1594PREOPERATIVE PREDICTORS OF PATHOLOGIC UPSTAGINGFOLLOWING CYSTECTOMY FOR T1 BLADDER CANCER

Gautam Jayram*, G. Joel Decastro, Mark A. Wille, Chicago, IL;Manoj Rao, Cory Hugen, Chandy Ellimoottil, Robert C. Flanigan,Marcus L. Quek, Maywood, IL; Norm D. Smith, Gary D. Steinberg,Chicago, IL

INTRODUCTION AND OBJECTIVES: Patients with T1 high-grade (T1HG) bladder cancer represent a unique subset of urothelialcarcinoma patients in whom both conservative and radical therapy maybe advocated. Proponents of early cystectomy cite high rates of clinicalunderstaging and eventual disease progression with conservative ther-apies. The purpose of this study was to identify clinical disease char-acteristics in a large cohort of patients predictive of final pathologicupstaging.

METHODS: We performed a retrospective database review ofall patients treated with radical cystectomy at 2 university urologycenters from 1997–2007. All patients had histologic confirmation ofhigh-grade urothelial cancer invasive into the lamina propria withoutmuscle invasion prior to undergoing radical cystectomy. Pertinent pre-and postoperative clnical and pathologic factors were recorded andanalyzed. Multivariate analysis was performed using Stata statisticalsoftware.

RESULTS: Ninety patients undergoing radical cystectomy wereclinical stage T1. Median age was 67 years (range: 48–87) and 72patients (80%) were male. 59% of the cohort had multifocal diseaseand 37% had associated carcinoma in-situ (CIS) on transurethralresection. 51% of patients received intravesical BCG and 14% hadother intravesical treatment prior to cystectomy. Thirty patients (33.3%)demonstrated pathologic upstaging at cystectomy, defined as �pT2and/or lymph node involvement. Seven of 90 patients (7.8%) had lymphnode metastases at cystectomy, while 17 (18.9%) had extravesicaldisease. On multivariate analysis (Table 1) the presence of CIS was theonly preoperative factor significantly associated with pathologic upstag-ing at radical cystectomy (p � 0.03, OR � 0.24 (0.06–0.89)).

CONCLUSIONS: Clinical T1HG bladder cancer is an aggres-sive malignancy with a substantial risk of disease progression. Our datasuggests that up to one-third of these patients were clinically under-staged, and the presence of concomitant CIS is significantly associatedwith this finding. The lower incidence of adverse pathologic outcomes(LN �, �pT2) in our cohort compared to other T1HG series may be dueto the emphasis on early cystectomy prior to progression in thesepatients.

Table 1. Multivariate Analysis of Upstaging ( T1 or Node Positive Disease)

OR (95% CI) p-valueMultifocal Disease 1.3 (0.4 - 4.0) 0.68

CIS 0.24 (0.06 - 0.89) 0.03

Intravesical BCG 0.58 (0.25 - 2.2) 0.58

Other Intravesical Agent 0.20 (0.02 - 1.8) 0.15

# Nodes removed (cont.) 1.0 (0.97 - 1.1) 0.66

Source of Funding: None

1595EXTENDED LYMPHADENECTOMY AND CHEMOTHERAPYOFFER SURVIVAL ADVANTAGE IN MUSCLE-INVASIVEBLADDER CANCER

Peter J. Bostrom*, Toronto, Canada; Tuomas Mirtti, Helsinki, Finland;Martti Nurmi, Matti Laato, Turku, Finland; Bas W.G van Rhijn, Neil E.Fleshner, Antonio Finelli, Michael A Jewett, Alexandre R. Zlotta,Toronto, Canada

INTRODUCTION AND OBJECTIVES: The role of extendedpelvic lymph node dissection (ePLND) and adjuvant chemotherapy inthe treatment of muscle-invasive bladder cancer (BC) remain unclear.Our large database from two centers (Turku, Finland and Toronto,Canada) offer an opportunity to study these factors, as there have been

different institutional practice policies. In Turku, ePLND was not com-mon practice and adjuvant chemotherapy was nearly never offeredwhereas standard of care in Toronto included ePLND and adjuvantchemotherapy when indicated.

METHODS: Consecutive BC patients undergoing radical cys-tectomy in UHN, Toronto, Canada (1992–2008) and University ofTurku, Turku, Finland (1986–2005) were studied. After exclusion ofnon-urothelial cases and neoadjuvant treatment, 563 patients wereavailable for analysis. Clinicopathological variables, the rate and extentof PLND and the rate of adjuvant cisplatin-based chemotherapy wereanalyzed using the Chi-squared-test. Kaplan-Meier method and multi-variate Cox regression analysis were used to analyze survival.

RESULTS: In the Toronto cohort, patients were older (meanage 68 vs. 63y, p�0.001), had more extensive PLNDs (�10 nodesremoved, 58% vs. 8%, p�0.001), had more nodal metastasis (26% vs.7%, p�0.001), and adjuvant chemotherapy was administered moreoften (21% vs. 1%, p�0.001). Positive margin rate was similar (4% inboth centers). No BC specific survival differences could be demon-strated in � pT2a tumors or in pT4a/b tumors. In contrast, there was atrend for improved survival in pT2b tumors (10y BC specific survival65% vs. 42%, p�0.23) and a significant difference favouring theToronto cohort in pT3a and pT3b tumors (55% vs. 31%, p�0.025; 43%vs. 28% p�0.06, respectively). In multivariate analysis, pT-stage (HR1.8, 95% CI 1.2–2.8; p�0.005), N-stage (HR 2.5, 95% CI 1.5–4.1;p�0001), and ePLND (HR 0.53, 95% CI 0.31–0.93, p�0.026) signifi-cantly affected disease specific survival. Adjuvant chemotherapy of-fered borderline significant benefit (HR 0.61, 95% CI 0.36–1.05,p�0.072). An interaction model combining ePLND and chemotherapywas significant when ePLND with more than 10 nodes removed andadjuvant chemotherapy were combined (HR 0.49, 95% CI 0.26–0.92,p�0.026).

CONCLUSIONS: With the limitations of not being a randomizedstudy but with an unique setting as our study centers had oppositemanagement in terms of ePLND and adjuvant chemotherapy, ourresults show that the combination of ePLND and adjuvant chemother-apy offer a survival advantage in muscle-invasive BCs treated with RC.

Source of Funding: None

1596LYMPH NODE DISSECTION DURING RADICAL CYSTECTOMY:IMPACT OF TEMPLATE AND LYMPH NODE COUNT ONDISEASE FREE SURVIVAL

Giuseppe Simone*, Rocco Papalia, Mariaconsiglia Ferriero,Salvatore Guaglianone, Cristina Falavolti, Maurizio Buscarini,Michele Gallucci, Rome, Italy

INTRODUCTION AND OBJECTIVES: We retrospectively ana-lyzed the impact of the extent of Lymph Node Dissection (LND) in asingle series of 604 patients undergone RC in a single centre.

METHODS: Between May 2001 and September 2009 data of750 RCs performed at our Institute were collected in a prospectively-maintained database.

Exclusions criteria were non-urothelial carcinoma, metastasisat diagnosis, pNx, neoadjuvant and adjuvant treatments; out of 475patients included in the analysis, 134 patients were pN� and 341 werepN0.

Template of LND (Lymph-node dissection) was defined asstandard when all lymphatic tissue was removed from the obturatorfossa up to the aortic bifurcation, limited in all other cases.

Once LN-d and lymph-node count (LN-c) cut-off values wereidentified by ROC analyses, the prognostic role of pT, pN, LN-d, LN-cand template on disease free survival (DFS) was assessed with uni-variate and multivariate Cox regression analyses.

RESULTS: Significant thresholds were 11% and 30% for LN-dand 30 lymph nodes for LN-c.

Statistically significant variables at univariate analysis were pT(p�0.001), pN (p�0.001), LN-d (p�0.001), LN-c (p�0.003) and tem-plate (p�0.001).

e640 THE JOURNAL OF UROLOGY� Vol. 185, No. 4S, Supplement, Tuesday, May 17, 2011