- Email: [email protected]
THE PRESENCE OF LYMPHOVASCULAR INVASION IN RADICAL CYSTECTOMY SPECIMENS FOR PATIENTS WITH TRANSITIONAL CELL CARCINOMA INDEPENDENTLY PREDICTS POOR CLINICAL OUTCOMES
550
THE JOURNAL OF UROLOGY®
CONCLUSIONS: In our experience, LRCP showed acceptable oncologic outcomes. Further studies should be done to accurately assess its oncologic safety. Clinical Features No Patients Mean Patient Age (y) Mean OR time (min) No readmissions Median estimated blood loss (cc) Transfusion rate Systemic therapy Neadyuvant Adyuvant Summary of complications No Patients with complications Total No. complications Grade of complications GI G II G III G IV No reinterventions No reexplorations
56 64 (48-78) 274 min (210-350) 10 700 (200- 1700) 12% 6 19 18 22 10 8 3 0 None None
Source of Funding: None
1610 THE FINDING OF POSITIVE SURGICAL MARGINS ON PATHOLOGICAL EXAMINATION OF RADICAL CYSTECTOMY SPECIMENS PORTENDS A POOR PROGNOSIS Daniel Canter*, Thomas J Guzzo, Matthew J Resnick, Seema Sonnad, Meredith Bergey, John Tomaszewski, Keith VanArsdalen, S Bruce Malkowicz. Philadelphia, PA, and Baltimore, MD. INTRODUCTION AND OBJECTIVE: The best chance for a durable cure for patients with muscle-invasive transitional cell carcinoma 7&& RI WKH EODGGHU RU UHIUDFWRU\ KLJKJUDGH VXSHU¿FLDO GLVHDVH LV radical cystectomy (RC) and diversion. The objective of this study is to evaluate the impact of positive surgical margins in the soft tissue of RC specimens on survival. METHODS: A retrospective evaluation of a prospectively maintained HIPAA compliant/IRB approved RC database was performed. Surgical margin status was determined from investigation RIWKH¿QDOSDWKRORJ\UHSRUWVIURPDVLQJOHSDWKRORJLVWZKRVSHFLDOL]HV LQJHQLWRXULQDU\SDWKRORJ\ -= DQGLWZDVXVHGDVDELQDU\YDULDEOH Cox regression analysis and Kaplan Meier tables were developed to HYDOXDWHWKHFRQWULEXWLRQRIWKLV¿QGLQJWRFOLQLFDORXWFRPHV RESULTS: 344 patients treated between 1988 and 2005 ZLWKDPHDQIROORZXSRIPRQWKVZHUHDQDO\]HG2IWKLVJURXSRI patients, 304 (88%) patients had negative surgical margins in the RC specimen whereas 40 (12%) patients had positive surgical margins. 37/40 (93%) of patients with positive surgical margins had extra-vesical disease (pT3 or pT4). Of the 40 patients with positive surgical margins, 21/40 (53%) had lymph node positive disease. On univariate analysis WKH SRVLWLYH VXUJLFDO PDUJLQV FRQIHUUHG D VLJQL¿FDQW ULVN IRU SRRUHU RYHUDOO 26 FDQFHUVSHFL¿F '66 DQGUHFXUUHQFHIUHH 5)6 VXUYLYDOV S \HDURYHUDOODQGGLVHDVHVSHFL¿FVXUYLYDOZDV DQG for patients with positive surgical margins compared to 48% and 65% for patients with negative surgical margins.The multivariable analysis GHPRQVWUDWHGVLJQL¿FDQWLQGHSHQGHQWULVNIRUGHFUHDVHG5)6'66DQG 26IRUSDWLHQWVZLWKSRVLWLYHVXUJLFDOPDUJLQV7KHKD]DUGUDWLRVZHUH 2.29 (95% CI=1.54-3.41, p<0.001), 1.71 (95% CI=1.15-2.56, p<0.009) and 1.70 (95% CI=1.23-2.34, p <0.001), respectively. CONCLUSIONS: The presence of positive surgical margins in WKHSDWKRORJLFVSHFLPHQFRQIHUVVLJQL¿FDQWLQGHSHQGHQWULVNIRUUHGXFHG RFS, DSS, and OS. Further investigation into this subset of patients in a SURVSHFWLYHPDQQHULVLQGLFDWHGWRGHWHUPLQHLIWKH\ZRXOGEHQH¿WIURP adjuvant chemotherapy. Source of Funding: None
Vol. 179, No. 4, Supplement, Tuesday, May 20, 2008
1611 THE PRESENCE OF LYMPHOVASCULAR INVASION IN RADICAL CYSTECTOMY SPECIMENS FOR PATIENTS WITH TRANSITIONAL CELL CARCINOMA INDEPENDENTLY PREDICTS POOR CLINICAL OUTCOMES Daniel Canter*, Thomas J Guzzo, Matthew J Resnick, Seema Sonnad, Meredith Bergey, John Tomaszewski, Keith VanArsdalen, S Bruce Malkowicz. Philadelphia, PA, and Baltimore, MD. INTRODUCTION AND OBJECTIVE: In contradistinction to other cancers, survival among patients with bladder cancer has not improved over the years. There has been a great deal of interest in stratifying patients with transitional cell carcinoma (TCC) of the bladder WRGHWHUPLQHZKRZRXOGEHQH¿WIURPDPXOWLPRGDOWUHDWPHQWDSSURDFK based on clinical or pathologic data. The presence of lymphovascular invasion (LVI) in the radical cystectomy (RC) specimen is one such data point. The objective of this study is to evaluate the impact of LVI on clinical outcomes in our RC database. METHODS: A retrospective evaluation of a prospectively maintained HIPAA compliant/IRB approved cystectomy database was performed. The presence or absence of LVI was determined IURP LQYHVWLJDWLRQ RI WKH ¿QDO SDWKRORJ\ UHSRUWV DQG LW ZDV XVHG DV a binary variable. Cox regression analysis and Kaplan Meier tables ZHUH GHYHORSHG WR HYDOXDWH WKH FRQWULEXWLRQ RI WKLV ¿QGLQJ WR FOLQLFDO outcomes. RESULTS: 356 patients treated between 1988 and 2003 with a PHDQIROORZXSRIPRQWKVZHUHDQDO\]HG2IWKLVJURXSRISDWLHQWV 242 (68%) patients showed no evidence of LVI in the RC specimen whereas 114 (32%) patients had the presence of LVI. Patients with LVI WHQGHG WR SUHVHQW ZLWK KLJKHU SDWKRORJLFDO VWDJH RI WKHVH patients had pT3 or pT4 disease. On univariate analysis the presence RI /9, FRQIHUUHG D VLJQL¿FDQW ULVN IRU RYHUDOO FDQFHUVSHFL¿F DQG UHFXUUHQFHIUHHVXUYLYDOV S \HDURYHUDOODQGGLVHDVHVSHFL¿F survival was 53% and 70% for patients without LVI compared to 24% and 7KHPXOWLYDULDEOHDQDO\VLVGHPRQVWUDWHGVLJQL¿FDQWLQGHSHQGHQW ULVN IRU FDQFHU VSHFL¿F VXUYLYDO DQG RYHUDOO VXUYLYDO IRU SDWLHQWV ZLWK WKHSUHVHQFHRI/9,7KHKD]DUGUDWLRVZHUH &, p-value <0.01) and 1.74 (95% CI=1.16-2.59, p-value <0.007) for overall DQGGLVHDVHVSHFL¿FVXUYLYDOVUHVSHFWLYHO\ CONCLUSIONS: The presence of LVI in the pathologic VSHFLPHQ FRQIHUV VLJQL¿FDQW LQGHSHQGHQW ULVN IRU UHGXFHG EODGGHU FDQFHU VSHFL¿F VXUYLYDO DQG RYHUDOO VXUYLYDO 7KLV YDULDEOH FRXOG EH XVHGWRVWUDWLI\SDWLHQWVWKDWZRXOGEHQH¿WIURPPXOWLPRGDOWKHUDS\LQ a prospective study. Source of Funding: None
1612 MULTIVARIATE ANALYSIS OF PATIENTS TREATED WITH RADICAL CYSTECTOMY EVALUATING NEWLY PROPOSED PROGNOSTIC FACTORS FOR BLADDER CANCER SPECIFIC SURVIVAL Thomas Hofner*, Axel Haferkamp, Lena Knapp, Hildegard Jakobi, Jens Bedke, Sascha Pahernik, Markus Hohenfellner. Heidelberg, Germany. INTRODUCTION AND OBJECTIVE: To evaluate the recently SURSRVHG SURJQRVWLF IDFWRUV IRU FDQFHU VSHFL¿F VXUYLYDO LQ SDWLHQWV undergoing a radical cystectomy for bladder cancer. Still controversially discussed factors like gender, body mass index and hydronephrosis are DQDO\]HGWRJHWKHUZLWKHVWDEOLVKHGIDFWRUVVXFKDVWKH710VWDJLQJDQG surgical margins in a multivariate modality to investigate their status as LQGHSHQGHQWSURJQRVWLFIDFWRUVIRUEODGGHUFDQFHUVSHFL¿FVXUYLYDO METHODS: We studied a cohort of 275 patients (median age 64, range 40 to 87) who underwent radical cystectomy for bladder cancer in our institution. The median follow-up time was 3,7 years (range 0,3 to 18,0). Statistical analysis was performed using the Kaplan-Meier method and multivariate analysis was done with the Cox proportional KD]DUGVPRGHO$QDO\]HGIDFWRUVLQFOXGHGDJHJHQGHUERG\PDVVLQGH[ hydronephrosis, TNM-staging, grading, surgical margins, hematuria, urethral or prostatic invasion and uni- vs. multifocality. RESULTS: When comparing the mean estimated survival in univariate analyses the factors age, uni- vs. multifocality, T stage, N stage (N0 vs. N1), grading (G2 vs. G3), surgical margins (R0 vs. R1 vs.
THE JOURNAL OF UROLOGY®
CONCLUSIONS: In our experience, LRCP showed acceptable oncologic outcomes. Further studies should be done to accurately assess its oncologic safety. Clinical Features No Patients Mean Patient Age (y) Mean OR time (min) No readmissions Median estimated blood loss (cc) Transfusion rate Systemic therapy Neadyuvant Adyuvant Summary of complications No Patients with complications Total No. complications Grade of complications GI G II G III G IV No reinterventions No reexplorations
56 64 (48-78) 274 min (210-350) 10 700 (200- 1700) 12% 6 19 18 22 10 8 3 0 None None
Source of Funding: None
1610 THE FINDING OF POSITIVE SURGICAL MARGINS ON PATHOLOGICAL EXAMINATION OF RADICAL CYSTECTOMY SPECIMENS PORTENDS A POOR PROGNOSIS Daniel Canter*, Thomas J Guzzo, Matthew J Resnick, Seema Sonnad, Meredith Bergey, John Tomaszewski, Keith VanArsdalen, S Bruce Malkowicz. Philadelphia, PA, and Baltimore, MD. INTRODUCTION AND OBJECTIVE: The best chance for a durable cure for patients with muscle-invasive transitional cell carcinoma 7&& RI WKH EODGGHU RU UHIUDFWRU\ KLJKJUDGH VXSHU¿FLDO GLVHDVH LV radical cystectomy (RC) and diversion. The objective of this study is to evaluate the impact of positive surgical margins in the soft tissue of RC specimens on survival. METHODS: A retrospective evaluation of a prospectively maintained HIPAA compliant/IRB approved RC database was performed. Surgical margin status was determined from investigation RIWKH¿QDOSDWKRORJ\UHSRUWVIURPDVLQJOHSDWKRORJLVWZKRVSHFLDOL]HV LQJHQLWRXULQDU\SDWKRORJ\ -= DQGLWZDVXVHGDVDELQDU\YDULDEOH Cox regression analysis and Kaplan Meier tables were developed to HYDOXDWHWKHFRQWULEXWLRQRIWKLV¿QGLQJWRFOLQLFDORXWFRPHV RESULTS: 344 patients treated between 1988 and 2005 ZLWKDPHDQIROORZXSRIPRQWKVZHUHDQDO\]HG2IWKLVJURXSRI patients, 304 (88%) patients had negative surgical margins in the RC specimen whereas 40 (12%) patients had positive surgical margins. 37/40 (93%) of patients with positive surgical margins had extra-vesical disease (pT3 or pT4). Of the 40 patients with positive surgical margins, 21/40 (53%) had lymph node positive disease. On univariate analysis WKH SRVLWLYH VXUJLFDO PDUJLQV FRQIHUUHG D VLJQL¿FDQW ULVN IRU SRRUHU RYHUDOO 26 FDQFHUVSHFL¿F '66 DQGUHFXUUHQFHIUHH 5)6 VXUYLYDOV S \HDURYHUDOODQGGLVHDVHVSHFL¿FVXUYLYDOZDV DQG for patients with positive surgical margins compared to 48% and 65% for patients with negative surgical margins.The multivariable analysis GHPRQVWUDWHGVLJQL¿FDQWLQGHSHQGHQWULVNIRUGHFUHDVHG5)6'66DQG 26IRUSDWLHQWVZLWKSRVLWLYHVXUJLFDOPDUJLQV7KHKD]DUGUDWLRVZHUH 2.29 (95% CI=1.54-3.41, p<0.001), 1.71 (95% CI=1.15-2.56, p<0.009) and 1.70 (95% CI=1.23-2.34, p <0.001), respectively. CONCLUSIONS: The presence of positive surgical margins in WKHSDWKRORJLFVSHFLPHQFRQIHUVVLJQL¿FDQWLQGHSHQGHQWULVNIRUUHGXFHG RFS, DSS, and OS. Further investigation into this subset of patients in a SURVSHFWLYHPDQQHULVLQGLFDWHGWRGHWHUPLQHLIWKH\ZRXOGEHQH¿WIURP adjuvant chemotherapy. Source of Funding: None
Vol. 179, No. 4, Supplement, Tuesday, May 20, 2008
1611 THE PRESENCE OF LYMPHOVASCULAR INVASION IN RADICAL CYSTECTOMY SPECIMENS FOR PATIENTS WITH TRANSITIONAL CELL CARCINOMA INDEPENDENTLY PREDICTS POOR CLINICAL OUTCOMES Daniel Canter*, Thomas J Guzzo, Matthew J Resnick, Seema Sonnad, Meredith Bergey, John Tomaszewski, Keith VanArsdalen, S Bruce Malkowicz. Philadelphia, PA, and Baltimore, MD. INTRODUCTION AND OBJECTIVE: In contradistinction to other cancers, survival among patients with bladder cancer has not improved over the years. There has been a great deal of interest in stratifying patients with transitional cell carcinoma (TCC) of the bladder WRGHWHUPLQHZKRZRXOGEHQH¿WIURPDPXOWLPRGDOWUHDWPHQWDSSURDFK based on clinical or pathologic data. The presence of lymphovascular invasion (LVI) in the radical cystectomy (RC) specimen is one such data point. The objective of this study is to evaluate the impact of LVI on clinical outcomes in our RC database. METHODS: A retrospective evaluation of a prospectively maintained HIPAA compliant/IRB approved cystectomy database was performed. The presence or absence of LVI was determined IURP LQYHVWLJDWLRQ RI WKH ¿QDO SDWKRORJ\ UHSRUWV DQG LW ZDV XVHG DV a binary variable. Cox regression analysis and Kaplan Meier tables ZHUH GHYHORSHG WR HYDOXDWH WKH FRQWULEXWLRQ RI WKLV ¿QGLQJ WR FOLQLFDO outcomes. RESULTS: 356 patients treated between 1988 and 2003 with a PHDQIROORZXSRIPRQWKVZHUHDQDO\]HG2IWKLVJURXSRISDWLHQWV 242 (68%) patients showed no evidence of LVI in the RC specimen whereas 114 (32%) patients had the presence of LVI. Patients with LVI WHQGHG WR SUHVHQW ZLWK KLJKHU SDWKRORJLFDO VWDJH RI WKHVH patients had pT3 or pT4 disease. On univariate analysis the presence RI /9, FRQIHUUHG D VLJQL¿FDQW ULVN IRU RYHUDOO FDQFHUVSHFL¿F DQG UHFXUUHQFHIUHHVXUYLYDOV S \HDURYHUDOODQGGLVHDVHVSHFL¿F survival was 53% and 70% for patients without LVI compared to 24% and 7KHPXOWLYDULDEOHDQDO\VLVGHPRQVWUDWHGVLJQL¿FDQWLQGHSHQGHQW ULVN IRU FDQFHU VSHFL¿F VXUYLYDO DQG RYHUDOO VXUYLYDO IRU SDWLHQWV ZLWK WKHSUHVHQFHRI/9,7KHKD]DUGUDWLRVZHUH &, p-value <0.01) and 1.74 (95% CI=1.16-2.59, p-value <0.007) for overall DQGGLVHDVHVSHFL¿FVXUYLYDOVUHVSHFWLYHO\ CONCLUSIONS: The presence of LVI in the pathologic VSHFLPHQ FRQIHUV VLJQL¿FDQW LQGHSHQGHQW ULVN IRU UHGXFHG EODGGHU FDQFHU VSHFL¿F VXUYLYDO DQG RYHUDOO VXUYLYDO 7KLV YDULDEOH FRXOG EH XVHGWRVWUDWLI\SDWLHQWVWKDWZRXOGEHQH¿WIURPPXOWLPRGDOWKHUDS\LQ a prospective study. Source of Funding: None
1612 MULTIVARIATE ANALYSIS OF PATIENTS TREATED WITH RADICAL CYSTECTOMY EVALUATING NEWLY PROPOSED PROGNOSTIC FACTORS FOR BLADDER CANCER SPECIFIC SURVIVAL Thomas Hofner*, Axel Haferkamp, Lena Knapp, Hildegard Jakobi, Jens Bedke, Sascha Pahernik, Markus Hohenfellner. Heidelberg, Germany. INTRODUCTION AND OBJECTIVE: To evaluate the recently SURSRVHG SURJQRVWLF IDFWRUV IRU FDQFHU VSHFL¿F VXUYLYDO LQ SDWLHQWV undergoing a radical cystectomy for bladder cancer. Still controversially discussed factors like gender, body mass index and hydronephrosis are DQDO\]HGWRJHWKHUZLWKHVWDEOLVKHGIDFWRUVVXFKDVWKH710VWDJLQJDQG surgical margins in a multivariate modality to investigate their status as LQGHSHQGHQWSURJQRVWLFIDFWRUVIRUEODGGHUFDQFHUVSHFL¿FVXUYLYDO METHODS: We studied a cohort of 275 patients (median age 64, range 40 to 87) who underwent radical cystectomy for bladder cancer in our institution. The median follow-up time was 3,7 years (range 0,3 to 18,0). Statistical analysis was performed using the Kaplan-Meier method and multivariate analysis was done with the Cox proportional KD]DUGVPRGHO$QDO\]HGIDFWRUVLQFOXGHGDJHJHQGHUERG\PDVVLQGH[ hydronephrosis, TNM-staging, grading, surgical margins, hematuria, urethral or prostatic invasion and uni- vs. multifocality. RESULTS: When comparing the mean estimated survival in univariate analyses the factors age, uni- vs. multifocality, T stage, N stage (N0 vs. N1), grading (G2 vs. G3), surgical margins (R0 vs. R1 vs.