The Prognostic Value of Lymphovascular Invasion in Combination with Nodal Stage on Disease-specific Survival in Patients with Bladder Cancer Following Upfront Radical Cystectomy.

Abstract

The prognostic value of lymphovascular invasion (LVI) after radical cystectomy (RC) remains debated, particularly in relation to pathological tumor stage (pT) and pathological nodal status (pN). We analyzed the strongest prognostic factors for disease-specific survival (DSS) in a multicenter study with local pathology review, including 1229 patients with cT1-4aN0M0 urothelial bladder cancer (BC) treated with upfront RC (1986-2020). A classification and regression tree (CART) analysis was used to prioritize prognostic variables. CART identified pN status as the primary discriminator, followed by LVI as the second strongest prognostic factor within pN-negative disease. LVI was present in 584 patients (48%). Median follow-up was 4.1 yr. In multivariable Cox regression models, LVI was independently associated with DSS in both the pN-negative (hazard ratio [HR] 1.50, 95% confidence interval (CI) = 1.16-1.94; p = 0.002) and pN-positive (HR 1.38, 95%CI = 1.04-1.83; p = 0.03) cohorts. CART defined three prognostic groups: favorable prognosis (pN negative/LVI negative), intermediate prognosis (pN negative/LVI positive), and poor prognosis (pN positive), with 5-yr DSS of 65%, 48%, and 25%, respectively. Among patients with poor prognosis, adjuvant chemotherapy (AC) was associated with longer DSS (HR 0.47; p < 0.001). In the intermediate-prognosis group, receipt of AC was not statistically associated with DSS (HR 0.66, 95%CI 0.39-1.10; p = 0.10). Combined assessment of pN status and LVI provides clinically meaningful postoperative risk stratification that may help refine postoperative risk assessment, surveillance planning, and multidisciplinary discussion regarding adjuvant treatment.