BACKGROUND The presence of lymph node metastasis is a poor prognostic sign for patients with prostate carcinoma. Results of published reports on survival among patients with lymph node metastasis are difficult to assess because of treatment selections. The extent to which lymph node status will have an impact on a patient's survival is uncertain. METHODS The authors analyzed 3463 consecutive Mayo Clinic patients who underwent radical prostatectomy and bilateral pelvic lymphadenectomy for prostate carcinoma between 1987 and 1993. Of these patients, 322 had lymph node metastasis at the time of surgery, and 297 lymph node positive patients also received adjuvant hormonal therapy within 90 days of surgery. The progression free rate and the cancer specific survival rate were used as outcome endpoints in univariate and multivariate Cox proportional hazards models. The median follow‐up was 6.3 years. Progression was defined by elevation of serum prostate specific antigen (PSA) ≥ 0.4 ng/mL after surgery, development of local recurrence, or distant metastasis documented by biopsy or radiographic examination. RESULTS The 5‐year and 10‐year progression free survival rates (± standard error [SE]) for patients with lymph node metastasis were 74% ± 2% and 64% ± 3%, respectively, compared with 77% ± 1% and 59% ± 2%, respectively, for patients without lymph node metastasis. The 5‐year and 10‐year cancer specific survival rates were 94% ± 1% and 83% ± 4%, respectively, compared with 99% ± 0.1% and 97% ± 0.5%, respectively, for patients without lymph node metastasis. Among patients with a single lymph node metastasis, the 5‐year and 10‐year cancer specific survival rates were 99% ± 1% and 94% ± 3%, respectively. After adjustment for extraprostatic extension, seminal vesicle invasion, Gleason grade, surgical margins, DNA ploidy, preoperative serum PSA concentration, and adjuvant therapy, the hazard ratio for death from prostate carcinoma among patients with a single lymph node metastasis compared with patients who were without lymph node metastasis was 1.5 (95% confidence interval, 0.5–5.0; P = 0.478), whereas the hazard ratio for death from prostate carcinoma was 6.1 (95% confidence interval, 1.9–19.6; P = 0.002) for those with two positive lymph nodes and 4.3 (95% confidence interval, 1.4–13.0; P = 0.009) for those with three or more positive lymph nodes. There was no significant difference in the progression free survival rate among patients with or without lymph node metastasis in multivariate analysis after controlling for all relevant variables, including treatments (hazard ratio,1.0; 95% CI, 0.7–1.3; P = 0.90). CONCLUSIONS Patients with prostate carcinoma who have multiple regional lymph node metastases had increased risk of death from disease, whereas patients with single lymph node involvement appeared to have a more favorable prognosis after radical prostatectomy and immediate adjuvant hormonal therapy. Excellent local disease control was achieved by using combined surgery and adjuvant hormonal therapy in patient...

Progression-free survival determined by the model score group identified a wide range of risk levels for patients with specimen confined prostate cancer. This simple predictive model allows identification of patients at high risk for cancer progression with specimen confined disease who may be targeted for closer surveillance and adjuvant therapy, while those at lower risk may be simply observed.

BACKGROUND Clinical outcomes vary for patients treated with radical cystectomy. The authors sought to identify factors associated with the survival of patients treated with radical cystectomy for urothelial carcinoma of the urinary bladder. METHODS The authors studied 218 patients treated with radical cystectomy for urothelial carcinoma between 1980 to 1984. Patient ages ranged from 41 to 78 years (mean, 64 years). Using the 1997 TNM system, T classifications were Ta (17 patients), T1 (44), T2 (71), T3a (42), T3b (14), T4a (28), and T4b (2). Thirty‐two patients had lymph node metastasis at the time of surgery. Histologic grade was determined according to the newly proposed World Health Organization and International Society of Urological Pathology grading system; tumor was low grade in 43 patients and high grade in 175. The male‐to‐female ratio was 4.9 to 1. The mean follow‐up of patients still alive was 13.1 years (median, 13.8 years; range, 30 days to 18 years). Cox proportional hazards models were used to determine the impact of numerous clinical and pathologic findings on survival. RESULTS Ten‐year local recurrence free, distant metastasis free, cancer specific, and all‐cause survival were 71%, 73%, 67%, and 41%, respectively. In univariate analysis, cancer size, T classification, and lymph node status were associated with distant metastasis free, cancer specific, and all‐cause survival. Histologic grade and surgical margin status were significantly associated with worse cancer specific and all‐cause survival, but not with distant metastasis free survival. In multivariate analysis, cancer size, margin status, T classification, and lymph node status were identified as significantly associated with cancer specific survival after adjustment for age and gender. CONCLUSIONS Long term survival is achieved in a significant number of patients treated with radical cystectomy. In this study, patients with organ‐confined (≤ pT2) and small size (≤ 3 cm) cancer had favorable 10‐year distant metastasis free (93%) and cancer specific survival (88%) after cystectomy. Tumor size, margin status, extravesical involvement, and lymph node metastasis are important pathologic factors and should be considered as stratification variables in identifying patients for whom adjuvant chemotherapy should be evaluated in clinical trials. Cancer 2000;88:2326–32. © 2000 American Cancer Society.

We compared the grading and staging of transurethral resection of the bladder (TURB) and cystectomy specimens for 105 patients who underwent radical cystectomy for urothelial carcinoma between 1980 and 1984. Of 105 patients, 96% underwent cystectomy within 100 days of TURB (median interval, 10 days). Grading was performed according to the 1998 World Health Organization/International Society of Urologic Pathology grading system and staging according to the 1997 TNM classification. Histologic grade was low-grade, 13; high-grade, 92 in TURB specimens; low-grade, 17; high-grade, 88 in cystectomy specimens. Pathologic stage was Ta, 15; T1, 55; and T2, 35 in TURB specimens; Ta, 5; T1, 19; T2, 19; T3, 46; and T4, 16 in cystectomy specimens. Histologic grade at TURB was associated with pathologic stage at cystectomy (P < .001). When all advanced-stage (muscle-invasive) carcinomas (pT2 or more) were considered together, 55 patients were understaged by TURB, 4 had higher stage in TURB than in cystectomy, and 46 were the same stage as by cystectomy. Forty-three of 55 patients with stage T1 carcinoma at TURB had advanced-stage carcinoma at cystectomy, including 34 who had extravesicular extension (pT3 or more). We found pathologic understanding by TURB occurs in a significant number of patients with bladder cancer; the newly proposed grading system predicted final pathologic stage.

BACKGROUND.A significant number of T1 bladder carcinoma patients are understaged by transurethral resection of the bladder (TURB), indicating a substantial need for more accurate staging. METHODS.The authors studied 55 patients with T1 bladder carcinoma detected by TURB at the Mayo Clinic between December 1979 and July 1984. The mean age of the patients was 66 years (range, 50 -78 years). All patients were treated by cystectomy. The median interval from TURB to cystectomy was 10 days. Grading was performed according to the 1998 World Health Organization/International Society of Urologic Pathology grading system. The 1997 TNM classification was used for pathologic staging. In addition, the depth of invasion was measured from the mucosal basement membrane by micrometer. Receiver operating characteristic (ROC) analysis was used to evaluate the usefulness of depth of invasion as a marker for advanced stage bladder carcinoma (Ն T2). RESULTS.The final pathologic stages were Ta (2 patients), T1 (10 patients), T2a (9 patients), T2b (13 patients), T3 (11 patients), and T4 (10 patients) at cystectomy.There was a significant correlation between the depth of invasion at TURB and the final pathologic stage (Spearman correlation coefficient ϭ 0.63; P Ͻ 0.001). The overall accuracy for the prediction of advanced stage (Ն T2) bladder carcinoma as measured by the area under the ROC curve was 0.89 (standard error, 0.05). Using 1.5 mm as a threshold (with Ͼ1.5 mm indicating advanced stage disease), the sensitivity, specificity, and positive and negative predictive values were 81%, 83%, 95%, and 56%, respectively. Histologic grade at the time of TURB also was associated significantly with final pathologic stage at cystectomy (P ϭ 0.03) whereas stratification of patients according to invasion above or below the muscularis mucosae at TURB was not a significant predictor of final pathologic stage. CONCLUSIONS.The results of the current study show that substaging of T1 bladder carcinoma according to the depth of invasion (as measured by micrometer) provides significant prognostic information. Therefore the authors recommend that it be reported in specimens obtained by TURB. [See also editorial counterpoint on pages 908 -9 and reply to counterpoint on pages 910 -2, this issue.] Cancer 1999;86: 1035-43.