The impact of positive soft tissue surgical margins following radical cystectomy for high-grade, invasive bladder cancer.
ABSTRACT We evaluate the incidence and risk factors associated with positive soft tissue surgical margins (STSM) and determine the association with various surgical and pathological characteristics and clinical outcomes in patients undergoing radical cystectomy (RC) for bladder cancer.
From November 1971 to December 2005, 1,591 patients with primary transitional cell carcinoma (TCC) of the bladder underwent RC, with an extended bilateral pelvic lymphadenectomy and urinary diversion. A positive STSM was defined as tumor identified at the inked perivesical soft tissue surrounding the cystectomy specimen. Data were analyzed according to various clinical and pathologic variables, and survival analysis was performed.
A total of 18 patients (1%) demonstrated pathologic evidence of a positive STSM following RC. Positive STSM were significantly associated with lymphovascular invasion, advanced pathologic stage, lymph node involvement, extent of nodal involvement and lymph node density. No patient with an organ-confined primary bladder tumor had a positive STSM, while 3% with extravesical tumor extension demonstrated a positive STSM. Recurrence-free and overall survival at 5 and 10 years for patients with a positive STSM was 29 and 22%, and 29 and 11%, respectively (p < 0.001). A positive STSM increased the risk of recurrence by threefold and the overall risk of death by 2.6 times. Only nine patients (1%) without evidence of nodal involvement had a positive STSM with a worse survival compared to those same pathologic subgroup and negative STSM. Nine patients (2%) with lymph node tumor involvement had positive STSM and also demonstrated significantly worse survival.
Although a positive STSM was present in only 1% of patients undergoing a RC for TCC of the bladder, it was found to be an independent risk factor for advanced disease, lymph node involvement and tumor progression with worse survival. A dedicated effort should be made to avoid a positive STSM at the time of RC.
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ABSTRACT: We studied the effect of radical cystectomy for transitional cell carcinoma of the bladder on survival and failure patterns when the 2 surgical standards cystectomy and neobladder were combined, when possible. A consecutive series of patients undergoing radical cystectomy with pelvic lymph node dissection for transitional cell carcinoma of the bladder with curative intent was analyzed. Patients with neoadjuvant radiotherapy/chemotherapy were excluded. Pathological characteristics based on the 2002 TNM system, recurrence-free/overall survival and metastatic patterns were determined. A total of 788 patients with a mean age +/- SD of 65 +/- 10 years and a mean followup of 53.5 months who underwent surgery between 1986 and 2003 were analyzed. A neobladder was constructed in 75.4% of patients. Ten-year recurrence-free and overall survival rates were 59.1% and 44.9%, respectively. Positive lymph nodes were present in 143 patients (18%). The rate of recurrence-free survival at 5 years was 82.5% for pT2a pN0, 61.9% for pT2b and pT3a pN0, and 53.1% for pT3b pN0 disease. Local and distant failure rates were 4% and 9.5% for organ confined tumors, 15.9% and 19.2% for nonorgan confined tumors, and 20.4% and 45.1% in patients with positive lymph nodes, respectively. In patients with organ confined, lymph node negative transitional cell carcinoma excellent survival data can be achieved as long as the tumor is limited to the inner half of the detrusor. These data on a large group of patients support early aggressive surgical management for invasive bladder cancer. The results of this surgery only series may serve as a reference for other treatment modalities for bladder cancer.The Journal of Urology 09/2006; 176(2):486-92; discussion 491-2. · 3.70 Impact Factor
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ABSTRACT: Despite aggressive local therapy, patients with locally advanced bladder cancer are at significant risk for metastases. We evaluated the ability of neoadjuvant chemotherapy to improve the outcome in patients with locally advanced bladder cancer who were treated with radical cystectomy. Patients were enrolled if they had muscle-invasive bladder cancer (stage T2 to T4a) and were to be treated with radical cystectomy. They were stratified according to age (less than 65 years vs. 65 years or older) and stage (superficial muscle invasion vs. more extensive disease) and were randomly assigned to radical cystectomy alone or three cycles of methotrexate, vinblastine, doxorubicin, and cisplatin followed by radical cystectomy. We enrolled 317 patients over an 11-year period, 10 of whom were found to be ineligible; thus, 154 were assigned to receive surgery alone and 153 to receive combination therapy. According to an intention-to-treat analysis, the median survival among patients assigned to surgery alone was 46 months, as compared with 77 months among patients assigned to combination therapy (P=0.06 by a two-sided stratified log-rank test). In both groups, improved survival was associated with the absence of residual cancer in the cystectomy specimen. Significantly more patients in the combination-therapy group had no residual disease than patients in the cystectomy group (38 percent vs. 15 percent, P<0.001). As compared with radical cystectomy alone, the use of neoadjuvant methotrexate, vinblastine, doxorubicin, and cisplatin followed by radical cystectomy increases the likelihood of eliminating residual cancer in the cystectomy specimen and is associated with improved survival among patients with locally advanced bladder cancer.New England Journal of Medicine 08/2003; 349(9):859-66. · 51.66 Impact Factor
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