What is the prognosis for bladder cancer with muscularis propria (muscle layer) invasion and no lymph node involvement?

From the Guidelines

The prognosis for bladder cancer that has invaded the muscular layer (stage T2) without lymph node involvement (N0) is generally moderate, with a 5-year survival rate of approximately 60-70%. Treatment typically involves radical cystectomy (complete removal of the bladder) with pelvic lymph node dissection as the standard of care. Neoadjuvant chemotherapy before surgery, usually with a cisplatin-based regimen such as MVAC (methotrexate, vinblastine, adriamycin, and cisplatin) or gemcitabine plus cisplatin for 3-4 cycles, improves survival by about 5-8% and is recommended for eligible patients 1. For those who cannot undergo surgery, a bladder-preserving approach combining transurethral resection, radiation therapy, and concurrent chemotherapy may be considered. Some key points to consider in the management of bladder cancer include:

• The use of neoadjuvant chemotherapy, which has been shown to improve survival rates in patients with muscle-invasive bladder cancer 1
• The importance of radical cystectomy with pelvic lymph node dissection as the standard of care for patients with muscle-invasive bladder cancer 1
• The potential benefits of a bladder-preserving approach for patients who are not candidates for surgery 1
• The need for regular follow-up, including cystoscopy, imaging studies, and urine cytology, to monitor for recurrence 1 The depth of muscle invasion, tumor grade, presence of lymphovascular invasion, and patient factors like age and overall health significantly influence individual prognosis. Early detection of recurrence is crucial as it allows for prompt intervention and potentially improved outcomes.

From the Research

Prognosis for Bladder Cancer Invading Muscular Layer with No Lymph Node Involvement

• The prognosis for bladder cancer invading the muscular layer with no lymph node involvement can be improved with neoadjuvant chemotherapy, as shown in studies 2, 3, 4, 5, 6.
• Neoadjuvant chemotherapy has been associated with improved overall survival and disease-free survival in patients with muscle-invasive bladder cancer, with a 5-year absolute overall survival benefit of 5% and a 9% improvement in disease-free survival 4.
• The use of platinum-based treatment, such as cisplatin with vinblastine, methotrexate, doxorubicin, gemcitabine, adriamycin, or epirubicin, is the gold standard for neoadjuvant chemotherapy in muscle-invasive bladder cancer 4.
• Recent studies have also investigated the use of immunotherapy in the neoadjuvant setting, with promising results, including complete response rates of 29% with atezolizumab and 39.5% with pembrolizumab 4.
• The safety and efficacy of neoadjuvant chemotherapy have been demonstrated in patients of all ages, including older adults, with careful selection based on clinical variables rather than age 5.
• Radical cystectomy and extended pelvic lymph node dissection should be performed by expert surgeons to ensure optimal surgery and improve prognosis 6.

Factors Affecting Prognosis

• The adequacy of lymph node dissection has been associated with improved overall survival, with a hazard ratio of 0.62 for <10 nodes and 0.48 for ≥10 nodes 2.
• The presence of neoadjuvant chemotherapy has been associated with improved progression-free survival and cancer-specific survival, with median progression-free survival and cancer-specific survival not reached in patients who received neoadjuvant chemotherapy 3.
• Age, pN+, pT2, high neutrophil-to-lymphocyte ratio, and high C-reactive protein level have been identified as independent poor prognostic factors for cancer-specific survival 3.