Comparison of the new American Joint Committee on Cancer substratification in node‐negative pT2 urothelial carcinoma of the bladder: analysis of patient outcomes in a contemporary series

Abstract

patients with pT2b UCB had LN-positive disease ( P = 0.02).• The median (range) number of LNs removed in LN-positive disease was 18 (11-30) and in LN-negative disease was 20 (4-38) ( P = 0.52).• In LN-negative disease, actuarial 5-year RFS was 85.9% in patients with pT2a UCB vs 37.5% in those with pT2b UCB ( P < 0.001). Actuarial 5-year CSS was 84.8% in patients with LN-negative pT2a UCB vs 59.6% in patients with LN-negative pT2b UCB ( P = 0.01).• In Cox regression analysis, pT2 substratification was the only independent risk factor of recurrence and cancer-specific death ( P < 0.001 and P = 0.008). CONCLUSIONS• In this contemporary series of patients undergoing RC with ePLND, there was a significant difference in RFS and CSS between LN-negative pT2a and pT2b UCB, and pT2 substratification was the only risk factor of recurrence and cancer-specific death.• These data are supportive of the current concept of substratification in LN-negative pT2 UCB. KEYWORDSlymph node metastasis, pelvic lymphadenectomy, muscle-invasive, urothelial carcinoma of the bladder, substratification, survival What's known on the subject? and What does the study add?The prognostic value of pathological substratification in lymph node-negative pT2 urothelial carcinoma of the bladder based on tumour depth has been controversially discussed in recent studies. In 1997, the AJCC and UICC modified the TNM staging system in bladder cancer providing a new substratification in pT2 bladder cancer based on a previous study of Jewett in 1952 reporting a worse prognosis for patients with deep muscle invasion compared to those with superficial muscle invasion. Recently, this prognostic significance has been considered of minor importance compared to significance of lymph node tumor involvement. Thus, many of these studies concluded that future revisions of the TNM staging system should consolidate both substages. However, these studies were hampered by the inclusion of patients with non-urothelial carcinoma components, unknown number of retrieved lymph nodes, unknown extent of pelvic lymphadenectomy, and inclusion of patients undergoing neoadjuvant chemotherapy.This study addresses specifically the prognostic significance of pT2 substaging in urothelial cancer in a contemporary, consecutive series of patients treated with radical cystectomy. All patients had pure urothelial cell carcinoma, and underwent an extended lymphadenectomy approach. The number of retrieved lymph nodes was recorded. There was a significant difference in survival in patients with lymph-node negative pT2a vs. pT2b disease. Therefore, this study supports the prognostic value of the current substratification in pT2 urothelial carcinoma of the bladder.Study Type -Prognosis (case series) Level of Evidence 4 OBJECTIVE• To determine whether there is a difference in survival in patients with node-negative pT2a vs pT2b urothelial carcinoma of the bladder (UBC), as recent studies suggest that the new American Joint Committee on Cancer substratification may not have prognostic significance. P...

Prognostic Significance of Measured Depth of Invasion of Urothelial Carcinoma of the Bladder Compared to the 2010 American Joint Committee on Cancer pT2 and pT3 Classifications

“…6 In contrast, in 72 patients with pT2 tumors Gakis et al noted 85% CSS for patients with pT2a vs 60% for patients with pT2b tumors. 2 Moreover, a multi-institutional study by Tilki et al in 440 patients with pT2 lymph node-negative disease treated between 1979 and 2008 demonstrated a 5-year CSS of 82.6% for patients with pT2a tumors compared to 70% for those with pT2b tumors. 3 In a risk stratification model in 707 men with pT2N0 bladder cancer treated with radical cystectomy from 1971 to 2008 Sonpavde et al identified a recurrencefree survival HR of 1.7 for pT2a and 3.0 for pT2b when using less than pT2 as a reference.…”

“…However, the clinical significance of these substratifications continue to be debated with conflicting data from large studies in regard to outcome, and pT2 and pT3 substages. [2][3][4][5][6][7][8][9][10][11] To our knowledge none of the studies to date that evaluated the prognostic significance of pathological 1706 www.jurology.com substaging included a centralized pathological review by urological pathologists. In our experience there is interobserver variability in the current definition of pT3 substaging in regard to microscopic vs macroscopic invasion, while an extravesical mass is not well defined.…”

Staging of bladder cancer

“…This admission of error by Jewett may have been premature, however, as several recent, large studies found clinical utility in the current pT2a/b staging classification . Gakis et al .…”

“…Gakis et al . studied 252 patients with pT2 tumours and found a significant difference in recurrence‐free survival (85.9 versus 37.5%, respectively) and cancer‐specific survival (84.8 versus 59.6%, respectively) between pT2aN0 and pT2bN0 patients . Additionally, pT2 substratification was the only risk factor of recurrence and cancer‐specificity .…”

Can we rely on lymphovascular invasion for determining the need for adjuvant chemotherapy in organ‐confined bladder cancer?

“…In the present study, the only variable associated with a higher risk of LVI was found to be pathological stage (pT1 vs pT2); however, substratification in pT2N0 bladder cancer has also been shown to be of prognostic importance for predicting recurrence after cystectomy [4]. The unknown anatomical extent of lymph node dissection at radical cystectomy makes it difficult to assess the impact of LVI on outcomes because patients with localized tumours and presumed micrometastatic disease (as suggested by LVI) may still be cured with an extended pelvic lymph node dissection [6]. While the authors tried to adjust for this bias by reporting on the number of retrieved lymph nodes, 30% of their patients had < 15 lymph nodes removed at surgery.…”