title: Clinical risk stratification in patients with surgically resectable micropapillary bladder cancer.
abstract: To analyse survival in patients with clinically localised, surgically resectable micropapillary bladder cancer (MPBC) undergoing radical cystectomy (RC) with and without neoadjuvant chemotherapy (NAC) and develop risk strata based on outcome data.
  
  
  
  A review of our database identified 103 patients with surgically resectable (≤cT4acN0 cM0) MPBC who underwent RC. Survival estimates were calculated using Kaplan-Meier method and compared using log-rank tests. Classification and regression tree (CART) analysis was performed to identify risk groups for survival.
  
  
  
  For the entire cohort, estimated 5-year overall survival and disease-specific survival (DSS) rates were 52% and 58%, respectively. CART analysis identified three risk subgroups: low-risk: cT1, no hydronephrosis; high-risk: ≥cT2, no hydronephrosis; and highest-risk: cTany with tumour-associated hydronephrosis. The 5-year DSS for the low-, high-, and highest-risk groups were 92%, 51%, and 17%, respectively (P < 0.001). Patients down-staged at RC <pT1 regardless of the use of NAC had the best survival (5-year DSS of 96% vs 45% for those not down-staged; P < 0.001), while those who were not down-staged despite NAC had 5-year DSS of only 17%.
  
  
  
  In patients with surgically resectable MPBC, NAC appears to confer benefit to patients with muscle-invasive disease without hydronephrosis, while patients with cT1 disease can proceed to upfront RC. Patients with hydronephrosis do not appear to respond well to NAC and have poor prognosis regardless of treatment paradigm. However, further external validation studies are needed to support the proposed risk stratification before treatment recommendations can be made.
authors.affiliation: Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Mario I
authors.initials: MI
authors.lastname: Fernández
authors.affiliation: Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Stephen B
authors.initials: SB
authors.lastname: Williams
authors.affiliation: Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Daniel L
authors.initials: DL
authors.lastname: Willis
authors.affiliation: Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Rebecca S
authors.initials: RS
authors.lastname: Slack
authors.affiliation: Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Rian J
authors.initials: RJ
authors.lastname: Dickstein
authors.affiliation: Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Sahil
authors.initials: S
authors.lastname: Parikh
authors.affiliation: Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Edmund
authors.initials: E
authors.lastname: Chiong
authors.affiliation: Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Arlene O
authors.initials: AO
authors.lastname: Siefker-Radtke
authors.affiliation: Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Charles C
authors.initials: CC
authors.lastname: Guo
authors.affiliation: Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Bogdan A
authors.initials: BA
authors.lastname: Czerniak
authors.affiliation: Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: David J
authors.initials: DJ
authors.lastname: McConkey
authors.affiliation: Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Jay B
authors.initials: JB
authors.lastname: Shah
authors.affiliation: Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Louis L
authors.initials: LL
authors.lastname: Pisters
authors.affiliation: Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: H Barton
authors.initials: HB
authors.lastname: Grossman
authors.affiliation: Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Colin P N
authors.initials: CP
authors.lastname: Dinney
authors.affiliation: Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
authors.forename: Ashish M
authors.initials: AM
authors.lastname: Kamat
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002291:Carcinoma, Papillary / Q000188:drug therapy / Q000401:mortality / Q000601:surgery*; D017024:Chemotherapy, Adjuvant; D015653:Cystectomy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D012189:Retrospective Studies; D018570:Risk Assessment; D015996:Survival Rate; D001749:Urinary Bladder Neoplasms / Q000188:drug therapy / Q000401:mortality / Q000601:surgery*
keywords: cystectomy; multimodal treatment; neoadjuvant therapy; transitional cell carcinoma; urinary bladder neoplasms