Decreased Overall and Bladder Cancer-Specific Mortality with Adjuvant Chemotherapy After Radical Cystectomy: Multivariable Competing Risk Analysis

Adding chemotherapy to radical cystectomy (RC) may improve outcome. Neoadjuvant treatment is advocated by guidelines based on meta-analysis data but is severely underused in clinical practice. Adjuvant treatment of patients at risk could be an alternative. We analyzed a sample of 798 patients who underwent RC between 1993 and 2011 for high-risk superficial or muscle-invasive urothelial or undifferentiated bladder cancer, of which 23% received adjuvant cisplatin-based chemotherapy and %5 received neoadjuvant chemotherapy. The use of adjuvant chemotherapy was an independent predictor of decreased overall mortality (hazard ratio [HR]: 0.50; 95% confidence interval [CI], 0.38-0.66; p<0.0001) and bladder cancer-specific mortality (HR: 0.71; 95% CI, 0.52-0.97; p=0.0321), but it was not associated with competing mortality. Similar figures were obtained when analyzing the number of cisplatin-containing cycles administered or when restricting the analysis to patients with lymph node-positive or extravesical but lymph node-negative disease, suggesting a mortality-reducing treatment effect after adjusting for several patient- and tumor-related confounders. Future trials should directly compare the concepts of neoadjuvant and adjuvant application of chemotherapy in candidates for RC.

PATIENT SUMMARY

Adjuvant chemotherapy may decrease overall and bladder cancer-specific mortality after radical cystectomy (RC). Future trials should directly compare the concepts of neoadjuvant and adjuvant application of chemotherapy in candidates for RC.

Retroperitoneal Leiomyosarcoma Associated with an Elevated beta-HCG Serum Level Mimicking Extragonadal Germ Cell Tumor

Patient. A 65-year-old man was admitted with a large primary retroperitoneal tumor and an increased β-human chorionic gonadotropin (β-HCG) serum level. A germ cell tumor was suspected; however, a computed tomography-guided biopsy failed to enable tumor classification. After two courses of chemotherapy, the β-HCG serum level had returned to the normal level and a diagnostic laparotomy with incisional biopsy was performed. The immunohistochemical examination of the specimen identified the tumor as a retroperitoneal pleomorphic leiomyosarcoma.

Discussion. Tumor markers play only a marginal role in the work-up of patients with soft tissue sarcomas. In men with suspected retroperitoneal sarcomas, however, the determination of germ cell tumor markers occasionally enables a preoperative distinguishing of primary retroperitoneal germ cell tumors with considerable consequences for management. In this setting, a retroperitoneal tumor associated with a moderately elevated β-HCG is a diagnostic dilemma, and surgeons should be aware of the pitfall of a β-HCG-producing leiomyosarcoma in the differential diagnosis.

Magnetic resonance imaging of bone metastases in patients with nonseminomatous germ cell tumors

OBJECTIVE

To investigate the role of magnetic resonance imaging (MRI) of bone metastases in nonseminomatous germ cell tumors.

METHODS AND MATERIALS

There were 5 consecutive patients with bone metastases from nonseminomatous germ cell tumors treated between 2003 and 2006 who underwent imaging studies, including MRI. The characteristic imaging findings are discussed in the light of the clinical course.

RESULTS

Of the 5 patients, 3 had symptoms related to bone involvement at diagnosis. All patients received conventional x-ray of their bony lesions, but only 1 of them was considered abnormal. Skeletal MRI was obtained in all patients. A bone scan was available in 3 cases with spinal involvement. It was normal in 1 case and detected only a minority of the lesions visible on MRI in the other 2 cases. Follow-up MRIs were available in all patients. A partial resolution of bone involvement during chemotherapy was observed in only 1 of them. In 2 cases, there was a slight progression of a diffuse alteration of the bone marrow during treatment. In 1 patient, severe spinal bone marrow changes were visible on MRI 2 years after cessation of treatment without evidence of disease recurrence.

CONCLUSIONS

MRI may disclose bone metastases in nonseminomatous germ cell tumors, which otherwise may be missed. MRI findings of bone lesions during treatment do not directly reflect the course of the disease and have to be interpreted with caution using clinical information.

Changing comorbidity classification patterns at radical prostatectomy during a 10-year period

OBJECTIVE

To investigate the consistency of several comorbidity classifications and concomitant diseases at radical prostatectomy (RP) during a 10-year period.

METHODS AND MATERIALS

In 1,297 patients who underwent RP between 1993 and 2002, age and several comorbidity classifications were derived from patient records and assigned to the year of surgery. Trends were evaluated using the Cochran-Armitage trend test.

RESULTS

Parallel to an increasing frequency of RPs and a shift toward more organ-confined tumors (P = 0.0094), the proportion of patients aged > or =70 years increased (P = 0.0077). The proportion of the American Society of Anesthesiologists (ASA) Physical Status class 3 increased (P < 0.0001), whereas that of ASA class 1 decreased (P < 0.0001). A Charlson score > or =1 has been assigned with an increasing frequency (P = 0.0008), whereas the trend with a Charlson score of > or =2 did not reach statistical significance (P = 0.07). In contrast to the latter 2 classifications, no significant trends were observed with classifications related to diabetes mellitus and heart disease.

CONCLUSIONS

This study shows that the application of the ASA classification may change significantly over time, whereas cardiac and diabetes-related conditions, as well as the Charlson score were apparently less sensitive to changing classification standards in the RP setting.

Comorbidity is poor predictor of survival in patients undergoing radical prostatectomy after 70 years of age

OBJECTIVES

To investigate several comorbidity classifications as possible predictors of mortality, because the value of comorbidity as a prognostic factor is uncertain in patients older than 70 years of age and radical prostatectomy in patients older than 70 years is controversial.

METHODS

A total of 214 consecutive patients aged 70 years or older who underwent radical prostatectomy from December 1992 to December 2002 were stratified according to the Charlson score, American Society of Anesthesiologists physical status classification, New York Heart Association classification of cardiac insufficiency, classification of angina pectoris from the Canadian Cardiovascular Society, and age (70 to 72 versus 73 to 74 versus 75 years or older). The mean follow-up in the surviving patients was 5.1 years (range 1.3 to 12.5). A sample of 240 consecutive patients aged 67.0 to 69.9 years treated during the same period was used for comparison. The overall and comorbid mortality were the study endpoints. Mantel-Haenszel hazard ratios were calculated. Comparisons were made using the log-rank test.

RESULTS

Unlike for patients aged 67.0 to 69.9 years, for those 70 years old or older, only one of the investigated stratifications reached significance as a predictor of mortality. A New York Heart Association classification of 2+ versus 0 was significant for overall mortality (hazard ratio 5.8, P = 0.021) and comorbid mortality (hazard ratio 15.9, P = 0.046).

CONCLUSIONS

Comorbidity is of limited prognostic value in patients selected for radical prostatectomy and 70 years old or older.

Comparison of tumor- and comorbidity-related predictors of mortality after radical prostatectomy

OBJECTIVES

To identify and compare tumor- and non-tumor-related predictors of survival after radical prostatectomy and to incorporate the latter into the tumor node metastasis classification of prostate cancer.

MATERIAL AND METHODS

A total of 402 patients who underwent radical prostatectomy (mean follow-up period 6.9 years) were stratified according to postoperative tumor stage, Gleason score, prostate-specific antigen level, age and five comorbidity classifications. Cox proportional hazard models were used to identify independent prognostic factors predicting overall survival.

RESULTS

Comorbidity (American Society of Anesthesiologists Physical Status classification), Gleason score and age, but not tumor stage, were independent predictors of overall survival. Based on tumor stage and the identified independent prognostic factors, an easily applicable prognostic score was developed to predict overall mortality.

CONCLUSION

A prognostic classification of radical prostatectomy patients based on Gleason score, comorbidity and age and supplementary to a coarsened variant of the tumor node metastasis classification may be of clinical value.

Qualitative and quantitative assessment of urinary cytokeratin 8 and 18 fragments compared with voided urine cytology in diagnosis of bladder carcinoma

OBJECTIVES

To evaluate the value of urine tests based on the detection of cytokeratins 8 and 18 for the diagnosis of bladder cancer compared with urine cytology.

METHODS

Samples from 112 patients before transurethral resection (group 1), 40 patients before secondary surgical treatment (group 2), 29 healthy control subjects (group 3, controls), and 10 women with acute urinary tract infection (group 4, controls) were examined with the UBC Rapid and UBC II enzyme-linked immunosorbent assay (ELISA) tests and voided urine cytology.

RESULTS

Of the 112 patients in group 1, 90 had transitional cell carcinoma. For the UBC Rapid, UBC ELISA, and cytology, the sensitivity and specificity was 64.4%, 46.6%, and 70.5% and 63.6%, 86.3%, and 79.5%, respectively. The cytology had the greatest accuracy (72.3%) compared with both cytokeratin tests (54.4% and 64.2%). For all three tests, sensitivity increased with tumor grade and stage. In group 2, 16 of 40 patients had residual carcinoma. The sensitivity was similar for all three tests, and the specificity of cytology was lower compared with its specificity in group 1 (47.9% versus 70.5% in group 1). In the controls with or without urinary tract infection, the specificity of cytology was greater than that of both other tests. The combination of the UBC ELISA test with cytology increased the sensitivity to 83% (specificity 68%).

CONCLUSIONS

Both cytokeratin tests detected patients with transitional cell carcinoma, but were inferior to voided urine cytology in test quality.

Feasibility and Limitations of Comorbidity Measurement in Patients Undergoing Radical Prostatectomy

OBJECTIVE

To compare different comorbidity classifications as predictors of survival after radical prostatectomy (RPE).

METHODS

444 consecutive RPE patients (mean follow-up 6.9 years) were stratified according to age, Charlson score, American Society of Anesthesiologists Physical Status classification (ASA), New York Heart Association classification of cardiac insufficiency, classification of angina pectoris of the Canadian Cardiovascular Society and a combination of both cardiac risk scores. Comorbid and overall mortality were the study endpoints. Mantel-Haenszel hazard ratios, p values and 8-year survival probabilities were used for comparison. A modified Charlson score was created by a restriction to the five individual conditions significantly associated with comorbid mortality.

RESULTS

When three strata (low, intermediate, high risk) were used, all stratifications displayed dose-response patterns and reached statistical significance as predictors of survival at least for the high-risk group. Only the ASA classification, however, discriminated three significantly different risk groups. Only the modified (restricted) Charlson score reached statistical significance as predictor of comorbid mortality in the age group of 70 or more years.

CONCLUSION

Although all investigated comorbidity classifications had some prognostic relevance in patients selected for RPE, their clinical applicability appears to be limited beyond the 70th year of life. The results of this study might, nevertheless, assist the treatment decision in patients with low-risk tumors eligible for modern watchful waiting strategies who mainly belong to the age group between 60-69 years where comorbidity seems to be of distinct prognostic value.

Which Conditions Contributing to the Charlson Score Predict Survival After Radical Prostatectomy?

PURPOSE

The Charlson score is likely to be the most frequently used comorbidity measure in prostate cancer. However, to our knowledge the individual prognostic significance of contributing conditions has not been previously studied in a radical prostatectomy sample.

MATERIALS AND METHODS

A total of 444 consecutive patients were entered into this study. The 19 conditions contributing to the Charlson score were obtained from the preoperative cardiopulmonary risk assessment and the hospital discharge document. Mantel-Haenszel hazard ratios were estimated for comorbid (noncancer) and overall survival. Thereafter, the Charlson score was refined by excluding conditions with low predictive value.

RESULTS

Mean followup was 5.9 years. Only 3 single conditions (congestive heart failure, peripheral vascular disease and severe renal disease) were significantly associated with excess overall mortality. Concerning comorbid mortality, in addition to these 3 diseases, chronic pulmonary disease was associated with increased risk. Refinement of the Charlson score improved the circumscription of patients at risk for premature death after radical prostatectomy.

CONCLUSIONS

This study suggests that restricting the Charlson score to some clinically meaningful diseases may increase its usefulness in candidates for radical prostatectomy. The conventional Charlson score did not add clinically meaningful information supplementary to congestive heart failure, which is the most important single contributing condition.

Comparison of the American Society of Anesthesiologists Physical Status classification with the Charlson score as predictors of survival after radical prostatectomy

OBJECTIVES

To compare the American Society of Anesthesiologists Physical Status (ASA) classification with the Charlson score in the radical prostatectomy setting. The ASA classification is a widely accepted way to evaluate perioperative risk. At present, the Charlson score is probably the most frequently used comorbidity measure to predict long-term survival after radical prostatectomy.

METHODS

A total of 444 consecutive patients were enrolled in this study. The ASA classification was obtained from the anesthesia chart, and the Charlson score was assigned based on conditions noted during the preoperative cardiopulmonary risk assessment or mentioned on the discharge document. Kaplan-Meier time-event curves and Mantel-Haenszel hazard ratios were estimated for comorbid (noncancer) and overall survival.

RESULTS

After a mean follow-up of 5.9 years, both classifications were able to predict comorbid and overall survival in dose-response patterns. The ASA classification was superior in terms of a clearer discrimination of the survival curves (lower P values, higher hazard ratios). Both classifications identified a high-risk group (ASA 3 and Charlson score 2 or more), but only the ASA classification sufficiently defined a low-risk group (ASA 1).

CONCLUSIONS

In experienced hands, the ASA classification is a promising tool to improve the classification of prognostic comorbidity in the radical prostatectomy setting and may be used as an alternative to the Charlson score.

Preoperative cardiopulmonary risk assessment as predictor of early noncancer and overall mortality after radical prostatectomy

OBJECTIVES

To evaluate the capability of the preoperative cardiopulmonary risk assessment to predict early noncancer and overall mortality after radical prostatectomy for clinically localized prostate cancer.

METHODS

In 444 consecutive radical prostatectomy patients, the American Society of Anesthesiologists Physical Status classification and the presence of cardiac insufficiency (New York Heart Association classification), angina pectoris (Canadian Cardiovascular Society classification), diabetes, hypertension, history of thromboembolism, and chronic obstructive or restrictive pulmonary disease were assessed. Kaplan-Meier time-event curves and Mantel-Haenszel hazard ratios were estimated for noncancer (other deaths were censored) and overall mortality. Cox proportional hazard models were used to analyze possible combined effects of risk factors.

RESULTS

During an average follow-up of 4.7 years, 36 patients died: 15 of noncancer causes, 14 of prostate cancer, 6 of other cancers, and 1 in a car accident. The comorbidity scores for American Society of Anesthesiologists Physical Status classification, New York Heart Association classification, and Canadian Cardiovascular Society classification and combinations between the latter two scores were significantly associated with early noncancer mortality in a dose-response pattern. Furthermore, patients with chronic obstructive pulmonary disease were at increased risk. The association with overall mortality was less strong.

CONCLUSIONS

The preoperative cardiopulmonary risk assessment may be used as a predictor of early noncancer and overall mortality after radical prostatectomy and should be evaluated further as a source of prognostic information in surgical oncology.

Is systematic sextant biopsy suitable for the detection of clinically significant prostate cancer?

BACKGROUND

The optimal extent of the prostate biopsy remains controversial. There is a need to avoid detection of insignificant cancer but not to miss significant and curable tumors. In alternative treatments of prostate cancer, repeated sextant biopsies are used to estimate the response. The aim of this study was to investigate the reliability of a repeated systematic sextant biopsy as the standard biopsy technique in patients with significant tumors which are being considered for curative treatment.

METHODS

Systematic sextant biopsy was performed in vitro in 92 radical prostatectomy specimens. Of these patients, 81 (88.0%) had palpable lesions.

RESULTS

Of the 92 investigated patients, 70 (76.1%) had potentially curable pT2-3pN0 prostate cancers. In these patients, the cancer was detected only in 72.9% of cases by a repeated in vitro biopsy. In the pT2 tumors, there was a detection rate of only 66.7%.

CONCLUSIONS

This study underlines the fact that a considerable number of significant and potentially curable tumors remain undetected by the conventional sextant biopsy. A negative sextant biopsy does not rule out significant prostate cancer.

Unusual semi-spheric perivesical calcification after pelvic radiotherapy

An uncommon case with semi-spheric perivesical calcification after pelvic radiotherapy is reported and the possible pathogenesis of this phenomenon is discussed.