OncologyPathological Upstaging During Radical Cystectomy Is Associated With Worse Recurrence-free Survival in Patients With Bacillus Calmette-Guerin-refractory Bladder Cancer
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)
- et al.
Management of stage T1 tumors of the bladder: International consensus panel
Urology
(2005) - et al.
Thirty years of BCG immunotherapy for non-muscle invasive bladder cancer: a success story with room for improvement
Biomed Pharmacother.
(2007) - et al.
Radical cystectomy for stages Ta, Tis and T1 transitional cell carcinoma of the bladder
J Urol.
(1994) - et al.
Clinical under staging of high risk nonmuscle invasive urothelial carcinoma treated with radical cystectomy
J Urol.
(2001) - et al.
Cystectomy in patients with high risk superficial bladder tumors who fail intravesical BCG therapy: pre-cystectomy prostate involvement as a prognostic factor
Eur Urol.
(2005) - et al.
Outcomes of patients with clinical T1 grade 2 urothelial cell bladder carcinoma treated with radical cystectomy
Urology
(2008) - et al.
Management of clinical T1 bladder transitional cell carcinoma by radical cystectomy
Urol Oncol.
(2004) - et al.
A randomized multicenter trial of adjuvant therapy in superficial bladder cancer: transurethral resection only versus transurethral resection plus mitomycin C versus transurethral resection plus bacillus Calmette-Guerin
J Urol.
(1996) - et al.
Intravesical bacillus Calmette-Guerin reduces the risk of progression in patients with superficial bladder cancer: a meta-analysis of the published results of randomized trials
J Urol.
(2002) - et al.
A retrospective analysis of 153 patients treated with or without intravesical bacillus Calmette-Guerin for primary stage T1 grade 3 bladder cancer: recurrence, progression and survival
J Urol.
(2003)
Cited by (37)
CD47-targeted optical molecular imaging and near-infrared photoimmunotherapy in the detection and treatment of bladder cancer
2022, Molecular Therapy OncolyticsCitation Excerpt :As a result, the recurrence and progression rates of NMIBC patients were 15%–61% and 0.2%–17% at 1 year, and 31%–78% and 0.8%–45% at 5 years, respectively.1 Compared with the newly diagnosed stage T2 BC patients who underwent RC immediately, patients with NMIBC upstaged to stage T2, confirmed by histopathological analysis after RC had a worse oncological prognosis.34 Several optical-imaging technologies have been developed as an auxiliary mode of WLC to assist urologists in improving intraoperative decision-making.
High-Risk Nonmuscle Invasive Bladder Cancer: Selecting the Appropriate Patient for Timely Cystectomy
2021, UrologyCitation Excerpt :A major driver of this recommendation lies in the propensity for T1 disease to be upstaged, with up to 50% of T1 NMIBC upstaged at radical cystectomy.41 These upstaged patients have a decreased survival following cystectomy when compared to patients who undergo cystectomy for known MIBC.48,49 Furthermore patients with residual T1 at re-resection have up an 82% rate of progression to muscle invasion.
Treatment Strategy for Newly Diagnosed T1 High-grade Bladder Urothelial Carcinoma: New Insights and Updated Recommendations [Figure presented]
2018, European UrologyCitation Excerpt :Second, patients who were understaged are appropriately treated with aggressive management. Upstaging at the time of cystectomy for T1HG tumours on TUR ranges from 25% to 50% [51–56]. Predictors of reduced risk of understaging include solitary tumour (OR 0.43; p = 0.004) and fewer prior TURs (OR 0.84; p = 0.05), with multiple tumours and multiple prior TURs increasing the risk [52].
New Agents for Bacillus Calmette-Guérin-Refractory Bladder Cancer
2013, Urologic Clinics of North AmericaCitation Excerpt :It is difficult to determine exactly when and how to treat a patient who fails BCG. Guzzo and colleagues17 examined a cohort of 184 patients with cT1 or CIS who underwent cystectomy (64% with prior BCG). Nineteen percent (35 of 184) of patients were upstaged to pT2, and when compared with a group of cT2 who underwent cystectomy (and found also to be pT2), recurrence-free survival rates were lower at 3 and 5 years (64% and 61% vs 83% and 74%).
Defining good candidates for extraperitoneal cystectomy: Results from random peritoneum biopsies of 136 cases
2013, UrologyCitation Excerpt :In previous studies, 15%-43% of patients staged cT1 were upstaged to pT2 at pathological examination of the radical cystectomy specimen. The results were even worse for patients with cT2 disease, who were upstaged in 35%-77% of the patients.22-24 A precystectomy decision model may enable a surgeon to readily identify the patients with cT2 bladder cancer who have the greatest probability of being upstaged at cystectomy.25