The role of radical cystectomy in patients with clinical T4b bladder cancer

ObjectivesPatients with clinical T4b bladder cancer (extension to pelvic wall and/or adjacent organs other than prostate, vagina, or uterus) are commonly considered unresectable. We hypothesized that select patients might achieve durable benefit from multiagent chemotherapy and extirpative surgery.MethodsWe identified patients with clinical T4bN0 bladder cancer from our IRB-approved database of patients undergoing radical cystectomy (n = 1,194). Relevant demographic, clinical, and pathologic data were compiled. Overall (OS), disease-specific (DSS), and recurrence-free survival (RFS) were analyzed by Kaplan-Meier estimation. Cox proportional hazards regression modeling was used to evaluate the influence of several potential prognostic factors.ResultsTwenty-three patients (16 male) with a median age of 65 years met study criteria. Chemotherapy was administered preoperatively to 19 (83%) and postoperatively to 8 (35%) patients. Eight patients died of disease and 1 of other causes. The 1-, 2-, and 5-year DSS was 91% (95% C.I. 70%–98%), 66% (95% C.I. 42%–83%), and 60% (95% C.I. 34%–78%), respectively. Eight of 17 patients with pT2-4 tumors succumbed to disease compared with none of 6 who were ≤pT1 (P = 0.04). Other predictors of decreased DSS included positive surgical margins (HR = 5.34, 95% C.I. 1.25–22.83) and presence of pathologic nodal metastasis (HR = 29.33, 95% C.I. 3.13–275.19). Variant histology was more common in this cohort than in the overall cystectomy database (43% vs. 11%).ConclusionsLong-term survival can be achieved in a proportion of patients with cT4b bladder cancer undergoing chemotherapy and extirpative surgery. Careful selection of patients and meticulous surgical technique to avoid positive margins are critical.