Pollack A, Zagars G K, Dinney C P, Swanson D A, von Eschenbach A C
Department of Radiotherapy, University of Texas M. D. Anderson Cancer Center, Houston 77030.
Cancer. 1994 Nov 15;74(10):2819-27. doi: 10.1002/1097-0142(19941115)74:10<2819::aid-cncr2820741013>3.0.co;2-l.
This study was performed to determine the importance of various potential prognostic factors in a large cohort of patients with transitional cell carcinoma of the bladder who were treated relatively uniformly at a single institution.
Between 1960 and 1983, 338 patients with muscle-invasive bladder carcinoma received preoperative radiotherapy (50 Gy in 25 fractions) followed 4-6 weeks later with radical cystectomy. Lymph node sampling was performed only when suspicious adenopathy was encountered. Ninety-eight percent of the patients completed the treatment as planned. The median followup for those living was 90 months.
Actuarial 5-year pelvic control, disease free, and overall survival rates were 84, 51, and 44%, respectively, for all patients, and 88, 58, and 50%, respectively, for those who treatment completed. The overwhelming majority of failures were from distant metastases (43% at 5 years). The pathologic complete response rate was 42%, and downstaging was seen in 65% of the patients. Univariate actuarial analyses revealed clinical stage, clinical perivesical extension, tumor size, pretreatment hemoglobin level, pretreatment blood urea nitrogen (BUN) concentration, results of intravenous pyelography, sex, age, pathologic response, and pathologic complete response, correlated with disease outcome. A Cox proportional hazards model showed pathologic response (P < 0.0001), clinical stage (P = 0.01), hemoglobin level (P < 0.02), pathologic complete response (P < 0.05), and BUN concentration (P < 0.05), were correlated significantly with pelvic control. When only pretreatment factors were analyzed, clinical stage, hemoglobin level, and BUN concentration remained the only factors predictive of pelvic control. Similar results were obtained when overall survival was used as the endpoint, except that pathologic complete response and BUN concentration were replaced by sex as significant covariates. A Cox proportional hazards model using disease free status as the endpoint revealed pathologic response and tumor size to be independent predictors of patient outcome. Restricting this analysis only to pretreatment factors showed that pretreatment hemoglobin and tumor size were the only factors correlated with disease free status.
The most significant prognostic factor was pathologic response, which correlated highly with all disease endpoints investigated. The most consistently significant pretreatment factors were hemoglobin level and clinical stage, although tumor size, sex, and BUN concentration also were independent predictors of patient outcome. These factors should be considered in patients receiving radiotherapy for bladder preservation.
本研究旨在确定在一家机构接受相对统一治疗的一大群膀胱移行细胞癌患者中，各种潜在预后因素的重要性。
1960年至1983年间，338例肌肉浸润性膀胱癌患者接受了术前放疗（25次分割，共50 Gy），4至6周后接受根治性膀胱切除术。仅在发现可疑淋巴结肿大时进行淋巴结采样。98%的患者按计划完成了治疗。存活患者的中位随访时间为90个月。
所有患者的精算5年盆腔控制率、无病生存率和总生存率分别为84%、51%和44%，完成治疗的患者分别为88%、58%和50%。绝大多数复发来自远处转移（5年时为43%）。病理完全缓解率为42%，65%的患者出现降期。单因素精算分析显示，临床分期、临床膀胱周围浸润、肿瘤大小、治疗前血红蛋白水平、治疗前血尿素氮（BUN）浓度、静脉肾盂造影结果、性别、年龄、病理反应和病理完全缓解与疾病转归相关。Cox比例风险模型显示，病理反应（P < 0.0001）、临床分期（P = 0.01）、血红蛋白水平（P < 0.02）、病理完全缓解（P < 0.05）和BUN浓度（P < 0.05）与盆腔控制显著相关。仅分析治疗前因素时，临床分期、血红蛋白水平和BUN浓度仍然是盆腔控制的唯一预测因素。以总生存率作为终点时也得到了类似结果，只是病理完全缓解和BUN浓度被性别取代为显著协变量。以无病状态作为终点的Cox比例风险模型显示，病理反应和肿瘤大小是患者转归的独立预测因素。仅将此分析限制在治疗前因素时，治疗前血红蛋白和肿瘤大小是与无病状态相关的唯一因素。
最显著的预后因素是病理反应，它与所有研究的疾病终点高度相关。最一致显著的治疗前因素是血红蛋白水平和临床分期，尽管肿瘤大小、性别和BUN浓度也是患者转归的独立预测因素。在接受放疗以保留膀胱的患者中应考虑这些因素。
