title: Downstaging to non-invasive urothelial carcinoma is associated with improved outcome following radical cystectomy for patients with cT2 disease.
abstract: BACKGROUND
  Pathologic stage is a critically important prognostic factor after radical cystectomy (RC) that is used to guide the use of secondary therapies. However, the risk of disease recurrence, for patients clinically diagnosed with muscle-invasive tumors who are found not to have muscle-invasive disease at RC are poorly defined. Therefore, we reviewed the long-term outcomes in patients who were downstaged to non-invasive urothelial carcinoma at time of RC.
  
  
  METHODS
  We identified 1,177 consecutive patients with muscle-invasive urothelial carcinoma of the bladder who underwent radical cystectomy at our institution between 1980 and 1999 without neoadjuvant therapy. Postoperative disease recurrence and survival were estimated using the Kaplan-Meier method and compared using the log rank test. Cox proportional hazard regression models were used to analyze the impact of pathologic stage on survival.
  
  
  RESULTS
  Pathologic downstaging to non-muscle invasive disease was identified in 538 (45.7 %) patients. The 10-year cancer-specific survival was 84.1, 77.4, 71.1 and 58.5 % for those with pT0, pTis, pT1 and pT2 tumors, respectively. On multivariate analysis, the risk of cancer-specific mortality was significantly decreased for patients with non-muscle invasive disease than those with organ-confined muscle invasion (RR-0.39; p = 0.002). There was no difference in disease-specific mortality among patients who had non-invasive (pT0, pTa, or pTis) disease (p = 0.19).
  
  
  CONCLUSIONS
  Downstaging from clinical muscle-invasive bladder cancer to non-muscle invasive disease at RC is associated with a significant reduction in cancer-specific mortality. However, even patients with residual non-muscle invasive disease may suffer disease recurrence and require continued surveillance after surgery.
authors.affiliation: Department of Urology, Mayo Medical School and Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA. tollefson.matthew@mayo.edu
authors.forename: Matthew K
authors.initials: MK
authors.lastname: Tollefson
authors.forename: Stephen A
authors.initials: SA
authors.lastname: Boorjian
authors.forename: Sara A
authors.initials: SA
authors.lastname: Farmer
authors.forename: Igor
authors.initials: I
authors.lastname: Frank
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002295:Carcinoma, Transitional Cell / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D015653:Cystectomy / Q000379:methods*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011379:Prognosis; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D015996:Survival Rate; D016896:Treatment Outcome; D001749:Urinary Bladder Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D019459:Urothelium / Q000473:pathology / Q000601:surgery