Discordant Response in Pelvic Lymph Nodes and Cystectomy Specimens After Neoadjuvant Chemotherapy in Muscle-invasive Bladder Cancer.

Authors

Luca Antonelli, Luca Afferi, Francesco Del Giudice, Eugenio Bologna, Francesco Esperto, Francesco Chierigo, Alessandro Antonelli, Karl Tully, Paolo Umari, Simone Albisinni, Andrea Mari, Renate Pichler, Francesco Claps, Jeremy Yuen-Chun Teoh, Mathieu Roumiguié, Gerald Bastian Schulz, Luca Orecchia, Francesco Soria, Morgan Roupret, Gautier Marcq, Cedric Poyet, Girish S Kulkarni, Michael Rink, Tobias Klatte, Riccardo Campi, Wojciech Krajewski, Laura Mertens, Meftun Culpan, Luke T Lavallée, Marco Moschini, Christian Daniel Fankhauser, EAU YAU urothelial carcinoma working group

Published in

European urology focus. Jul 28, 2026. Epub Jul 28, 2026.

Abstract

Radical cystectomy with pelvic lymph node dissection (PLND) remains the standard treatment for muscle-invasive bladder cancer (MIBC). Neoadjuvant chemotherapy (NAC) improves survival, and recent immunochemotherapy trials have reported complete pathological responses in up to 60% of patients, increasing interest in bladder-sparing strategies. However, the ability to accurately identify patients without residual pelvic lymph node metastases after NAC remains limited.
To evaluate the association between pathological response in the bladder and pelvic lymph node status after NAC in patients with MIBC undergoing radical cystectomy (RC) and PLND.
This retrospective, multi-institutional cohort study included 751 patients with MIBC treated with NAC followed by RC and PLND between 2000 and 2021 across 26 institutions.
Neoadjuvant chemotherapy followed by RC and PLND.
The primary outcome was residual lymph node involvement (ypN+). Multivariable logistic regression was used to identify factors associated with ypN+.
Overall, 175 patients (23%) achieved a complete pathological response in the bladder (ypT0), 102 (14%) were downstaged to non-muscle-invasive disease (ypTa/ypTis/ypT1), and 185 (25%) had residual lymph node involvement. On multivariable analysis, cN+ disease before NAC was associated with higher odds of ypN+ (OR 1.97, 95% CI 1.32-2.94), whereas ypT0 (OR 0.11, 95% CI 0.05-0.21) and ypTa/ypTis/ypT1 (OR 0.24, 95% CI 0.12-0.47) were associated with lower odds of ypN+. Notably, 5% of ypT0 and 10% of downstaged patients harboured residual lymph node metastases. Limitations include potential selection bias and centre-level variability in surgical and pathological assessment, which may affect the generalizability of the findings.
Current clinical and radiological variables cannot reliably exclude residual pelvic lymph node disease, even in patients achieving ypT0-1. Novel imaging techniques and liquid biomarkers require validation before bladder-sparing approaches can be safely expanded.

PMID:
42521520
Bibliographic data and abstract were imported from PubMed on 29 Jul 2026.

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