Solsona Eduardo, Iborra Inmaculada, Rubio Jose, Casanova Juan, Almenar Sergio
Department of Urology, Instituto Valenciano de Oncología, Valencia, Spain.
BJU Int. 2004 Dec;94(9):1258-62. doi: 10.1111/j.1464-410X.2004.05228.x.
To establish the optimum time of radical cystectomy (RC) for patients with recurrent high-risk superficial bladder tumours after the failure of intravesical therapy.
Among 318 patients with transitional cell carcinoma treated with RC and with no neoadjuvant therapy, there were 46 with clinical stage Ta, T1 or Tis refractory to transurethral resection associated with intravesical therapy. These patients had at least one of: (i) high-risk superficial bladder tumours after failure of two consecutive induction courses of intravesical therapy; (ii) superficial bladder tumours with prostatic stromal invasion; (iii) superficial bladder tumours with mucosa/ducts involvement after failure of one course of intravesical therapy; (iv) uncontrolled superficial tumours with transurethral resection associated or not with intravesical therapy. Progression and cause-specific survival of these patients were compared to those with muscle-invasive tumours. Univariate and multivariate analyses of predictive factors for cause-specific survival were also used in patients with superficial tumours. The incidence of significant prognostic factors was compared in both superficial and muscle-invasive tumours, as were the progression pattern and survival.
The progression-free and cause-specific survival of patients with superficial tumours was 54% and 67%, respectively, with no significant difference from those with muscle-invasive tumours. In multivariate analysis, positive lymph-nodes and prostatic stromal invasion were significant and independent variables for survival. The incidence of positive lymph nodes was 15% vs 30% (P < 0.05) and of stromal invasion was 32% vs 1.5% (P < 0.001) in patients with superficial and muscle-invasive tumours, respectively. Accounting for the progression pattern in patients with superficial tumours, extravesical urothelial recurrence prevailed over local or distant recurrences (30% vs 15%), whereas in patients with muscle-invasive tumours the opposite occurred (5% vs 33%, respectively). The cause-specific survival of patients with superficial tumour and prostatic stromal invasion was one of three, and in those who developed extravesical urothelial recurrence was 28.5%.
In patients with recurrent high-risk superficial bladder cancer after intravesical therapy, our criteria for RC were inappropriate, and patients had a survival rate similar to those with muscle-invasive tumours. RC might have been used too late, as there was a high incidence of prostatic stromal invasion and extravesical urothelial recurrence after RC. Both events seem to be responsible of the low cause-specific survival. Predictive factors for progression are needed to indicate early RC in patients with recurrent high-risk superficial tumours. From a previous analysis the pathological pattern of the clinical lack of response (T1, G3, bladder carcinoma in situ and prostate involvement) to intravesical therapy evaluated at 3 months might be important for predicting progression, and an early RC at that time might be useful.
确定膀胱内灌注治疗失败后复发的高危浅表性膀胱肿瘤患者行根治性膀胱切除术（RC）的最佳时机。
在318例行RC且未接受新辅助治疗的移行细胞癌患者中，有46例临床分期为Ta、T1或Tis，经尿道切除联合膀胱内灌注治疗无效。这些患者至少具备以下一项：（i）连续两个诱导疗程膀胱内灌注治疗失败后的高危浅表性膀胱肿瘤；（ii）侵犯前列腺基质的浅表性膀胱肿瘤；（iii）一个疗程膀胱内灌注治疗失败后累及黏膜/导管的浅表性膀胱肿瘤；（iv）经尿道切除联合或不联合膀胱内灌注治疗无法控制的浅表性肿瘤。将这些患者的疾病进展情况和特定病因生存率与肌层浸润性肿瘤患者进行比较。对浅表性肿瘤患者的特定病因生存预测因素进行单因素和多因素分析。比较浅表性和肌层浸润性肿瘤中显著预后因素的发生率、疾病进展模式和生存率。
浅表性肿瘤患者的无进展生存率和特定病因生存率分别为54%和67%，与肌层浸润性肿瘤患者无显著差异。多因素分析显示，阳性淋巴结和前列腺基质侵犯是生存的显著独立变量。浅表性和肌层浸润性肿瘤患者的阳性淋巴结发生率分别为15%和30%（P<0.05），基质侵犯发生率分别为32%和1.5%（P<0.001）。考虑浅表性肿瘤患者的疾病进展模式，膀胱外尿路上皮复发高于局部或远处复发（30%对15%），而肌层浸润性肿瘤患者则相反（分别为5%对33%）。伴有前列腺基质侵犯的浅表性肿瘤患者的特定病因生存率为三分之一，发生膀胱外尿路上皮复发的患者为28.5%。
对于膀胱内灌注治疗后复发的高危浅表性膀胱癌患者，我们的RC标准不合适，这些患者的生存率与肌层浸润性肿瘤患者相似。RC可能实施得太晚，因为RC后前列腺基质侵犯和膀胱外尿路上皮复发的发生率很高。这两个情况似乎是特定病因生存率低 的原因。需要有进展预测因素来指导复发高危浅表性肿瘤患者早期行RC。根据先前的分析，3个月时评估的对膀胱内灌注治疗临床无反应（T1、G3、原位膀胱癌和前列腺受累）的病理模式可能对预测进展很重要，此时早期行RC可能有用。
