title: Patterns of Failure After Radical Cystectomy for pT3-4 Bladder Cancer: Implications for Adjuvant Radiation Therapy.
abstract: OBJECTIVE
  In patients with muscle-invasive bladder cancer, local-regional failure (LF) has been reported to occur in up to 20% of patients following radical cystectomy. The goals of this study were to describe patterns of LF, as well as assess factors associated with LF in a cohort of patients with pT3-4 bladder cancer. This information may have implications towards the use of adjuvant radiation therapy.
  
  
  METHODS
  Patients with pathologic T3-4 N0-1 bladder cancer were examined from an institutional radical cystectomy database. Preoperative demographics and pathologic characteristics were examined. Outcomes included overall survival and LF. Local-regional failures were defined using follow-up imaging reports and scans, and the locations of LF were characterized. Variables were tested by univariate and multivariate analysis for association with LF and overall survival.
  
  
  RESULTS
  A total of 334 patients had pT3-4 and N0-1 disease after radical cystectomy and bilateral pelvic lymph node dissection. Of these, 46% received perioperative chemotherapy. The median age was 71 years old, and median follow-up was 11 months. On univariate analysis, margin status, pT stage, and pN stage, were all associated with LF (P<.05), however, on multivariate analysis, only pT and pN stages were significantly associated with LF (P<.05). Three strata of risk were defined, including low-risk patients with pT3N0 disease, intermediate-risk patients with pT3N1 or pT4N0 disease, and high-risk patients with pT4N1 disease, who had a 2-year incidence of LF of 12%, 33%, and 72%, respectively. The most common sites of pelvic relapse included the external and internal iliac lymph nodes (LNs) and obturator LN regions. Notably, 34% of patients with LF had local-regional only disease at the time of recurrence.
  
  
  CONCLUSIONS
  Patients with pT4 or N1 disease have a 2-year risk of LF that exceeds 30%. These patients may be the most likely to benefit from local adjuvant therapies.
authors.affiliation: Department of Radiation and Cellular Oncology, University of Chicago Pritzker School of Medicine, Chicago, Illinois.
authors.forename: Abhinav V
authors.initials: AV
authors.lastname: Reddy
authors.affiliation: Section of Urology, Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois.
authors.forename: Joseph J
authors.initials: JJ
authors.lastname: Pariser
authors.affiliation: Section of Urology, Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois.
authors.forename: Shane M
authors.initials: SM
authors.lastname: Pearce
authors.affiliation: Department of Radiation and Cellular Oncology, University of Chicago Pritzker School of Medicine, Chicago, Illinois.
authors.forename: Ralph R
authors.initials: RR
authors.lastname: Weichselbaum
authors.affiliation: Section of Urology, Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois.
authors.forename: Norm D
authors.initials: ND
authors.lastname: Smith
authors.affiliation: Section of Urology, Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois.
authors.forename: Gary D
authors.initials: GD
authors.lastname: Steinberg
authors.affiliation: Department of Radiation and Cellular Oncology, University of Chicago Pritzker School of Medicine, Chicago, Illinois. Electronic address: sliauw@radonc.uchicago.edu.
authors.forename: Stanley L
authors.initials: SL
authors.lastname: Liauw
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D000970:Antineoplastic Agents / Q000627:therapeutic use; D017024:Chemotherapy, Adjuvant; D015653:Cystectomy / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008197:Lymph Node Excision; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local; D016016:Proportional Hazards Models; D018714:Radiotherapy, Adjuvant; D012306:Risk; D015996:Survival Rate; D017211:Treatment Failure; D001749:Urinary Bladder Neoplasms / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy* / Q000628:therapy
chemical_list: D000970:Antineoplastic Agents