McFadden J, Tachibana I, Adra N, Collins K, Cary C, Koch M, Kaimakliotis H, Masterson T A, Rice K R
Department of Urology, Indiana University School of Medicine, Indianapolis, IN.
Department of Urology, Indiana University School of Medicine, Indianapolis, IN.
Urol Oncol. 2024 Mar;42(3):69.e11-69.e16. doi: 10.1016/j.urolonc.2023.12.008. Epub 2024 Jan 23.
Variant histology (VH) of urothelial carcinoma is uncommon and frequently presents at the muscle-invasive stage. VH is considering a significant risk factor for progression among patients with nonmuscle invasive bladder cancer (NMIBC). While there is some debate, expert opinion is generally that upfront radical cystectomy (RC) should be consider for these patients. Limited data exists to support this position. In this study, we sought to examine the rate of upstaging and overall survival for patients with VH NMIBC against patients with pure urothelial NMIBC who underwent RC, to help clarify the optimal treatment strategy for these patients.
The institutional REDCap database was utilized to identify all patients with T1 and Ta bladder cancer that underwent RC over the study period (2004-2022). Matched-pair analysis was performed between patients with VH and pure urothelial NMIBC; 42 pairs were matched on prior intravesical therapy, presence of muscularis propria on transurethral resection of bladder tumor (TURBT), any carcinoma in situ presence on prior TURBTs, and final tumor staging on TURBT. The primary outcomes of interest were pathologic tumor upstaging rate at RC and overall survival. Secondary outcomes of interest included association of demographic or pretreatment variables with upstaging, and upstaging rates for specific variant histologies.
Patients with VH NMIBC undergoing RC were upstaged at a significantly higher rate than a matched cohort of patients with pure urothelial NMIBC (73.8% vs. 52.4%, P = 0.0244) and among those upstaged, had significantly higher rates of pT3 to pT4 (54.7% vs. 23.8%, P = 0.0088). Rate of node positivity at RC for VH NMIBC was also higher compared to pure urothelial NMIBC (40.5% vs. 21.4%, P = 0.0389). Among histologic variants, patients with plasmacytoid and sarcomatoid subtypes demonstrated the highest rates of upstaging; differences were not statistically significant. The overall median survival was 28.4 months for patients with VH after RC compared to 155.1 months for patients with pure urothelial NMIBC (P = 0.009).
Patients with VH NMIBC undergoing RC are at significantly higher risk of upstaging at RC when compared to patients with pure urothelial NMIBC and have worse overall survival. While this study supports the concept of an aggressive treatment approach for patients with VH NMIBC, improvements in understanding of the disease are necessary to improve outcomes.
尿路上皮癌的组织学变异型（VH）并不常见，且常出现在肌层浸润阶段。VH被认为是非肌层浸润性膀胱癌（NMIBC）患者病情进展的一个重要危险因素。尽管存在一些争议，但专家普遍认为，对于这些患者应考虑 upfront 根治性膀胱切除术（RC）。支持这一观点的数据有限。在本研究中，我们试图比较 VH NMIBC 患者与接受 RC 的纯尿路上皮 NMIBC 患者的分期上调率和总生存率，以帮助明确这些患者的最佳治疗策略。
利用机构的 REDCap 数据库识别在研究期间（2004 - 2022 年）接受 RC 的所有 T1 和 Ta 期膀胱癌患者。对 VH 和纯尿路上皮 NMIBC 患者进行配对分析；根据既往膀胱内治疗、经尿道膀胱肿瘤切除术（TURBT）时固有肌层的存在情况、既往 TURBT 中是否存在原位癌以及 TURBT 的最终肿瘤分期，匹配了 42 对患者。感兴趣的主要结局是 RC 时的病理肿瘤分期上调率和总生存率。感兴趣的次要结局包括人口统计学或治疗前变量与分期上调的关联，以及特定组织学变异型的分期上调率。
接受 RC 的 VH NMIBC 患者分期上调的发生率显著高于匹配的纯尿路上皮 NMIBC 患者队列（73.8%对 52.4%，P = 0.0244），且在分期上调的患者中，pT3 至 pT4 的发生率显著更高（54.7%对 23.8%，P = 0.0088）。VH NMIBC 患者 RC 时的淋巴结阳性率也高于纯尿路上皮 NMIBC 患者（40.5%对 21.4%，P = 0.0389）。在组织学变异型中，浆细胞样和肉瘤样亚型患者的分期上调率最高；差异无统计学意义。RC 后，VH 患者的总体中位生存期为 28.4 个月，而纯尿路上皮 NMIBC 患者为 155.1 个月（P = 0.009）。
与纯尿路上皮 NMIBC 患者相比，接受 RC 的 VH NMIBC 患者在 RC 时分期上调的风险显著更高，且总体生存率更差。虽然本研究支持对 VH NMIBC 患者采取积极治疗方法的概念，但有必要提高对该疾病的认识以改善预后。
