THE RELATIONSHIP OF LOCAL-CONTROL TO DISTANT METASTASIS IN MUSCLE INVASIVE BLADDER-CANCER

Purpose: We examined the relationship of local failure to distant meta stasis 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 inst itution between 1984 and 1990 for clinical stage T2 to T4 transitional cell carcinoma of the bladder. The distribution of patients by clinic al stage was 89 T2, 77 T3a, 51 T3b and 23 T4. Median followup was 55 m onths. Results: The actuarial 5-year local control, freedom from dista nt metastasis and overall survival rates were 80%, 68% and 52%, respec tively. 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 metasta sis rate for those with local control was 77% compared to 29% for thos e with local failure (p < 0.0001, log rank test). This relationship he ld when the group was subdivided by stage and when only cases of compl ete cystectomy were analyzed. The significance of this finding in ligh t of the possible contribution of potential prognostic factors was exa mined. Univariate analyses revealed late clinical stage, abnormal pret reatment serum creatinine levels, the administration of chemotherapy, late pathological stage and lymph node involvement to correlate signif icantly with distant metastasis rates. Multivariate analyses using Cox proportional hazards models with freedom from distant metastasis as t he 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 plann ing 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 ra diotherapy as an adjunct to chemotherapy and radical surgery, should b e considered in this high risk population.