Willis Daniel L, Fernandez Mario I, Dickstein Rian J, Parikh Sahil, Shah Jay B, Pisters Louis L, Guo Charles C, Henderson Samuel, Czerniak Bogdan A, Grossman H Barton, Dinney Colin P, Kamat Ashish M
Departments of Urology and Pathology (CCG, SH, BAC), University of Texas M.D. Anderson Cancer Center, Houston, Texas.
Departments of Urology and Pathology (CCG, SH, BAC), University of Texas M.D. Anderson Cancer Center, Houston, Texas.
J Urol. 2015 Apr;193(4):1129-34. doi: 10.1016/j.juro.2014.09.092. Epub 2014 Sep 22.
While many urologists recommend radical cystectomy for micropapillary bladder cancer invading the lamina propria (cT1), contradictory small reports exist on the efficacy of conservative management with intravesical bacillus Calmette-Guérin for this disease. We report our updated experience in what to our knowledge is the largest series of patients with cT1 micropapillary bladder cancer.
An institutional review board approved review of our cancer database identified 283 patients with micropapillary bladder cancer, including 72 staged with cT1N0M0 disease at diagnosis and initiation of therapy. Survival analysis was performed using the Kaplan-Meier estimator and compared using the log rank test.
In this cohort of 72 patients 40 received primary intravesical bacillus Calmette-Guérin and 26 underwent up-front radical cystectomy. Of patients who received bacillus Calmette-Guérin 75%, 45% and 35% experienced disease recurrence, progression and lymph node metastasis, respectively. Patients treated with up-front cystectomy had improved survival compared to patients treated with primary bacillus Calmette-Guérin (5-year disease specific survival 100% vs 60% p = 0.006) and patients who underwent delayed cystectomy after recurrence (5-year disease specific survival 62%, p = 0.015). Prognosis was especially poor in patients who waited for progression before undergoing radical cystectomy with an estimated 5-year disease specific survival of only 24% and a median survival of 35 months. In patients treated with up-front cystectomy pathological up-staging was found in 27%, including 20% with lymph node metastasis.
While certain patients with T1 micropapillary bladder cancer may respond to intravesical bacillus Calmette-Guérin, survival is improved in those who undergo early radical cystectomy. Further molecular studies are needed to identify subsets of patients in whom the bladder can be safely spared.
虽然许多泌尿外科医生推荐对侵犯固有层的微乳头型膀胱癌（cT1）进行根治性膀胱切除术，但关于采用膀胱内卡介苗进行保守治疗对该病疗效的报道却相互矛盾且数量不多。我们报告了我们最新的经验，据我们所知，这是最大的一组cT1微乳头型膀胱癌患者。
机构审查委员会批准对我们的癌症数据库进行审查，确定了283例微乳头型膀胱癌患者，其中72例在诊断和开始治疗时分期为cT1N0M0疾病。使用Kaplan-Meier估计器进行生存分析，并使用对数秩检验进行比较。
在这72例患者中，40例接受了原发性膀胱内卡介苗治疗，26例接受了 upfront 根治性膀胱切除术。接受卡介苗治疗的患者中，分别有75%、45%和35%经历了疾病复发、进展和淋巴结转移。与接受原发性卡介苗治疗的患者相比， upfront 膀胱切除术治疗的患者生存率有所提高（5年疾病特异性生存率100%对60%，p = 0.006），与复发后接受延迟膀胱切除术的患者相比也有所提高（5年疾病特异性生存率62%，p = 0.015）。在接受根治性膀胱切除术之前等待疾病进展的患者预后特别差，估计5年疾病特异性生存率仅为24%，中位生存期为35个月。在接受 upfront 膀胱切除术治疗的患者中，27%发现病理分期上调，其中20%有淋巴结转移。
虽然某些T1微乳头型膀胱癌患者可能对膀胱内卡介苗有反应，但早期进行根治性膀胱切除术的患者生存率更高。需要进一步的分子研究来确定哪些患者亚组可以安全地保留膀胱。
