Wijkström H, Norming U, Lagerkvist M, Nilsson B, Näslund I, Wiklund P
Department of Urology, Huddinge Hospital, Sweden.
Br J Urol. 1998 May;81(5):686-91. doi: 10.1046/j.1464-410x.1998.00637.x.
To evaluate retrospectively the clinical staging in a consecutive series of patients selected for cystectomy and to define its limitations with a view to possible improvements.
From 1979 to 1988, 276 patients with newly detected or recurring transitional cell carcinoma (TCC) of the bladder, were offered pre-operative irradiation (20 Gy) and cystectomy. The patients were assessed during 1995 and the outcome related to both clinical and surgical data. Survival was analysed on the basis of 'intention to treat'. Estimates of survival probabilities were calculated by the method of Kaplan and Meier. Differences in survival among subgroups were assessed using the log rank test and Cox stepwise regression analysis.
Cancer-specific actuarial survival for the whole series was 68% at 5 years and 63% at 10 years. Survival was closely related to the depth of invasion found at surgery, clearly discriminating those with tumours confined to the bladder wall (< or = P3A) from those with extravesical extension (> or = P3B). The cancer-specific survival at 5 years for patients with < or = P3A tumours was 85% and for those with > or = P3B tumours was 50%. This important distinction was anticipated accurately using bimanual palpation before surgery, those patients with no palpable mass after transurethral resection of bladder tumour (TURBT) having an actuarial survival of 83%, and those with a residual mass a survival of 50% at 5 years. In the multivariate analysis, increasing clinical stage was the only pretreatment variable with significant prognostic value for survival. However, this variable was highly dependent on the palpatory findings after TURBT, the presence of a residual mass being a prerequisite for the clinical stage T3 in case of muscle-invasive tumour.
Bimanual palpation remains crucially important in clinical staging, and there is a need for further standardization and refinement of this procedure.
回顾性评估一系列因行膀胱切除术而入选患者的临床分期，并明确其局限性，以期做出可能的改进。
1979年至1988年期间，276例新诊断或复发的膀胱移行细胞癌（TCC）患者接受了术前放疗（20 Gy）及膀胱切除术。于1995年对这些患者进行评估，结果与临床及手术数据相关。基于“意向性治疗”分析生存率。采用Kaplan-Meier法计算生存概率估计值。使用对数秩检验和Cox逐步回归分析评估亚组间生存率的差异。
整个系列的癌症特异性精算生存率5年时为68%，10年时为63%。生存率与手术时发现的浸润深度密切相关，能明确区分肿瘤局限于膀胱壁（≤P3A）者与有膀胱外扩展（≥P3B）者。≤P3A肿瘤患者5年时的癌症特异性生存率为85%，≥P3B肿瘤患者为50%。术前通过双手触诊可准确预测这一重要差异，经尿道膀胱肿瘤电切术（TURBT）后未触及肿块的患者精算生存率为83%，有残留肿块的患者5年生存率为50%。在多变量分析中，临床分期增加是唯一对生存有显著预后价值的预处理变量。然而，该变量高度依赖于TURBT后的触诊结果，对于肌层浸润性肿瘤，残留肿块的存在是临床分期为T3的前提条件。
双手触诊在临床分期中仍然至关重要，有必要对该操作进行进一步的标准化和完善。
