Prediction of cancer-specific survival after radical cystectomy in pT4a urothelial carcinoma of the bladder: development of a tool for clinical decision-making.
OBJECTIVE
To externally validate the pT4a-specific risk model for cancer-specific survival (CSS) proposed by May et al. (Urol Oncol 2013; 31: 1141-1147) and to develop a new pT4a-specific nomogram predicting CSS in an international multicentre cohort of patients undergoing radical cystectomy (RC) for urothelial carcinoma of the bladder (UCB) PATIENTS AND METHODS: Data from 856 patients with pT4a UCB treated with RC at 21 centres in Europe and North-America were assessed. The risk model proposed by May et al., which includes female gender, presence of positive lymphovascular invasion (LVI) and lack of adjuvant chemotherapy administration as adverse predictors for CSS, was applied to our cohort. For the purpose of external validation, model discrimination was measured using the receiver-operating characteristic-derived area under the curve. A nomogram for predicting CSS in pT4a UCB after RC was developed after internal validation based on multivariable Cox proportional hazards regression analysis evaluating the impact of clinicopathological variables on CSS. Decision-curve analyses were applied to determine the net benefit derived from the two models.


RESULTS
The estimated 5-year-CSS after RC was 34% in our cohort. The risk model devised by May et al. predicted individual 5-year-CSS with an accuracy of 60.1%. In multivariable Cox proportional hazards regression analysis, female gender (hazard ratio [HR] 1.45), LVI (HR 1.37), lymph node metastases (HR 2.54), positive soft tissue surgical margins (HR 1.39), neoadjuvant (HR 2.24) and lack of adjuvant chemotherapy (HR 1.67, all P < 0.05) were independent predictors of an adverse CSS rate and formed the features of our nomogram with a predictive accuracy of 67.1%. Decision-curve analyses showed higher net benefits for the use of the newly developed nomogram in our cohort over all thresholds.


CONCLUSIONS
The risk model devised by May et al. was validated with moderate discrimination and was outperformed by our newly developed pT4a-specific nomogram in the present study population. Our nomogram might be particularly suitable for postoperative patient counselling in the heterogeneous cohort of patients with pT4a UCB.
Department of Urology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.
Atiqullah
A
Aziz
Department of Urology, Medical University Vienna, Vienna, Austria.
Shahrokh F
SF
Shariat
Department of Urology, Marienhospital Herne, Ruhr-University Bochum, Herne, Germany.
Florian
F
Roghmann
Department of Urology, Ludwig-Maximilians-University Munich, Munich, Germany.
Sabine
S
Brookman-May
Department of Urology, Ludwig-Maximilians-University Munich, Munich, Germany.
Christian G
CG
Stief
Department of Urology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.
Michael
M
Rink
Department of Urology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.
Felix K
FK
Chun
Department of Urology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.
Margit
M
Fisch
Department of Urology, University Hospital 'Carl Gustav Carus', Dresden Technical University, Dresden, Germany.
Vladimir
V
Novotny
Department of Urology, University Hospital 'Carl Gustav Carus', Dresden Technical University, Dresden, Germany.
Michael
M
Froehner
Department of Urology, University Hospital 'Carl Gustav Carus', Dresden Technical University, Dresden, Germany.
Manfred P
MP
Wirth
Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany.
Marco J
MJ
Schnabel
Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany.
Hans-Martin
HM
Fritsche
Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany.
Maximilian
M
Burger
Department of Urology, General Hospital of Bolzano, Bolzano, Italy.
Armin
A
Pycha
Department of Urology, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic.
Antonin
A
Brisuda
Department of Urology, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic.
Marko
M
Babjuk
Department of Urology, Goethe-University Frankfurt, Frankfurt am Main, Germany.
Stefan
S
Vallo
Department of Urology, Goethe-University Frankfurt, Frankfurt am Main, Germany.
Axel
A
Haferkamp
Department of Urology, Vivantes Medical Centre im Friedrichshain and am Urban, Berlin, Germany.
Jan
J
Roigas
Department of Urology, Marienhospital Herne, Ruhr-University Bochum, Herne, Germany.
Joachim
J
Noldus
Department of Urology, Kassel Medical Centre, Kassel, Germany.
Regina
R
Stredele
Department of Urology, Kassel Medical Centre, Kassel, Germany.
Björn
B
Volkmer
Department of Urology, Paracelsus Medical Centre Golzheim, Düsseldorf, Germany.
Patrick J
PJ
Bastian
Department of Urology, Cochin Hospital, APHP, Paris Descartes University, Paris, France.
Evanguelos
E
Xylinas
Department of Urology, St. Elisabeth Medical Centre Straubing, Straubing, Germany.
Matthias
M
May
D000328:Adult; D000368:Aged; D002295:Carcinoma, Transitional Cell / Q000401:mortality* / Q000473:pathology / Q000601:surgery; D017024:Chemotherapy, Adjuvant; D000066491:Clinical Decision-Making; D015653:Cystectomy / Q000379:methods / Q000401:mortality*; D005060:Europe / Q000453:epidemiology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D049451:Nomograms; D009656:North America / Q000453:epidemiology; D017063:Outcome Assessment, Health Care; D011379:Prognosis; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D001749:Urinary Bladder Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery
bladder cancer; mortality; nomograms; outcome; radical cystectomy