The Relationship of Local Control to Distant Metastasis in Muscle Invasive Bladder Cancer

Purpose: We examined the relationship of local failure to distant metastasis 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 institution between 1984 and 1990 for clinical stage T2 to T4 transitional cell carcinoma of the bladder. The distribution of patients by clinical stage was 89 T2, 77 T3a, 51 T3b and 23 T4. Median followup was 55 months. Results: The actuarial 5-year local control, freedom from distant metastasis and overall survival rates were 80 percent, 68 percent and 52 percent, respectively. There was a profoundly significant relationship between local failure and distant metastasis with distant metastasis in 56 percent of those with local failure. The actuarial 5-year freedom from distant metastasis rate for those with local control was 77 percent compared to 29 percent for those with local failure (p less than 0.0001, log rank test). This relationship held when the group was subdivided by stage and when only cases of complete cystectomy were analyzed. The significance of this finding in light of the possible contribution of potential prognostic factors was examined. Univariate analyses revealed late clinical stage, abnormal pretreatment serum creatinine levels, the administration of chemotherapy, late pathological stage and lymph node involvement to correlate significantly with distant metastasis rates. Multivariate analyses using Cox proportional hazards models with freedom from distant metastasis as the 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 planning 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 radiotherapy as an adjunct to chemotherapy and radical surgery, should be considered in this high risk population.