title: The role of radical cystectomy in patients with clinical T4b bladder cancer.
abstract: OBJECTIVE
  Patients with clinical T4b bladder cancer (extension to pelvic wall and/or adjacent organs other than prostate, vagina, or uterus) are commonly considered unresectable. We hypothesized that select patients might achieve durable benefit from multiagent chemotherapy and extirpative surgery.
  
  
  METHODS
  We identified patients with clinical T4bN0 bladder cancer from our IRB-approved database of patients undergoing radical cystectomy (n = 1,194). Relevant demographic, clinical, and pathologic data were compiled. Overall (OS), disease-specific (DSS), and recurrence-free survival (RFS) were analyzed by Kaplan-Meier estimation. Cox proportional hazards regression modeling was used to evaluate the influence of several potential prognostic factors.
  
  
  RESULTS
  Twenty-three patients (16 male) with a median age of 65 years met study criteria. Chemotherapy was administered preoperatively to 19 (83%) and postoperatively to 8 (35%) patients. Eight patients died of disease and 1 of other causes. The 1-, 2-, and 5-year DSS was 91% (95% C.I. 70%-98%), 66% (95% C.I. 42%-83%), and 60% (95% C.I. 34%-78%), respectively. Eight of 17 patients with pT2-4 tumors succumbed to disease compared with none of 6 who were ≤ pT1 (P = 0.04). Other predictors of decreased DSS included positive surgical margins (HR = 5.34, 95% C.I. 1.25-22.83) and presence of pathologic nodal metastasis (HR = 29.33, 95% C.I. 3.13-275.19). Variant histology was more common in this cohort than in the overall cystectomy database (43% vs. 11%).
  
  
  CONCLUSIONS
  Long-term survival can be achieved in a proportion of patients with cT4b bladder cancer undergoing chemotherapy and extirpative surgery. Careful selection of patients and meticulous surgical technique to avoid positive margins are critical.
authors.affiliation: Department of Urology, The University of Texas, M. D. Anderson Cancer Center, Houston, TX 77030, USA.
authors.forename: Peter C
authors.initials: PC
authors.lastname: Black
authors.forename: Colin P N
authors.initials: CP
authors.lastname: Dinney
authors.forename: Gordon A
authors.initials: GA
authors.lastname: Brown
authors.forename: Wassim
authors.initials: W
authors.lastname: Kassouf
authors.forename: Arlene O
authors.initials: AO
authors.lastname: Siefker-Radtke
authors.forename: Mark F
authors.initials: MF
authors.lastname: Munsell
authors.forename: H Barton
authors.initials: HB
authors.lastname: Grossman
authors.forename: Ashish M
authors.initials: AM
authors.lastname: Kamat
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D002295:Carcinoma, Transitional Cell / Q000188:drug therapy / Q000473:pathology / Q000601:surgery*; D003131:Combined Modality Therapy; D015653:Cystectomy / Q000379:methods* / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011184:Postoperative Period; D057234:Preoperative Period; D011379:Prognosis; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D016896:Treatment Outcome; D001743:Urinary Bladder / Q000187:drug effects / Q000473:pathology / Q000601:surgery*; D001749:Urinary Bladder Neoplasms / Q000188:drug therapy / Q000473:pathology / Q000601:surgery*
references.citation: J Urol. 2003 Jun;169(6):2113-7
references.pmid: 12771730
references.citation: J Clin Oncol. 2004 Jul 15;22(14):2781-9
references.pmid: 15199091
references.citation: Int Braz J Urol. 2007 Jan-Feb;33(1):25-31; discussion 31-2
references.pmid: 17335595
references.citation: J Urol. 2001 Mar;165(3):811-4
references.pmid: 11176475
references.citation: J Urol. 1994 Mar;151(3):598-600; discussion 600-1
references.pmid: 8308966
references.citation: N Engl J Med. 2003 Aug 28;349(9):859-66
references.pmid: 12944571
references.citation: Eur Urol. 2007 Jan;51(1):137-49; discussion 149-51
references.pmid: 16793197
references.citation: J Clin Oncol. 2001 Oct 15;19(20):4005-13
references.pmid: 11600601
references.citation: Br J Cancer. 1996 Nov;74(10):1655-9
references.pmid: 8932351