Although radical cystectomy has been considered the gold standard curative treatment for invasive bladder cancer, around one third of the patients relapse and die of the disease after surgery. The main reason for cancer death in patients treated with radical cystectomy has been associated with the development of distant metastasis. Meanwhile, long-term survival after local recurrence is also extremely rare. Thus, local recurrence is thought to be as important as distant metastasis for disease specific survival. However, few studies have discussed the clinical course and natural history of local recurrence in patients with bladder cancer. The association between local recurrence and distant metastasis has also not been fully evaluated.
In this study, we retrospectively reviewed patients who underwent radical cystectomy for invasive bladder cancer in order to examine the association between local recurrence and distant metastasis or disease specific survival and identify independent factor predictors for local recurrence.
We identified a study population of 146 consecutive patients treated surgically for invasive bladder cancer at our institution between 1987 and 2003. We clarified the relationship among local recurrence, distant metastasis and disease specific survival and identified significant predictors for local recurrence.
Local recurrence developed in 26 (17.8%) of the 146 patients at a median of 10 months (range, 1 to 73 months) after cystectomy. Local recurrence was independently associated with distant metastasis in addition to the number of retrieved lymph nodes. The 2- and 5-year metastasis free rates were 86.7% and 76.5% in patients without local recurrence and 26.5% and 0% in those with local recurrence (P <0.001). The presence or absence of local recurrence and tumor grade were independent predictors of disease specific survival. The 2- and 5-year disease specific survival rates were 93.5% and 88.3% in patients without local recurrence and 55.1% and 35.4% in those with local recurrence (P <0.001). The presence of concomitant adenocarcinoma component, pathological nodal involvement, and the number of retrieved lymph nodes were independent predictors of local recurrence.
Our study revealed that local recurrence was independently associated with distant metastasis and disease specific survival. The predictive factors described above might help us select a subgroup of patients who would benefit from optimal local control, subsequently reducing distant metastasis and improving disease specific survival. There are some strategies for local control such as aggressive surgical extirpation of tissue adjacent to bladder, extended lymph node dissection and adjuvant therapy that includes a new chemotherapeutic regimen or novel molecular targeting therapy in the future. Based on our results, extensive lymph node dissection would be of benefit to reduce local recurrence.
Hiroki Ide, MD, Eiji Kikuchi, MD, Akira Miyajima, MD, Ken Nakagawa, MD, Takashi Ohigashi, MD, Jun Nakashima, MD, and Mototsugu Oya, MD, as part of Beyond the Abstract on UroToday.com.