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Follow-up after cystectomy: regularly scheduled, risk adjusted, or symptom guided? Patterns of recurrence, relapse presentation, and survival after cystectomy

Eur J Surg Oncol. 2014 Dec;40(12):1677-85

Eur J Surg Oncol. 2014 Dec;40(12):1677-85

Abstract

AIMS:

To evaluate the efficacy of follow-up based on the patterns of recurrence, relapse presentation and survival after cystectomy, and to define a risk adjusted follow-up schedule.

PATIENTS AND METHODS:

The records of 343 patients with regular follow-up after cystectomy were reviewed for primary site of recurrence, accompanying symptoms, means of recurrence diagnosis, and clinicopathological factors. Based on Cox proportional hazard models, and the results of imaging studies low and high risk groups are identified and a risk adjusted follow-up protocol is proposed.

RESULTS:

The risk of a recurrence was related to increasing pT, tumour positive lymph nodes, tumour positive surgical margins, and pre-operative dilatation of the upper urinary tract, and low and high risk groups were defined consequently. 84% of all recurrences occurred within 2 years, with only one recurrence beyond 2 years in the low risk group. Although the minority of all patients (34%) is asymptomatic at time of recurrence, symptomatic recurrences were adversely associated with survival. CT-scans and chest X-rays accounted for 90% of the diagnostic tools to detect a recurrence in patients without symptoms.

CONCLUSIONS:

Asymptomatic patients may benefit from early treatment after disease recurrence. A risk adjusted follow-up strategy based on stage of disease and additional clinicopathological factors can dichotomise patients at high and low risk for recurrence. The small benefit in survival after early detection has to be confirmed in future studies, and weighed against the available treatment options of recurrences and their subsequent costs.

Copyright © 2013 Elsevier Ltd. All rights reserved.

KEYWORDS:

Bladder cancer; Cystectomy; Distant failure; Follow-up; Local failure; Pelvic recurrence; Recurrence; Survival

Comment from Maria Ribal: Follow-up after radical cystectomy for bladder cancer remains controversial. Surveillance protocols are commonly based on patterns of recurrence observed from retrospective series. Diagnosis of asymptomatic recurrence based on routine oncological follow-up and results from retrospective studies are controversial. Importantly, these retrospective studies use different follow-up regimens and imaging techniques that make final analysis and conclusive recommendations difficult. Prospective trials demonstrating the effectiveness of follow-up after RC and its impact on overall survival (OS) are lacking. In this paper the authors proposed a retrospective review of their series to establish a risk- adjusted strategy for follow-up based on stage and other clinical variables. Stage, positive lymph nodes, and positive margins as well as hydronephrosis at diagnosis, could help us to identify those at greater risk of recurrence. Survival has been related on this work to presence of symptoms at the moment of diagnosis of the recurrence.

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