Division of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
Eur Urol. 2009 Dec;56(6):903-10. doi: 10.1016/j.eururo.2009.07.005. Epub 2009 Jul 17.
To evaluate the indications for early and deferred cystectomy and to report the impact of this tailored approach on survival.
DESIGN, SETTING, AND PARTICIPANTS: We retrospectively studied 523 patients seen at our institution who were initially diagnosed with T1 disease between 1990 and 2007.
Variables analyzed included age, gender, multifocality, multifocal T1 disease, carcinoma in situ, grade, recurrence rate, and restaging status. End points were overall and disease-specific survival.
A restaging transurethral resection (TUR) was performed in 523 patients. Of the patients who underwent restaging, 106 (20%) were upstaged to muscle-invasive disease and 417 patients were considered true clinical T1 (cT1); 84 of the latter group underwent immediate cystectomy. The median follow-up for survivors was 4.3 yr. The cumulative incidence of disease-specific death at 5 yr was 8% (95% confidence interval [CI], 5-13%), 10% (95% CI, 5-17%), and 44% (95% CI, 35-56%) for those restaged with lower than T1, T1, and T2 disease, respectively. Immediate cystectomy was more likely in patients with cT1 disease at restaging than in those with disease lower than cT1, but there were no other obvious differences in clinical characteristics between those with and without immediate cystectomy. Survival was not statistically different for patients who underwent an immediate cystectomy versus those who were maintained on surveillance with deferred cystectomy if deemed appropriate. Of 333 patients who did not undergo immediate cystectomy, 59 had a deferred cystectomy, and the likelihood of deferred cystectomy was greater in those with T1 disease on restaging TUR (hazard ratio: 2.40; 95% CI, 1.43-4.01; p=0.001).
Restaging TUR should be performed in patients diagnosed with cT1 bladder cancer to improve staging accuracy. Patients with T1 disease on restaging are at higher risk of progression and should be considered for early cystectomy.
评估早期和延迟性膀胱切除术的适应证，并报告这种个体化方法对生存率的影响。
设计、设置和参与者：我们回顾性研究了在我院就诊的 523 例患者，这些患者在 1990 年至 2007 年间被诊断为 T1 期疾病。
分析的变量包括年龄、性别、多灶性、多灶性 T1 疾病、原位癌、分级、复发率和再分期状态。终点是总生存率和疾病特异性生存率。
523 例患者均进行了再分期经尿道切除术（TUR）。在进行再分期的患者中，有 106 例（20%）被升级为肌层浸润性疾病，417 例患者被认为是真正的临床 T1 （cT1）；其中 84 例患者立即接受了膀胱切除术。幸存者的中位随访时间为 4.3 年。5 年时疾病特异性死亡的累积发生率分别为 8%（95%置信区间[CI]，5%-13%）、10%（95%CI，5%-17%）和 44%（95%CI，35%-56%），分别为再分期时疾病低于 T1、T1 和 T2 的患者。在再分期时为 cT1 疾病的患者中，更有可能进行即刻膀胱切除术，而在疾病低于 cT1 的患者中则不然，但在立即行膀胱切除术和延迟性膀胱切除术的患者之间，在临床特征方面没有明显差异。如果认为合适，进行即刻膀胱切除术的患者与接受监测和延迟性膀胱切除术的患者的生存情况无统计学差异。在 333 例未行即刻膀胱切除术的患者中，有 59 例接受了延迟性膀胱切除术，在再分期 TUR 时为 T1 疾病的患者中，更有可能进行延迟性膀胱切除术（风险比：2.40；95%CI，1.43-4.01；p=0.001）。
对诊断为 cT1 膀胱癌的患者应进行再分期 TUR，以提高分期准确性。再分期时为 T1 疾病的患者进展风险较高，应考虑早期行膀胱切除术。
