Introduction & Objectives:

Literature about the impact and the reliability of clinical N+ in the context of radical cystectomy
(RC) due to bladder cancer is scarce. Under this light we presented the first work trying to assess
concordance between clinical and pathological N status and to calculate how these parameter could
impact on survival.
Material & Methods:
Overall, 3,966 consecutive BCa patients treated with radical cystectomy (RC) at a tree centers
between January 1980 and December 2013 were identified. Complete clinical, pathological and
follow-up data were available for all the patients. Clinical N+ are defined according European
guidelines as pelvic nodes >8 mm or abdominal nodes >10 mm in maximum short-axis diameter
detected by CT or MRI. Independent-samples t-test and chi-square test were, respectively used for
comparison of means and proportions. Kaplan Meyer estimates were used to assess cancer specific
mortality (CSM) and overall mortality (OM) after RC. Univariable (UVA) Cox regression analyses
were performed for prediction of CSM and OM for all available variables.
Results:
Mean age at RC was 67 years. Considering clinical N status, 413 (10.4%) patients were considered
clinical N+. Mean number of nodes removed and number of positive nodes were 31 vs. 28 (p=0.2)
and 1.15 vs. 5.5 for patients cN- and cN+ (p<0.001), respectively. Overall, 129 patients with clinical
N+ did not experienced lymph node invasion (LNI), and 725 patients that experienced LNI without
clinical n stage. Sensitivity in the detection of pN+ were 24% and specificity 90%. Although the
low sensitivity, patients with clinical N+ were more likeably to experienced LNI, worst pathological
stage and positive surgical margin, (all p<0.001), anyway patients with cN+ experienced higher
neoadjuvant chemotherapy rate (31.4% vs. 5.5%, p<0.001) in comparison to patients with cN-. With
a mean follow-up time of 126 months (Interquartile range: 122-130 months), the 5 and 10 years
CSM and OM were 67% vs. 57% and 60% vs. 41% respectively. Considering LNI population, at
univariable analyses, patients that experienced clinical N+ status were more like to succumb by
bladder cancer (Hazard ratio (HR): 1.29, Confidence Interval (CI): 1.05-1.59; p=0.02).

Conclusions:

Our study confirm the low sensibility of N staging in a big population, however cN+ is strongly
related to several predictors of adverse outcomes and to a worst survival even considering only LNI
population.

P<0.001