Can a restaging transurethral resection predict early progression in patients with superficial bladder cancer?

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Abstract

BACKGROUND

Most superficial bladder tumors are treated with transurethral resection (TUR) followed by chemotherapy, but recent studies suggest that performing a second TUR can improve prognosis by detecting residual disease missed at the initial TUR.

OBJECTIVE

To determine whether a restaging TUR can predict which patients are at high risk of early tumor progression.

DESIGN AND INTERVENTION

This study included 710 consecutive superficial bladder cancer patients who presented between 1993 and 2000. Patients were staged at initial TUR, and received a second TUR 2-4 weeks later. Following restaging TUR, bacillus Calmette-Guérin (BCG) therapy was administered to patients with high-risk tumors, and response was assessed at follow-up cystoscopy. All patients were followed for at least 5 years, with cystoscopy and TUR repeated as necessary. Patients with muscle-invasive disease, and those who underwent cystectomy, were excluded from the study.

OUTCOME MEASURES

The main endpoints were recurrence-free and progression-free survival time.

RESULTS

In total, 69% of patients had tumor recurrence. The overall median recurrence-free survival time was 19 months (range 16-21 months), with 21% of patients experiencing disease progression within 5 years. The rate of progression was significantly higher for high-grade, compared with low-grade, tumors (P = 0.001). On restaging TUR, residual tumor was found in most patients, with only 39% staged as T0. At the first follow-up cystoscopy, 70-96% of patients with noninvasive tumors had a complete response to therapy, compared with 45% of patients with T1 disease. Median time to first recurrence was 46 months, 16-20 months, and 6 months, among patients with stage T0, Ta or carcinoma in situ (CIS), and T1 tumors, respectively, on restaging TUR. A total of 76% of patients with T1 cancer on restaging TUR went on to develop muscle-invasive disease, compared with 14% of those with lower-stage disease (P = 0.001). Progression-free survival was significantly better in patients with tumors of lower stage and grade, compared with those of higher stage and grade, at initial TUR (P = 0.001). The 5-year progression-free survival for patients with T0 or TaG1 disease on restaging TUR was 91%, compared with 84% for TaG3 disease and 73% for CIS. Of the patients initially presenting with T1 disease, 29% progressed, whereas 76% of patients with T1 tumors on restaging TUR had progressed within a median of 15 months, irrespective of initial stage or grade, and 5-year progression-free survival in these patients was just 24%. Pathology on restaging TUR and response to treatment at first cystoscopy were the only significant predictors of tumor recurrence and progression on multivariate analysis.

CONCLUSION

The presence of residual tumor on restaging TUR identifies patients at high risk of early tumor recurrence and progression.

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