This paper assesses the incidence of nodal metastases and prognostic implications of pathologic substaging of pathologic stage T2b and T3 urothelial carcinoma of the bladder using SEER registry data. The authors provide an excellent review of the topic in the introduction, and place the subject in the proper context of decision making regarding prognosis and potential need for adjuvant chemotherapy. The SEER data used in this study are relevant for several reasons: (a) the authors included only those patients with pathologic examination of lymph nodes (26% were excluded, as there were no nodes recorded as being removed, reflecting recent reports of surgical quality in the SEER population); (b) the mean (but not the median) number of nodes reported for all 3 stages meets the minimum recommended in the AJCC 7 staging manual of greater than 12; and (c) the incidence of positive nodes increased with each substage and the percentages are consistent with those reported in contemporary cystectomy series. Furthermore, the data reflect that 43% of patients with node-positive pT2b, and most patients with node-positive pT3a and pTb disease had multiple positive nodes (>=N2), reflecting recent node mapping studies indicating that most patients with N+ have multiple positive nodes.
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