title: Pathological upstaging during radical cystectomy is associated with worse recurrence-free survival in patients with bacillus Calmette-Guerin-refractory bladder cancer.
abstract: OBJECTIVE
  To compare the outcomes of patients who were upstaged to pT2 at the time of radical cystectomy (RC) to those who were correctly staged as T2 before RC.
  
  
  METHODS
  The clinical and pathologic data were reviewed of 496 patients who underwent RC from 1994 to 2008. Patients who underwent RC for high-grade T1 (HGT1) or carcinoma in situ (CIS) (184) were compared with those with known muscle-invasive cancer (312) before RC. Patients were substratified based on preoperative intravesical therapy status. Recurrence-free survival (RFS) for patients who were upstaged to muscle-invasive disease was compared with patients who were correctly staged T2 preoperatively.
  
  
  RESULTS
  Patients who were upstaged to pT2 disease had significantly worse 3- and 5-year RFS compared with those who where accurately staged (cT2 = pT2) (64% and 61% vs 83% and 74%, respectively; P = .04). Upstaging to pT2 in patients with a history of bacillus Calmette-Guerin treatment resulted in worse 3- and 5-year RFS rates compared with those accurately staged (69% and 57% vs 100% and 86%, respectively; P = .03).
  
  
  CONCLUSIONS
  Upstaging to pT2 among patients with HGT1 or CIS is associated with worse RFS compared with patients with known muscle invasion before RC (HGT1/CIS = pT2 vs cT2 = pT2). This finding was most significant among patients with a history of bacillus Calmette-Guerin treatment. Factors such as understaging of disease or treatment delay may contribute to worse outcomes among this subset of patients and should be considered when discussing treatment options.
authors.affiliation: The James Buchanan Brady Urologic Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA. tguzzo1@jhmi.edu
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Guzzo
authors.forename: Ahmed
authors.initials: A
authors.lastname: Magheli
authors.forename: Trinity J
authors.initials: TJ
authors.lastname: Bivalacqua
authors.forename: Matthew E
authors.initials: ME
authors.lastname: Nielsen
authors.forename: Frank J
authors.initials: FJ
authors.lastname: Attenello
authors.forename: Mark P
authors.initials: MP
authors.lastname: Schoenberg
authors.forename: Mark L
authors.initials: ML
authors.lastname: Gonzalgo
mesh_terms: D000276:Adjuvants, Immunologic / Q000627:therapeutic use*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001500:BCG Vaccine / Q000627:therapeutic use*; D015653:Cystectomy / Q000379:methods; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D007432:Intraoperative Period; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011379:Prognosis; D012189:Retrospective Studies; D017211:Treatment Failure; D001749:Urinary Bladder Neoplasms / Q000188:drug therapy / Q000473:pathology* / Q000601:surgery*
chemical_list: D000276:Adjuvants, Immunologic; D001500:BCG Vaccine