A precystectomy decision model to predict pathological upstaging and oncological outcomes in clinical stage T2 bladder cancer

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Although radical cystectomy has been considered as standard treatment for carcinoma invading bladder muscle for many decades, long-term series have reported recurrence rates (even in organ-confined stages) in up to 20% of patients [1], which will render them to palliative chemotherapy with a dismal prognosis. Despite evidence derived from prospective randomized trials reporting a limited but significant survival benefit of 5–7% in favour of the neoadjuvant approach [2], its adoption into daily clinical routine is still not well established, as supported by a recent study reporting that only 17% of patients receive any perioperative chemotherapy even in tertiary referral centres [3]. This reluctance is a result of the lack of clinical indicators predicting reliably those patients who will profit the most from neoadjuvant chemotherapy and the fear that a delay of radical cystectomy in those not responding to chemotherapy may further reduce survival.

The success rate of predicting pathologically advanced disease based on modern cross-sectional imaging techniques is only ≈50%, which effectively means that accurate prediction is equivalent to the tossing of a coin [4]. Considering that the prognostic benefit of neoadjuvant chemotherapy is most pronounced in patients with locally advanced stages [2], prediction models may represent effective tools for identifying which patients should receive neoadjuvant treatment or upfront cystectomy.

Mitra et al. present a new, sophisticated pre-cystectomy decision-tree model aiming to predict pathological upstaging and outcomes in cT2 bladder cancer based on defined clinical and pathological parameters. This model yielded a predictive accuracy of ≈66% which, in turn, means that the pathological stage was not correctly predictable in every third patient. Nonetheless, in the future, this model may serve as a basis for investigating the prognostic role of new markers.

So what markers in carcinoma invading bladder muscle have the potential to be easily adopted into such basic models? Based on the accumulating evidence for a prognostic role of systemic disorders in carcinoma invading bladder muscle, recent studies have incorporated the presence of preoperatively elevated serum C-reactive protein and thrombocytosis into basic prognostic models for survival after radical cystectomy and have reported a significant increase in their predictive accuracy [4, 5].

Taken together, the investigation of new markers within basic clinicopathological prediction models, as has been introduced in the present study, appears to be promising because this may enhance the adoption of neoadjuvant chemotherapy for carcinoma invading bladder muscle in the urological community.

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