Discrepancy between clinical and pathological stage: external validation of the impact on prognosis in an international radical cystectomy cohort

Abstract

• Up staging to muscle invasive disease occurred in 45.9% (n = 592) of 1,291 patients with clinical ≤ T1, including 30.6% of patients with Tis only at transurethral resection.• Of the 3,166 patients with clinically organ confined (OC) tumor stage, 1,357 (42.9%) were up staged to non-organ confined pathologic tumor stage.• Within each clinical stage stratum, patients who were clinically under staged had a higher probability of disease relapse or death from UCB compared to those who were same staged or down staged on pathologic examination ( P < 0.05). CONCLUSIONS• We identified clinical under staging in half of the patients undergoing radical cystectomy for UCB.• Up staging resulted in a higher likelihood of disease progression and eventual death from UCB.• These findings should be considered when utilizing pre-operative risk-adapted strategies for selecting candidates for neoadjuvant chemotherapy. KEYWORDSbladder cancer, survival, radical cystectomy, stage, migration, discrepancy What's known on the subject? and What does the study add?Observations from small retrospective studies have indicated that a considerable number of patients undergoing radical cystectomy for bladder cancer experience a stage migration (either upstaging or downstaging) when comparing clinical and pathological staging. In addition, it is unclear if pathological upstaging is an adverse prognostic feature independent of pathological stage.We report the frequency of upstaging and downstaging using a large, international multicentre cohort of patients undergoing radical cystectomy for bladder cancer without neoadjuvant chemotherapy. Our findings indicate that pathological upstaging is not an independent adverse prognostic feature when considering pathological stage. Study Type -Prognosis (case series) Level of Evidence 4 OBJECTIVE• To compare the clinical and pathologic stage among a large, multi-institutional series of patients undergoing radical and to determine the effect of stage discrepancy on outcomes. PATIENTS AND METHODS• Data was collected from nine centers and 3,393 patients with urothelial carcinoma of the bladder (UCB) treated with radical cystectomy and pelvic lymphadenectomy without neo-adjuvant chemotherapy.• A retrospective cohort design was used to assess the percentage of patients experiencing stage discrepancy and the impact of stage discrepancy on time to disease relapse and time to death from UCB. RESULTS• Clinical under staging occurred in 50% of patients and pathologic down staging occurred in 18% of patients.

Treatment of muscle-invasive bladder cancer in Canada: A survey of genitourinary medical oncologists and urologists

“…24 Discrepancies between clinical and pathological staging is a major issue in MIBC with upstaging post-cystectomy occurring in almost 30% to 61% of cases. 16,[25][26][27] One of the strongest risk factors for upstaging is T2-disease. [25][26][27] As 20% to 30% of patients with pT2 disease relapse distantly and the SWOG-8710 trial reported a median 30-month improvement in overall survival with NC in patients with T2-tumours, there is a strong rationale to use NC even in these patients.…”

“…16,[25][26][27] One of the strongest risk factors for upstaging is T2-disease. [25][26][27] As 20% to 30% of patients with pT2 disease relapse distantly and the SWOG-8710 trial reported a median 30-month improvement in overall survival with NC in patients with T2-tumours, there is a strong rationale to use NC even in these patients. 6,22 An alternate strategy is to use a risk-stratified approach, in which patients with high-risk features receive NC and lowrisk patients who are upstaged receive adjuvant chemotherapy (AC).…”

Mesane Tümörü Çalışma Grubunda Mevcut Yürüyen Çalışmalar: Genel Bir Bakış

“…Faktörlerin Araştırılması" -Dr. Polat Türker Mesane tümörlerinde, radikal sistektomi sonrası evre yükselmesi sık izlenen bir problem olup klinik ve patolojik evrenin birbirleri ile uyumlu rapor edilmesi yani doğru klinik evreleme ancak %20-%80 oranında sağlanabilmektedir (4). Klinik evreleme ile T2-T4a N0M0 saptanan hastalıkta neoadjuvan kemoterapinin uygun hastalarda sağkalım avantajı sağladığı gösterilmiştir (1).…”

Predictive role of neutrophil-to-lymphocyte ratio on upstaging of organ-confined invasive urothelial bladder cancer to non-organconfined disease

“…While nearly half of the cases is understaged, 32% to 43% of the patients with clinically organ-confined (OC) (≤T2) bladder tumors are upstaged to nonorgan-confined pathological stage (NOC) (≥T3) at the time of RC. [3][4][5] Upstaging at the time of RC is associated with poor prognostic factors such as short disease-specific survival and higher risk for disease recurrence. [5,6] Beyond that patients with stage T2 bladder tumors who are subsequently upstaged at the time of cystectomy can potentially benefit mostly from neoadjuvant chemotherapy.…”

“…[3][4][5] Upstaging at the time of RC is associated with poor prognostic factors such as short disease-specific survival and higher risk for disease recurrence. [5,6] Beyond that patients with stage T2 bladder tumors who are subsequently upstaged at the time of cystectomy can potentially benefit mostly from neoadjuvant chemotherapy. [7] But the inability to identify such patients at the outset weakens its potential advantage, as documented by a modest 5% absolute 5-year overall survival benefit.…”