Dash Atreya, Galsky Matthew D, Vickers Andrew J, Serio Angel M, Koppie Theresa M, Dalbagni Guido, Bochner Bernard H
Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
Cancer. 2006 Aug 1;107(3):506-13. doi: 10.1002/cncr.22031.
Perioperative cisplatin-based chemotherapy has shown benefit in patients with high-risk localized urothelial bladder cancer, but it is not widely used. Renal impairment may be a major factor limiting its use. The current study was designed to determine the proportion of patients ineligible to receive adjuvant cisplatin-based chemotherapy based on inadequate renal function alone.
Patients who underwent radical cystectomy for urothelial cancer of the bladder with evidence of extravesical disease (> or =pT3 or any N+) were identified. Patients who received neoadjuvant chemotherapy were excluded. Serum creatinine immediately before and nadir serum creatinine after cystectomy were used to calculate creatinine clearance (CrCl) or glomerular filtration rate (GFR) using the Cockroft-Gault (CG), Jelliffe, and Modification of Diet in Renal Disease (MDRD) study formulas. A cutoff of CrCl <60 mL/min or GFR <60 mL/min/1.73 m2 was used to determine ineligibility for cisplatin-based chemotherapy. The proportion of patients ineligible by each formula was compared by univariate logistic regression. Univariate linear regression was performed to determine the effect of age on CrCl or GFR.
: Most patients were pT3 or greater; 39% were lymph node-positive. The overall proportion of patients ineligible for cisplatin-based chemotherapy was 28% by the CG formula, 52% by Jelliffe, and 24% by MDRD. Concordance between formulas was low. With all formulas the probability of ineligibility increased with age: by the CG equation, >40% of patients age >70 years were ineligible.
: The widespread use of cisplatin-based perioperative chemotherapy in patients with high-risk localized bladder cancer may be significantly limited by the high prevalence of baseline renal insufficiency in this population. This finding is most striking in the elderly. Better selection of patients who may safely receive cisplatin and more effective regimens devoid of cisplatin are required to optimize outcomes in this group of patients.
围手术期基于顺铂的化疗已显示对高危局限性尿路上皮膀胱癌患者有益，但尚未广泛应用。肾功能损害可能是限制其使用的主要因素。本研究旨在确定仅因肾功能不全而不符合接受辅助顺铂化疗条件的患者比例。
确定因膀胱尿路上皮癌行根治性膀胱切除术且有膀胱外疾病证据（≥pT3或任何N+）的患者。排除接受新辅助化疗的患者。使用Cockcroft-Gault（CG）、Jelliffe和肾脏病饮食改良（MDRD）研究公式，根据膀胱切除术前即刻血清肌酐和膀胱切除术后最低血清肌酐计算肌酐清除率（CrCl）或肾小球滤过率（GFR）。CrCl<60 mL/分钟或GFR<60 mL/分钟/1.73 m2的临界值用于确定不符合基于顺铂化疗的条件。通过单因素逻辑回归比较每个公式不符合条件的患者比例。进行单因素线性回归以确定年龄对CrCl或GFR的影响。
大多数患者为pT3及以上；39%为淋巴结阳性。CG公式显示不符合基于顺铂化疗条件的患者总体比例为28%，Jelliffe公式为52%，MDRD公式为24%。各公式之间的一致性较低。使用所有公式，不符合条件的概率随年龄增加：根据CG方程，年龄>70岁的患者中>40%不符合条件。
高危局限性膀胱癌患者围手术期基于顺铂化疗的广泛应用可能会受到该人群中基线肾功能不全高患病率的显著限制。这一发现在老年人中最为明显。需要更好地选择可能安全接受顺铂的患者以及更有效的不含顺铂的方案，以优化该组患者的治疗效果。
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