Articles

Letter to the Editor NOT referring to a recent journal article

Stage pT0 after Radical Cystectomy: Are All Patients Equal?

By: Thomas F. Chromeckia b, Eugene K. Chaa and Shahrokh F. Shariata lowast for the Bladder Cancer Research Consortium.

European Urology, Volume 60 Issue 1, September 2011, Pages 603-604

Published online: 01 September 2011

Abstract Full Text Full Text PDF (547 KB)

Although pT0 at radical cystectomy (RC) is associated with excellent prognosis for most patients, some pT0 patients still experience disease recurrence [1]. These heterogeneous outcomes in pT0 patients may be due to the initial treatment modality prior to RC (eg, transurethral resection [TUR] alone vs neoadjuvant chemotherapy [NAC]). Therefore, we compared the outcomes of patients who achieved pT0 after TUR alone versus those who received NAC.

We retrospectively reviewed the data from a multi-institutional cohort comprising 5018 patients treated with RC for urothelial carcinoma of the bladder (UCB). Statistics were performed using SPSS v.17.0 (IBM Corp., Somers, NY, USA). All reported p values are two-sided, and significance was set at 0.05.

Of the 433 pT0 cases, 41 (9.5%) had received NAC, whereas 392 (90.5%) underwent TUR alone. There was no statistical difference between TUR-alone and NAC patients with regard to gender (female: 22% vs 32%; p=0.18), age (median: 67 vs 62 yr; p=0.07), and lymph node metastasis (8.1% vs 9.8%; p=0.28). NAC patients were more likely to have clinically non-organ-confined disease (22% vs 2.3%; p<0.001). TUR-alone patients had more lymph nodes removed (median: 18 vs 14; p=0.014). Within a median follow-up of 46 mo (interquartile range: 19–94), 49 TUR-alone patients (12.8%) experienced disease recurrence. Within a median follow-up of 34 mo (interquartile range: 17–56), 10 NAC patients (24.4%) experienced disease recurrence. NAC was associated with a higher risk of disease recurrence (hazard ratio [HR]: 2.3; 95% confidence interval [CI], 1.2–4.6; p=0.016; Fig. 1). However, in multivariable analysis, NAC was not associated with disease recurrence anymore (p=0.13) after adjusting for the effects of gender (female gender; HR: 2.0; p=0.015), clinical non-organ-confined stage (HR: 2.8; p=0.02), and lymph node metastasis (HR: 11.8; p<0.001). Exclusion of patients with lymph node metastasis (n=34) did not change the statistical significance of the analyses.

gr1

Fig. 1 Recurrence-free survival stratified by transurethral resection (TUR) alone versus neoadjuvant chemotherapy in 433 pT0 patients treated with radical cystectomy and bilateral lymphadenectomy.

We found in univariable but not multivariable analysis that patients who are pT0 after NAC are at higher risk for disease recurrence compared with those who achieve pT0 after TUR alone. One explanation could be the higher rate of non-organ-confined clinical stage in patients selected for NAC. These findings contrast with those of a prospective trial and a retrospective single-center study that failed to find a difference between TUR alone and NAC [2] and [3]. Both of these studies had similar distributions in clinical stage between TUR-alone and NAC patients. In daily practice, however, NAC is preferentially given to patients who are likely to have non-organ-confined UCB, and pT0 after TUR alone is more likely to be achieved in organ-confined UCB. Thus the finding that NAC is associated with a higher rate of disease recurrence in pT0 patients reflects the underlying biologic potential of the tumor. Despite the preliminary nature of these data, we conclude that pT0 patients remain at risk for disease recurrence and must be followed closely, especially if they have received NAC.

Our study has several limitations such as its retrospective nature. Moreover, the evaluation was performed by multiple pathologists and multiple surgeons, possibly leading to misclassification of some cases.

Conflicts of interest

The authors have nothing to disclose.

References

  • [1] D. Tilki, R.S. Svatek, G. Novara, et al. Stage pT0 at radical cystectomy confers improved survival: an international study of 4,430 patients. J Urol. 2010;184:888-894 Crossref.
  • [2] W. Kassouf, P.E. Spiess, G.A. Brown, et al. P0 stage at radical cystectomy for bladder cancer is associated with improved outcome independent of traditional clinical risk factors. Eur Urol. 2007;52:769-776 Abstract, Full-text, PDF, Crossref.
  • [3] H.B. Grossman, R.B. Natale, C.M. Tangen, et al. Neoadjuvant chemotherapy plus cystectomy compared with cystectomy alone for locally advanced bladder cancer. N Engl J Med. 2003;349:859-866 Crossref.

Footnotes

a Weill Medical College of Cornell University, New York, NY, USA

b Medical University of Graz, Graz, Austria

lowast Corresponding author. Brady Urologic Health Center, Weill Medical College of Cornell University, New York-Presbyterian Hospital, 525 East 68th Street, Starr 912A, New York, NY 10065, USA. Tel. +1 212 746 5562; Fax: +1 212 746 8068.

Place a comment

Your comment *

max length: 5000