Dutta S C, Smith J A, Shappell S B, Coffey C S, Chang S S, Cookson M S
Departments of Urologic Surgery, Pathology and Preventive Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee 37232-2765, USA.
J Urol. 2001 Aug;166(2):490-3.
The role of radical cystectomy in patients with nonmuscle invasive urothelial carcinoma of the bladder remains controversial. The risk of overtreatment must be balanced against the potential benefit of aggressive therapy. We reviewed our results in these patients with a particular emphasis on clinical under staging.
We reviewed the records of 214 consecutive patients who underwent radical cystectomy for urothelial carcinoma between April 1995 and August 1999, focusing on those with nonmuscle invasive, stages T1 or less disease. We assessed clinical and pathological data as well as outcomes based on pathological disease extent.
A total of 78 patients (36%) underwent radical cystectomy for clinical stages T1 or less disease. Indications included disease refractory to intravesical therapy in 29 cases (37%), pathological findings reflective of high grade stage T1 or multifocal disease in 26 (33%), radiographic suspicion of invasive disease in 15 (20%) and severe symptoms in 8 (10%). Cancer was clinically under staged with stages pT2 or greater disease in 31 patients (40%) according to final pathology results. Under staging was most pronounced in the 10 patients (67%) with suspicious radiography and in the 18 (64%) with absent muscle in the biopsy specimen. Of the 78 patients with pathological stages pT1 disease or less 98% had no evidence of disease compared to 65% with stages pT2 or greater disease (p <0.01).
Despite the intent to perform early cystectomy a significant percent of patients harbored occult muscle invasive and/or metastatic disease. In clinical and pathological, superficial stages T1 or less cases disease-free survival was excellent. Due to these results, the selection of high risk superficial transitional cell carcinoma cases for continued bladder sparing treatment should include uninvolved muscle on biopsy and absent radiographic suspicion of invasion.
根治性膀胱切除术在非肌层浸润性膀胱尿路上皮癌患者中的作用仍存在争议。过度治疗的风险必须与积极治疗的潜在益处相权衡。我们回顾了这些患者的治疗结果，特别关注临床分期不足的情况。
我们回顾了1995年4月至1999年8月期间连续214例行根治性膀胱切除术治疗尿路上皮癌患者的记录，重点关注非肌层浸润、T1期或更低分期疾病的患者。我们根据病理疾病范围评估了临床和病理数据以及治疗结果。
共有78例患者（36%）因临床分期为T1期或更低分期疾病而行根治性膀胱切除术。手术指征包括29例（37%）膀胱内治疗无效的疾病、26例（33%）病理结果提示高级别T1期或多灶性疾病、15例（20%）影像学怀疑有浸润性疾病以及8例（10%）有严重症状。根据最终病理结果，31例患者（40%）临床分期不足，实际病理分期为pT2期或更高分期。分期不足在10例（67%）影像学可疑的患者和18例（64%）活检标本中无肌肉组织的患者中最为明显。78例病理分期为pT1期或更低分期的患者中，98%无疾病证据，而pT2期或更高分期的患者中这一比例为65%（p<0.01）。
尽管旨在早期行膀胱切除术，但仍有相当比例的患者存在隐匿性肌肉浸润和/或转移性疾病。在临床和病理上，浅表性T1期或更低分期病例的无病生存率极佳。基于这些结果，选择高危浅表性移行细胞癌病例继续进行保留膀胱治疗时，应包括活检时未累及肌肉且影像学无浸润可疑。
