selective bladder preservation by combined-modality therapy for invasive bladder cancer: the MGH experience. Eur Urol. 2012;61:705.PubMedCrossRefGoogle Scholar
  21. 21.
    Rodel C, Weiss C, Sauer R. Trimodality treatment and selective organ preservation for bladder cancer. J Clin Oncol. 2006;24:5536.PubMedCrossRefGoogle Scholar
  22. 22.
    Herr HW, Donat SM, Bajorin DF. Post-chemotherapy surgery in patients with unresectable or regionally metastatic bladder cancer. J Urol. 2001;165:811.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Department of UrologyTemple University School of MedicinePhiladelphiaUSA
  2. 2.The Department of UrologyAlbert Einstein College of Medicine & The Montefiore Medical Center, Medical Arts PavilionBronxUSA

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