Prognosis of Muscle-Invasive Bladder Cancer: Difference between Primary and Progressive Tumours and Implications for Therapy
Introduction
Transitional cell carcinoma (TCC) of the urinary bladder can present as a superficial or as a muscle-invasive lesion. The majority of patients (approximately 75%) present with relatively benign superficial tumours, which are limited to the mucosa (Ta) or the lamina propria (T1) [1]. Carcinoma in situ (Cis) can also be considered superficial. However, Cis tends to behave more aggressively and is often found in association with high-grade superficial tumours. Tumour recurrence with superficial tumour is quite common and can be as high as 50% to 70% following therapy [2], [3]. About 30% of these recurrent tumours will progress to a higher grade or stage, with approximately 10% of these recurrent cancers progressing to muscle-invasive disease [4], [5]. On the other hand, about 15% of patients who present with muscle-invasive tumours have a history superficial carcinoma. However, most of the diagnosed cases of muscle-invasive bladder cancer (80% to 90%) present without prior history of superficial disease i.e. primary invasive bladder cancer.
Patients with primary and progressive muscle-invasive bladder cancer are treated equally in normal daily practice assuming a similar cancer-specific survival for both patient groups. However, to our knowledge, studies on this subject do not exist. In addition, timing of radical treatment (cystectomy) for patients with high risk superficial disease remains a controversial issue. Therefore, we performed a retrospective study to determine the difference in survival between these two patient populations.
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Patients and methods
A retrospective study was performed in patients treated for muscle-invasive bladder cancer at the Department of Urology of the UMC (University Medical Centre), St Radboud Nijmegen and the Department of Urology of UMC Dijkzigt Rotterdam. Medical records of patients treated between 1986 and 2000 were reviewed. Seventy-four patients treated for muscle-invasive bladder cancer, who had shown progression from a superficial tumour, were identified. Diagnosis of superficial bladder cancer was made by
Results
A total of 163 patients were included in the study, 99 from the UMC Nijmegen and 64 from the UMC Rotterdam. Of the total study population, 89 cases showed a primary invasive bladder tumour and 74 patients had a history of treated superficial disease. One patient with a primary invasive bladder tumour and 2 patients with a progressive tumour were lost to follow-up. The last stage of the superficial tumour before progression to muscle-invasive bladder carcinoma was pTaG1 in 6, pTaG2 in 22, pTaG3
Discussion
The current study shows a large and clinically significant difference in disease-specific survival between primary and progressive muscle-invasive bladder cancer patients, favouring the primary group. The disease-specific survival appears to be approximately twice as high in the primary group at all times during follow-up. The 3- and 5-year survival rates are 67% and 55% respectively for patients with a primary invasive tumour and 37% and 28% respectively for patients with a progressive
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