title: Role of immediate radical cystectomy in the treatment of patients with residual T1 bladder cancer on restaging transurethral resection.
abstract: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Bladder cancer patients with lamina propria invasion (T1 disease) and residual T1 disease on restaging transurethral resection of bladder tumour (re-TURBT) are at a very high risk for recurrence and progression. Despite this risk, most patients are treated with a bladder preserving approach and not immediate radical cystectomy (RC). In this study we have shown that a quarter of patients with T1 bladder cancer and residual T1 on re-TURBT who are treated with immediate RC are found to have carcinoma invading bladder muscle at RC and 5% have lymph node metastases. We have also found that >30% of patients treated with deferred RC after initial bladder-preserving therapy harbour carcinoma invading bladder muscle and almost 20% of these patients have lymph node metastases. Thus, immediate RC should be considered in all patients with T1 bladder cancer and residual T1 on re-TURBT.
  
  
  OBJECTIVE
  To report the overall survival (OS) and cancer-specific survival (CSS) of patients with residual T1 bladder cancer on restaging transurethral resection of the bladder tumour (re-TURBT).
  
  
  METHODS
  We performed a retrospective review of 150 evaluable patients treated for T1 bladder cancer with residual T1 disease found on re-TURBT between 1990 and 2007. Patients were treated with immediate radical cystectomy (RC) or a bladder-preserving approach (deferred or no RC). A univariate Cox proportional hazards regression model was used to test the association between treatment approach and survival.
  
  
  RESULTS
  Residual T1 bladder cancer was found in 150 evaluable patients, of whom 57 received immediate RC and 93 were treated with a bladder-preserving approach. Fourteen out of 57 patients receiving immediate RC and 8/26 patients receiving deferred RC had carcinoma invading bladder muscle in the RC specimen. Three out of 57 and 5/26 patients had lymph node metastases in the RC specimen. Median follow-up was 3.74 years. Thirty-nine patients died during follow-up, 16 from bladder cancer. There was no significant association between immediate RC and CSS (hazard ratio [HR] 1.15, 95% confidence interval [CI] 0.43-3.09, P = 0.8) or OS (HR 0.79, 95% CI 0.4-1.53, P = 0.5).
  
  
  CONCLUSIONS
  Because of the low number of events we cannot conclude whether RC offers a survival advantage in patients with residual T1 bladder cancer on re-TURBT. Since a quarter of patients had carcinoma invading bladder muscle, RC should be considered in these patients. A larger, preferably randomized, study with longer follow-up is needed.
authors.affiliation: Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
authors.forename: Itay A
authors.initials: IA
authors.lastname: Sternberg
authors.forename: Gal E
authors.initials: GE
authors.lastname: Keren Paz
authors.forename: Ling Y
authors.initials: LY
authors.lastname: Chen
authors.forename: Harry W
authors.initials: HW
authors.lastname: Herr
authors.forename: Guido
authors.initials: G
authors.lastname: Dalbagni
mesh_terms: D000368:Aged; D002295:Carcinoma, Transitional Cell / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016001:Confidence Intervals; D015653:Cystectomy / Q000379:methods*; D004724:Endoscopy / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D018365:Neoplasm, Residual; D009518:New York / Q000453:epidemiology; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D016896:Treatment Outcome; D014521:Urethra; D001749:Urinary Bladder Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*