A. Pollack

The Relationship of Local Control to Distant Metastasis in Muscle Invasive Bladder Cancer

PURPOSE We examined the relationship of local failure to distant metastasis in patients with muscle invasive bladder cancer. MATERIALS AND METHODS This retrospective review included 240 patients treated with radical cystectomy with or without multiagent chemotherapy at our institution between 1984 and 1990 for clinical stage T2 to T4 transitional cell carcinoma of the bladder. The distribution of patients by clinical stage was 89 T2, 77 T3a, 51 T3b and 23 T4. Median followup was 55 months. RESULTS The actuarial 5-year local control, freedom from distant metastasis and overall survival rates were 80%, 68% and 52%, respectively. There was a profoundly significant relationship between local failure and distant metastasis with distant metastasis in 56% of those with local failure. The actuarial 5-year freedom from distant metastasis rate for those with local control was 77% compared to 29% for those with local failure (p < 0.0001, log rank test). This relationship held when the group was subdivided by stage and when only cases of complete cystectomy were analyzed. The significance of this finding in light of the possible contribution of potential prognostic factors was examined. Univariate analyses revealed late clinical stage, abnormal pretreatment serum creatinine levels, the administration of chemotherapy, late pathological stage and lymph node involvement to correlate significantly with distant metastasis rates. Multivariate analyses using Cox proportional hazards models with freedom from distant metastasis as the end point revealed pathological stage, local failure and lymph node involvement to be the only significant covariates. CONCLUSIONS Since local failure highly correlated with distant failure, treatment planning to optimize local control should be of foremost concern for those at high risk of failure by this mode (for example patients with T3b/4 disease). New treatment strategies, such as the use of preoperative radiotherapy as an adjunct to chemotherapy and radical surgery, should be considered in this high risk population.

Assessment of biochemical disease free progression in men with prostate cancer younger than 60 years of age :MD Anderson experience

:5, T4a :1, T3aN1:1. 47.8% had Gleason 6 or less, 47.8% had Gleason 7 and 4.3% had Gleason 9. All the CT scans and bone scans were negative for metastatic disease or local disease. The mean PSA prior to RT was 1.09ng/ml. Prostate bed biopsies were done in 9 patients of whom 7 had positive biopsies (1/ 7 patients who had a positive biopsy of the prostatic bed had a positive scan in the bed, both patients who had a negative biopsy had negative scan ).The median follow up was 2 years. The mean follow up after initial surgery was surgery was 5.6 years. The prostascint scan was negative in 13 patients, positive in the bed :18, the bed and lymph node: 3, bed and metastatic site: 3, lymph nodes alone: 3, metastatic sites alone: 6, lymph node and metastatic sites: 1 and all 3 sites: 2. Biochemical response (50% decrease in PSA from the pretreatment PSA) following radiation which indicates the reduction of disease in the bed was seen in 45/49 patients (24/26 with positive scans in the bed and 21/23 with negative scans){Positive predictive value [PPV] 92%, Negative predictive value [NPV] 9%}. The 3 year biochemical control rate for all patients was 78%. The 3 year biochemical control rates in patients with a pre RT PSA less than 1 was 92% compared to 50% with a pre RT PSA greater or equal to 1 ng/ml (p 0.005). 8 patients have failed biochemically: 3/26 patients with scan positive in the bed, 4/13 patients with a negative scan and 1/3 in patients positive in the lymph node regions alone. 3year biochemical control rates for prostate bed positive scan patients were 85% vs 74% for bed negative patients ( p 0.6). Of the 18 patients who had who had positive scan outside the bed only one has failed after local RT alone (PPV 6%, NPV is 77% ). Cox regression analysis using biochemical control as dependant variable and all other parameters (clinical and scan status) as independent variables showed that preop PSA and pre RT PSA are the only significant variables (backward stepwise selection).