UROLOGICAL ONCOLOGY

Discrepancy between Clinical and Pathologic Stage: Impact on Prognosis after Radical Cystectomy
Shariat SF, Palapattu GS, Karakiewicz PI, Rogers CG, Vazina A, Bastian PJ, Schoenberg MP, Lerner SP, Sagalowsky AI, Lotan Y
Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas 75390-9110, USA
Eur Urol. 2007; 51: 137-49; discussion 149-51

• Objectives: We compared clinical and pathologic staging in a large, contemporary, consecutive series of patients who were treated with radical cystectomy and pelvic lymphadenectomy, and determined the effect of stage discrepancy on outcomes.
• Methods: We collected retrospective data from 778 consecutive patients with bladder transitional cell carcinoma who were treated with radical cystectomy and pelvic lymphadenectomy, and for whom the clinical and pathologic stage were available.
• Results: Pathologic upstaging occurred in 42% of patients, and pathologic downstaging occurred in 22%. Forty percent of patients with non-muscle-invasive clinical stage had muscle-invasive pathologic stage. Thirty-six percent of patients with organ-confined clinical stage had non-organ-confined pathologic stage (> or = pT3N0 or pTanyN-positive). Patients with higher clinical stage were more likely to be upstaged to non-organ-confined disease (p < 0.001). Patients were stratified into three groups: pathologically upstaged, same clinical and pathologic stage, and pathologically downstaged. When adjusted for the effects of standard postoperative features, upstaged patients were at a significantly higher risk of disease recurrence and bladder cancer-specific death than patients who had the same pathologic and clinical stage, who in turn were at significantly higher risk than downstaged patients. This observation remained true within each clinical stage strata. Within each pathologic stage strata, clinical stage did not substratify into different risk groups.
• Conclusions: Clinical to pathologic stage discrepancy is a relatively common finding after extirpative surgery for bladder cancer. Clinical outcomes after radical cystectomy are largely driven by pathologic stage. Better clinical staging is necessary to improve patient evaluation and management.
  
  
• Editorial Comment
  A large series of 778 patients with infiltrative bladder cancer undergoing radical cystectomy was retrospectively analysed and the impact of staging error calculated.
  Most interestingly – and not debated much in this paper – is the fact that the percentage of correct peroperative staging declined (!) over the years with correct staging around 44% until 1994 and around 35% and lower from 1995 to 2003. What happened in these periods? Was there an institutional change or did surgeons not perform TURB as thoroughly as before?
  Notably, downstaging moderately decreased from 26% to around 20% during these years whereas upstaging sharply increased (!) from around 28% to 43% and 49% in the later periods mentioned above.
  The outcomes of pathologically staged cancer finally were in the expected range with rather good results showing roughly 80% bladder cancer specific survival in organ confined disease as compared to 37% in non organ-confined disease.
  These data again seem to justify adjuvant chemotherapy in this high-risk group of patients.

Dr. Andreas Bohle
Professor of Urology
HELIOS Agnes Karll Hospital
Bad Schwartau, Germany