Radical cystectomy for patients with pT4 urothelial carcinoma in a large population-based study

What's known on the subject? and What does the study add? Given the natural history of pT4 urothelial carcinoma of the urinary bladder, and the substantially poorer survival of pT4 patients relative to pT3, it may be argued that radical cystectomy is not justified in these patients. Relying on a large population-based retrospective analysis, the current study identified two main categories of patients with pT4 urothelial carcinoma of the urinary bladder. The first comprised of patients with pT4b disease, whose disease phenotype was clearly more aggressive than their pT3 counterparts. The second group consisted of patients with pT4a disease, whose disease phenotype was very similar to patients with pT3. These findings indicate that patients with pT4b disease should be provided with the maximal amount of therapeutic interventions, such as administration of early adjuvant chemotherapy and perhaps early adjuvant radiotherapy. OBJECTIVE To examine cancer-specific mortality (CSM) in patients with pT4N(0-3)M(0) urothelial carcinoma of the urinary bladder (UCUB) and to compare it to patients with pT3N(0-3)M(0), in a population-based cohort treated with radical cystectomy (RC). PATIENTS AND METHODS RCs were performed in 5625 pT3-T4bN(0-3)M(0) patients with UCUB within 17 Surveillance, Epidemiology and End Results (SEER) registries between 1988 and 2006. Univariable and multivariable models tested the effect of pT4a vs pT4b vs pT3 stages on CSM. Covariates consisted of age, gender, race, lymph node status and SEER registries. All analyses were repeated in 3635 pN(0) patients. RESULTS Of 5625 patients, 2043 (36.3%) had pT4aN(0-3), 248 (4.4%) had pT4bN(0-3) and 3334 had pT3N(0-3) (59.3%) UCUB. The 5-year CSM was 57.6% vs 81.7% vs 53.9% for, respectively, pT4aN(0-3) vs pT4bN(0-3) vs pT3N(0-3) patients (all log-rank P = 0.008). In multivariable analyses the rate of CSM was 2.3-fold higher in pT4b vs pT3 (P < 0.001), 1.1-fold higher in pT4a vs pT3 (P = 0.002) and 2.0-fold higher in pT4a vs pT4b patients. After restriction to pN(0) stage, pT4b patients had a 2.3-fold higher rate of CSM than pT3 patients (P < 0.001) and pT4b patients had a 2.1-fold higher rate of CSM than pT4a patients (P < 0.001). The CSM rate was the same for pT4a and pT3 patients (P = 0.1). CONCLUSIONS Our findings indicate that patients with pT4a UCUB have similar CSM as those with pT3 UCUB. Consequently, RC should be given equal consideration in patients with pT3 and pT4a UCUB.