Urologic Oncology: Seminars and Original Investigations
Original articleNomogram for predicting survival of postcystectomy recurrent urothelial carcinoma of the bladder
Introduction
Radical cystectomy (RC) with pelvic lymph node (LN) dissection is the standard treatment for muscle-invasive or high-risk non–muscle-invasive urothelial carcinoma of the bladder (UCB) [1]. Unfortunately, postsurgical recurrence is highly probable; however, the 5-year recurrence-free survival rate after RC is reportedly 48% to 68% [2], [3], [4], [5], [6]. Prognosis of recurrent UCB is variable but generally dismal: 1-year overall survival (OS) rate after recurrence is reportedly 32% to 70%, and the median survival time (MST) rate is merely 4.0 to 11.2 months [7], [8], [9], [10], [11].
Precise prediction of prognosis is mandatory in patient counseling and patient stratification for clinical trials. Nomogram is one of the most popular prediction models, and has several advantages over other prediction models [12], [13]. Overall, 3 major prognostic models, including 2 nomograms, have been proposed for metastatic UCB undergoing systemic chemotherapy [14], [15], [16]. However, those models excluded patients ineligible for systemic chemotherapy [14], [15], [16]. In an era of emerging immunotherapies and targeted therapies, even the patients ineligible for chemotherapy are to be considered for them because their toxic profiles differ from conventional cytotoxic chemotherapy [17]. Although previous studies identified potential prognostic factors and proposed prediction models for all patients after disease recurrence [7], [8], [9], [10], [11], a prognostic nomogram has not been available so far for these patients.
In this study, we aimed to develop a prognostic nomogram predicting survival of postcystectomy recurrence of UCB irrespective of eligibility for systemic chemotherapy.
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Patient population
The present study is approved by the institutional review board of each participating institute. We retrospectively reviewed medical records of 1,087 patients who underwent RC for bladder cancer at the University of Tokyo Hospital and 10 affiliated hospitals between January 1990 and December 2010. Patients who developed distant metastasis or local recurrence or both of UCB during post-RC follow-up were identified. Recurrence in the preserved urothelium (i.e., upper urinary tract and retained
Characteristics of the patients and OS
The cohort was 306 patients with recurrent UCB, 248 men and 58 women, with a median age of 69 years (range: 36–90; interquartile range: 63–75) at the time of recurrence (Table 1). Postrecurrence chemotherapy was administered in 119 patients (38.9%). During the follow-up period of up to 158 months, 268 (87.6%) died (median follow-up period was 6.8 months (interquartile range: 3.0–15.8); 260 died of disease progression of metastatic UCB; and 8 of other or unknown causes. The 6-month, 1-year, and
Discussion
Our data confirmed the highly aggressive nature of recurrent/metastatic UCB. The MST was as short as 7 months (95% CI: 5.8–8.5). It was worse than recent data from a single-center cohort (11.2 months) [8], and closer to a result of another multi-institutional study (6.9 months) [9]. The present data derived from multiple institutes may represent the clinical outcome in the real world.
Using these data, we developed a 5-variable nomogram predicting 6-month, 1-year, and 2-year probability of
Conclusion
In summary, we identified 9 clinicopathological factors as independent OS predictors for patients with postcystectomy recurrence of UCB. We also created a validated nomogram with 5 variables that efficiently stratified these patients regardless of eligibility for chemotherapy. The nomogram will be useful to acquire relevant prognostic information and stratify the patients for clinical trials.
Acknowledgments
The authors thank Dr. Kyoichi Tomita for his valuable advice.
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