M1-node-only disease in the bladder refers to nodes outside the pelvis. Metastatic bladder cancer is an aggressive disease that is incurable in most patients. The survival of this disease is driven by key prognostic factors, which include the performance status and sites of metastatic disease (where lymph node only metastatic disease has a relatively favorable prognosis).
Cisplatin-based chemotherapy has the potential to be curative, as opposed to other types of more contemporary therapy, such as immune checkpoint inhibitors. Patients cured by cisplatin have favorable prognostic factors. Surgery in these favorable patients is probably overtreatment and adds little value. Moreover, radical cystectomy is a morbid procedure and should probably not be performed in these patients.
A study published more than 20 years ago examined 203 metastatic bladder cancer patients who received chemotherapy for their metastatic disease.1 A total of 50 patients underwent postchemotherapy surgery of suspected residual disease. 17 patients had no viable disease, and their 5-year survival rate was 41%. 30 patients who had a viable disease which was completely resected – their 5-year survival rate was 33% (figure 1). Only patients with regional lymph node disease involvement at baseline were more likely to survive long term.1
In a large systematic review from 2018 examining the role of surgery in metastatic bladder cancer, the authors concluded that the beneficial role of consolidative surgery in metastatic bladder cancer is still unproven.2 In patients with clinically significant lymph node metastases only, data suggest a survival advantage for patients undergoing postchemotherapy surgery. Surgery can be considered in patients with pelvic or retroperitoneal lymph node disease, but only if the patient had a response to chemotherapy.
Figure 1 – Survival with postchemotherapy surgery:
Another study examined the effect of postchemotherapy retroperitoneal lymph node dissection (RPLND) in metastatic bladder cancer patients. The study included 11 highly selected patients with lymph node only metastases who all had a major response to first-line chemotherapy. RPLND was potentially curative but only if 2 or fewer positive nodes were present.3
Dr. Balar concluded his presentation by stating that the quality of evidence for surgery in this setting is still poor. While some of the data are pulled from prospective studies involving chemotherapy, the choice to undergo surgery was mostly physician/patient dependent. Therefore, there is a great deal of patient selection. It is critical to make sure that surgery is performed only in those who respond to chemotherapy (select only the “winners”) and to remember that surgery by itself is not curative in M1 disease. Importantly, we still lack biomarkers that can help pave the way to select responsive patients. Lastly, radical cystectomy is a morbid procedure with approximately 50-60% complication rate, 4-5% mortality rate, and a permanent impact on the quality of life, more than other major surgeries performed on other organs (Figure 2).
Figure 2- Comparison of time to readmission following major surgeries:4
Presented by: Arjun V. Balar, MD, Associate Professor, Department of Medicine and Director of the genitourinary medical oncology program at NYU Langone’s Perlmutter Cancer Center. NYU Langone Health, New York, New York
Written by: Hanan Goldberg, MD, MSc, Assistant Professor, Urology Department, SUNY Upstate Medical University, Syracuse, NY, USA @GoldbergHanan at the 2020 Society of Urologic Oncology Annual Meeting – December 2-5, 2020 – Washington, DC
References:
- Dodd PM, McCaffrey JA, Herr H, et al. Outcome of postchemotherapy surgery after treatment with methotrexate, vinblastine, doxorubicin, and cisplatin in patients with unresectable or metastatic transitional cell carcinoma. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 1999; 17(8): 2546-52.
- Abufaraj M, Dalbagni G, Daneshmand S, et al. The Role of Surgery in Metastatic Bladder Cancer: A Systematic Review. European urology 2018; 73(4): 543-57.
- Sweeney P, Millikan R, Donat M, et al. Is there a therapeutic role for post-chemotherapy retroperitoneal lymph node dissection in metastatic transitional cell carcinoma of the bladder? The Journal of urology 2003; 169(6): 2113-7.
- Stitzenberg KB, Chang Y, Smith A, Nielsen ME. Place of readmission and outcomes after major cancer surgery. Journal of Clinical Oncology 2014; 32(15_suppl): 6531