Elsevier

Urology

Volume 74, Issue 6, December 2009, Pages 1276-1280
Urology

Oncology
Pathological Upstaging During Radical Cystectomy Is Associated With Worse Recurrence-free Survival in Patients With Bacillus Calmette-Guerin-refractory Bladder Cancer

https://doi.org/10.1016/j.urology.2009.05.092Get rights and content

Objectives

To compare the outcomes of patients who were upstaged to pT2 at the time of radical cystectomy (RC) to those who were correctly staged as T2 before RC.

Methods

The clinical and pathologic data were reviewed of 496 patients who underwent RC from 1994 to 2008. Patients who underwent RC for high-grade T1 (HGT1) or carcinoma in situ (CIS) (184) were compared with those with known muscle-invasive cancer (312) before RC. Patients were substratified based on preoperative intravesical therapy status. Recurrence-free survival (RFS) for patients who were upstaged to muscle-invasive disease was compared with patients who were correctly staged T2 preoperatively.

Results

Patients who were upstaged to pT2 disease had significantly worse 3- and 5-year RFS compared with those who where accurately staged (cT2 = pT2) (64% and 61% vs 83% and 74%, respectively; P = .04). Upstaging to pT2 in patients with a history of bacillus Calmette-Guerin treatment resulted in worse 3- and 5-year RFS rates compared with those accurately staged (69% and 57% vs 100% and 86%, respectively; P = .03).

Conclusions

Upstaging to pT2 among patients with HGT1 or CIS is associated with worse RFS compared with patients with known muscle invasion before RC (HGT1/CIS = pT2 vs cT2 = pT2). This finding was most significant among patients with a history of bacillus Calmette-Guerin treatment. Factors such as understaging of disease or treatment delay may contribute to worse outcomes among this subset of patients and should be considered when discussing treatment options.

Section snippets

Material and Methods

With the internal review board approval, we retrospectively reviewed our RC database from 1994 to 2008. RC cases were performed by a single surgeon (M.P.S.) and all but 5 patients underwent a bilateral pelvic lymph node dissection. Of the 576 consecutive patients in our database, 184 (32%) had HGT1 or CIS as their indication for RC. The clinical and pathologic data of 184 patients with non-muscle-invasive bladder cancer were analyzed and compared with those of 312 patients with known

Results

Table 1 details the clinical and pathologic features of 184 patients who underwent RC for either HGT1 bladder cancer or CIS. Median age of the cohort was 66 years (range: 35-89), and 85% of the patients were male. This group did not differ significantly with regard to age, gender, race, or follow-up compared with the cohort of patients with known muscle-invasive disease. Median follow-up was 23 months (range: 1-144). A total of 65 patients (35%) had CIS only as an indication for RC and 119

Comment

The initial treatment of choice for non-muscle-invasive bladder cancer is complete TUR. However, approximately 75%-90% of patients with HGT1 disease will experience a recurrence.12 Given the high recurrence rates with HGT1 cancers and the inability to adequately treat CIS with TUR alone, intravesical therapy is an important component in the treatment of these lesions. The ability of BCG therapy to prevent recurrence and progression in patients with HGT1 and CIS lesions is well documented.13, 14

Conclusions

A significant proportion of patients with high-grade non-muscle-invasive (HGT1 or CIS) bladder cancer are upstaged during RC. Upstaging to muscle-invasive disease during RC is associated with a worse RFS compared with patients with known muscle-invasive cancer before RC. This finding was most pronounced in patients with previous BCG therapy, suggesting either understaging of disease or a treatment delay may contribute to worse outcomes in this subset of patients.

References (20)

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