Developing models to predict persistent disease after pituitary adenoma surgery

Introduction. Pituitary adenomas are the most frequent intracranial tumors of the central nervous system. Except for prolactinomas, surgery is the treatment of choice.Aim: to assess the percentage of patients with persistent disease after surgery and to identify independent predictors of persistent disease.Material and methods. Ambispective multicenter observational study. Data were collected from The Molecular Registry of Pituitary Adenomas (REMAH). Univariate and multivariate analysis were performed in 128 patients with histologically confirmed adenomas who underwent transsphenoidal surgery between 2009 and 2015 in hospitals from Madrid, with at least one month of follow-up.Results. During follow-up, persistent disease was observed in 50.8% of patients (radiological 30.7%, biochemical 2.4%, both 14.2%), especially in nonfunctioning tumors. Factors significantly associated with persistent disease in the univariate analysis were age, male gender, previous hypopituitarism, large tumor diameter and microscopic transsphenoidal surgery (p <0.05). Independent predictors of persistent disease in multivariate analysis were: patients over 76 years old, a greater tumor diameter, multiple hypopituitarism and microscopic transsphenoidal surgery (p <0.05).Conclusion. Age, tumor size, previous hypopituitarism and the type of surgical technique were independent predictors of persistent disease. These factors could be useful for clinicians in the follow-up of patients to better establish monitoring and treatment algorithms.

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Evaluation of potential predictors of hypopituitarism after pituitary adenoma surgery

Problems of Endocrinology ◽

10.14341/probl201662563-64 ◽

2016 ◽

Vol 62 (5) ◽

pp. 63-64

Author(s):

Miguel Antonio Sampedro-Nuñez ◽

Raquel Martin Garcia ◽

Guillermo Martin Avila ◽

Rogelio García Centeno ◽

Concepción Blanco Carrera ◽

...

Keyword(s):

Pituitary Adenomas ◽

Transsphenoidal Surgery ◽

Univariate Analysis ◽

Surgical Excision ◽

Study Data ◽

Tumor Diameter ◽

Multicenter Observational Study ◽

Pituitary Deficiency ◽

Modifiable Factor ◽

New Onset

Introduction. Pituitary adenomas are the most frequent intracranial tumors. Surgical excision is the primary approach for these tumors, except for prolactinomas, and secondary hypopituitarism is its main complication.Aim: to assess the prevalence of postoperative hypopituitarism and analyze the risk factors involved in its development.Materials and methods. Ambispective multicenter observational study. Data were collected from The Molecular Registry of Pituitary Adenomas (REMAH). Univariate and multivariate analysis were performed in 128 patients with histologically confirmed adenomas who underwent transsphenoidal surgery between 2009 and 2015 in hospitals from Madrid, with more than one-month follow-up.Results. Postoperative hypopituitarism was found in 73.9% of cases (28.4% of new onset). Combined pituitary deficiency was the most frequently observed (46.3%), and hypoadrenalism the most frequent single postsurgical deficit (63.7%). Factors significantly associated with postoperative hypopituitarism in the univariate analysis were: previous hypopituitarism, larger tumor diameter, transsphenoidal endoscopic approach and presence of other postoperative complications (p <0.05). Independent predictors in the multivariate model were: tumor diameter and presurgical hypopituitarism for both single and multiple postsurgical deficits (p <0.05).Conclusion. Tumor size and previous hypopituitarism were independent predictors of postoperative hypopituitarism. Endoscopic transsphenoidal surgery was associated to a higher rate of hypopituitarism, and can be reconsidered as a modifiable factor in future studies.

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PROGNOSTIC FACTORS OF RENAL TUMOR RECURRENCE AFTER RADICAL NEPHRECTOMY

British Journal of Surgery ◽

10.1093/bjs/znab160.044 ◽

2021 ◽

Vol 108 (Supplement_3) ◽

Author(s):

G Martínez Izquierdo ◽

A R Arnaiz Pérez ◽

E Escolano Fernández ◽

M Merayo Álvarez ◽

B Carrasco Aguilera ◽

...

Keyword(s):

Multivariate Analysis ◽

Prognostic Factors ◽

Radical Nephrectomy ◽

Univariate Analysis ◽

Malignant Neoplasms ◽

Histopathological Analysis ◽

Chi Square ◽

Renal Sinus ◽

Chi Square Test

Abstract INTRODUCTION Renal cell carcinoma (RCC) represents 3% of overall malignant neoplasms in adults. However, its aetiology has not been clearly established. Although surgery represents the cornerstone in treatment, recurrence postoperative rates are around 20-30%, what implies prognostic factors search must be mandatory in order to help to plan de follow-up and the different adjuvant therapy possibilities available in case they were necessary. MATERIAL AND METHODS A retrospective observational study was carried out in 110 patients who underwent radical nephrectomy between 2004 and 2018, with the aim of identifying possible prognostic factors of recurrence of RCC after these surgeries. Preoperative data (epidemiological, comorbidities and laboratory tests), surgical, pathological and variables related to follow-up were taken into account. A univariate and multivariate analysis were performed, using chi-square test and logistic regression, respectively. RESULTS The median follow-up time was 53.5 months (SD = 35.8), time in which 19 patients had a recurrence of RCC after radical nephrectomy (17.2%). Histopathological items such as the surgical piece size, the nodal and microvascular invasion, the renal sinus invasion and the presence of necrosis in the surgical piece were associated with RCC recurrence in the univariate analysis, while only the presence of necrosis in the surgical piece showed a significant result in the multivariate analysis (p = 0.004). CONCLUSIONS Histopathological analysis, highlighting the presence of necrosis in the histological sample, was proved to be the main risk factor of RCC recurrence.

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Pediatric Pituitary Adenoma: Case Series, Review of the Literature, and a Skull Base Treatment Paradigm

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1625984 ◽

2018 ◽

Vol 79 (01) ◽

pp. 091-114 ◽

Cited By ~ 19

Author(s):

Avital Perry ◽

Christopher Graffeo ◽

Christopher Marcellino ◽

Bruce Pollock ◽

Nicholas Wetjen ◽

...

Keyword(s):

Systematic Review ◽

Pituitary Adenoma ◽

Skull Base ◽

Pituitary Adenomas ◽

Pediatric Population ◽

Csf Leak ◽

Persistent Disease ◽

Treatment Paradigm ◽

Surgical Cure

Background Pediatric pituitary adenoma is a rare skull base neoplasm, accounting for 3% of all intracranial neoplasms in children and 5% of pituitary adenomas. Compared with pituitary tumors in adults, secreting tumors predominate and longer disease trajectories are expected due to the patient age resulting in a natural history and treatment paradigm that is complex and controversial. Objectives The aims of this study were to describe a large, single-institution series of pediatric pituitary adenomas with extensive long-term follow-up and to conduct a systematic review examining outcomes after pituitary adenoma surgery in the pediatric population. Methods The study cohort was compiled by searching institutional pathology and operative reports using diagnosis and site codes for pituitary and sellar pathology, from 1956 to 2016. Systematic review of the English language literature since 1970 was conducted using PubMed, MEDLINE, Embase, and Google Scholar. Results Thirty-nine surgically managed pediatric pituitary adenomas were identified, including 15 prolactinomas, 14 corticotrophs, 7 somatotrophs, and 4 non-secreting adenomas. All patients underwent transsphenoidal resection (TSR) as the initial surgical treatment. Surgical cure was achieved in 18 (46%); 21 experienced recurrent/persistent disease, with secondary treatments including repeat surgery in 10, radiation in 14, adjuvant pharmacotherapy in 11, and bilateral adrenalectomy in 3. At the last follow-up (median 87 months, range 3–581), nine remained with recurrent/persistent disease (23%).Thirty-seven publications reporting surgical series of pediatric pituitary adenomas were included, containing 1,284 patients. Adrenocorticotropic hormone (ACTH)-secreting tumors were most prevalent (43%), followed by prolactin (PRL)-secreting (37%), growth hormone (GH)-secreting (12%), and nonsecreting (7%). Surgical cure was reported in 65%. Complications included pituitary insufficiency (23%), permanent visual dysfunction (6%), chronic diabetes insipidus (DI) (3%), and postoperative cerebrospinal fluid (CSF) leak (4%). Mean follow-up was 63 months (range 0–240), with recurrent/persistent disease reported in 18% at the time of last follow-up. Conclusion Pediatric pituitary adenomas are diverse and challenging tumors with complexities far beyond those encountered in the management of routine adult pituitary disease, including nuanced decision-making, a technically demanding operative environment, high propensity for recurrence, and the potentially serious consequences of hypopituitarism with respect to fertility and growth potential in a pediatric population. Optimal treatment requires a high degree of individualization, and patients are most likely to benefit from consolidated, multidisciplinary care in highly experienced centers.

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Distant metastases after diagnosis: Racial disparities in breast cancer outcomes.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.1084 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. 1084-1084

Author(s):

Julia Blanter ◽

Ilana Ramer ◽

Justina Ray ◽

Emily J. Gallagher ◽

Nina A. Bickell ◽

...

Keyword(s):

Breast Cancer ◽

Multivariate Analysis ◽

Black Women ◽

Racial Disparities ◽

Late Stage ◽

White Women ◽

Univariate Analysis ◽

Distant Metastases ◽

Stage At Diagnosis

1084 Background: Black women diagnosed with breast cancer are more likely to have a poor prognosis, regardless of breast cancer subtype. Despite having a lower incidence rate of breast cancer when compared to white women, black women have the highest breast cancer death rate of all racial and ethnic groups, a characteristic often attributed to late stage at diagnosis. Distant metastases are considered the leading cause of death from breast cancer. We performed a follow up study of women with breast cancer in the Mount Sinai Health System (MSHS) to determine differences in distant metastases rates among black versus white women. Methods: Women were initially recruited as part of an NIH funded cross-sectional study from 2013-2020 to examine the link between insulin resistance (IR) and breast cancer prognosis. Women self-identified as black or white race. Data was collected via retrospective analysis of electronic medical records (EMR) between September 2020-January 2021. Distant metastases at diagnosis was defined as evidence of metastases in a secondary organ (not lymph node). Stage at diagnosis was recorded for all patients. Distant metastases after diagnosis was defined as evidence of metastases at any time after initiation of treatment. Univariate analysis was performed using Fisher’s exact test, multivariate analysis was performed by binary logistic regression, and results expressed as odds ratio (OR) and 95% confidence interval (CI). A p value <0.05 was considered statistically significant. Results: We identified 441 women enrolled in the IR study within the MSHS (340 white women, 101 black women). Median follow up time for all women was 2.95 years (median = 3.12 years for white and 2.51 years for black women (p=0.017)). Among these patients, 11 developed distant metastases after diagnosis: 4 (1.2%) white and 7 (6.9%) black (p=0.004). Multivariate analysis adjusting for age, race and stage at diagnosis revealed that black women were more likely to have distant metastasis (OR 5.8, CI 1.3-25.2), as were younger women (OR for age (years) 0.9, CI 0.9-1.0), and those with more advanced stage at diagnosis. Conclusions: Black women demonstrated a far higher percentage of distant metastases after diagnosis even when accounting for age and stage. These findings suggest that racial disparities still exist in the development of distant metastases, independent from a late-stage diagnosis. The source of existing disparities needs to be further understood and may be found in surveillance, treatment differences, or follow up.

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Minor salivary gland biopsy: its importance in rheumatoid arthritis and secondary Sjögren's síndrome

Revista Argentina de Reumatología ◽

10.47196/rar.v30i3.442 ◽

2019 ◽

pp. 15-18

Author(s):

María Florencia Rodriguez ◽

Cristian Troitiño ◽

Felix Enrique Romanini ◽

Anastasia Secco

Keyword(s):

Rheumatoid Arthritis ◽

Multivariate Analysis ◽

Salivary Gland ◽

Interstitial Lung Disease ◽

Univariate Analysis ◽

Minor Salivary Gland ◽

Minor Salivary Gland Biopsy ◽

Extraglandular Manifestations ◽

Salivary Gland Biopsy

Secondary Sjögren’s Syndrome (SSs) is common in patients with Rheumatoid Arthritis (RA). Objectives: to determine if lymphocytic sialoadenifitis (FLS) is associated with clinical and serological differences in a group of patients with RA and SSs. Methods: patients with a diagnosis of RA and SSs were included, which of them presented FLS in the salivary gland biopsy, clinical and serological characteristics were compared. Results: 88 patients were included, 92% women, mean age of 53 years (SD ± 11.3) and 12.5 years of evolution of RA (RIC 6-7). 63.6% had SLF versus 36.4% who did not. In the univariate analysis, a statistically significant association was found between FLS + and the variables: parotidomegaly, interstitial lung disease, hypergammaglobulinemia, hypocomplementemia, rheumatoid factor, positive ANF, and extra-articular and/ or extraglandular manifestations. In the multivariate analysis, the variables independently associated with the presence of FLS were: extra-articular and/or extraglandular manifestations (OR 5.67, 95% CI 1.6-20), positive ANF (OR 11.7, 95% CI 1.6-83) and hypergammaglobulinemia (OR 21, 95% CI 2.46-179). Conclusion: patients with RA and SSs with FLS have a higher frequency of extra-articular and extraglandular manifestations and serological differences, which would imply a different clinical follow-up.

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Impact of superselective intra-arterial and systemic chemoradiotherapy for gingival carcinoma; analysis of treatment outcomes and prognostic factors

10.21203/rs.3.rs-56332/v2 ◽

2020 ◽

Author(s):

Yuki Mukai ◽

Yuichiro Hayashi ◽

Izumi Koike ◽

Toshiyuki Koizumi ◽

Madoka Sugiura ◽

...

Keyword(s):

Overall Survival ◽

Multivariate Analysis ◽

Clinical Stage ◽

Performance Status ◽

Univariate Analysis ◽

Stage Iv ◽

Progression Free Survival ◽

Late Toxicity ◽

Free Survival

Abstract Background: We compared outcomes and toxicities between concurrent retrograde super-selective intra-arterial chemoradiotherapy (IACRT) and concurrent systemic chemoradiotherapy (SCRT) for gingival carcinoma (GC).　Methods: We included 84 consecutive patients who were treated for non-metastatic GC ≥ stage III, from 2006 to 2018, in this retrospective analysis (IACRT group: n=66; SCRT group: n=18).Results: The median follow-up time was 24 (range: 1–124) months. The median prescribed dose was 60 (6–70.2) Gy (IACRT: 60 Gy; SCRT: 69 Gy). There were significant differences between the two groups in terms of 3-year overall survival (OS; IACRT: 78.8%, 95% confidence interval [CI]: 66.0–87.6; SCRT: 50.4%, 95% CI: 27.6–73.0; P = 0.039), progression-free survival (PFS; IACRT: 75.6%, 95% CI: 62.7–85.2; SCRT: 42.0%, 95% CI: 17.7–70.9; P = 0.028) and local control rates (LC; IACRT: 77.2%, 95% CI: 64.2–86.4; SCRT: 42.0%, 95% CI: 17.7–70.9; P = 0.015). In univariate analysis, age ≥ 65 years, decreased performance status (PS) and SCRT were significantly associated with worse outcomes (P < 0.05). In multivariate analysis, age ≥ 65 years, clinical stage IV, and SCRT were significantly correlated with a poor OS rate (P < 0.05). Patients with poorer PS had a significantly worse PFS rate. Regarding acute toxicity, 22 IACRT patients had grade 4 lymphopenia, and osteoradionecrosis was the most common late toxicity in both groups.Conclusions: This is the first report to compare outcomes from IACRT and SCRT among patients with GC. ALL therapy related toxicities were manageable. IACRT is an effective and safe treatment for GC.

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Risk Factors for Progression in Vestibular Schwannomas After Incomplete Resection: A Single Center Retrospective Study

Frontiers in Neurology ◽

10.3389/fneur.2021.778590 ◽

2021 ◽

Vol 12 ◽

Author(s):

Jiuhong Li ◽

Xueyun Deng ◽

Daibo Ke ◽

Jian Cheng ◽

Si Zhang ◽

...

Keyword(s):

Risk Factors ◽

Multivariate Analysis ◽

Tumor Size ◽

Tumor Volume ◽

Univariate Analysis ◽

Residual Tumor ◽

Vestibular Schwannomas ◽

Incomplete Resection ◽

Cystic Component

Background and Purpose: The risk factors for progression in vestibular schwannomas (VSs) after incomplete resection (IR) remain to be elucidated. The purpose of this study was to investigate the risk factors for progression in remnant VSs after surgery.Methods: From January 2009 to January 2018, 140 consecutive patients who underwent IR of VSs via suboccipital retrosigmoid approach in our institution were retrospectively analyzed. During follow-up, if progression was detected, the patient was classified into Progressive Group (PG); if the residual tumor was stable or shrank, the patient was classified into Stable Group (SG). Univariate analysis and multivariate analysis were used to evaluate the risk factors for progression after IR of VSs.Results: After a mean follow-up of 80.4 months (range, 24–134 months), 35 (25.0%) patients (PG) had a progression, and no progression was detected in 105 (75.0%) patients (SG). The average tumor size was 36.5 ± 8.9 mm in PG and 31.0 ± 9.8 mm in SG, respectively. The residual tumor volume was 304.6 ± 443.3 mm3 in PG and 75.9 ± 60.0 mm3 in SG, respectively. Univariate analysis showed that preoperative tumor size, residual tumor volume, and irregular internal auditory canal (IAC) expansion were significantly different between the two groups, whereas gender, age, cystic component, or Ki-67 labeling index (LI) did not differ significantly between the two groups. Multivariate analysis showed residual tumor volume was the independent risk factor for progression.Conclusions: VSs that underwent IR with larger preoperative size, greater residual tumor volume, or irregular IAC expansion may have a higher progression rate. Strict follow-up with shorter interval in these patients to detect early progression is necessary.

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P1018Evolution of atrioventricular conduction disorders after TAVI

European Heart Journal ◽

10.1093/eurheartj/ehz747.0609 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

D Irles ◽

F Salerno ◽

R Cassagneau ◽

R Eschallier ◽

C Maupain ◽

...

Keyword(s):

Multivariate Analysis ◽

Primary Endpoint ◽

Univariate Analysis ◽

P Value ◽

Conduction Disorders ◽

Av Conduction ◽

One Year ◽

The One ◽

Valve Implantation

Abstract Background The evolution of atrioventricular block (AVB) after Trans Aortic Valve Implantation (TAVI) is poorly understood, and indications of pacemaker (PM) implantation after TAVI not well defined. Modern PM algorithms can help studying the evolution of these AV conduction disorders after TAVI. SafeR® mode (Sorin® PM) allows to monitor precisely the AV conduction and to store AVB episodes in the PM memory as intracardiac electrograms, which can be re-read and validated afterwards. Methods From November 2015 and January 2017, all patients implanted in one of the 19 French enrolling centers with a Sorin® PM set in SafeR® mode after TAVI could be prospectively included in the study. All the PM interrogation files were centrally collected. The primary endpoint (PE) was the presence of at least one episode of high grade AVB (HG-AVB) beyond day 7 (D7) to one year after the TAVI. It could be validated either by the presence of a HG-AVB on EKG or telemetry, or by the confirmation of a HG-AVB in the PM memory files. Results 273 patients were included in the study, the PE was assessable in 197 patients. PE was validated in 74.6% patients. In univariate analysis, the use of an oversized prothesis or balloon, and all early episodes of HG-AVB (all those occurring up to D7) influence the validation of the PE. Other AV conduction disorders have no influence on the PE (Table). In multivariate analysis, only HG-AVB occurring between D2 and D7 has a significant influence on the PE. Factors influencing HG-AVB after TAVI Studied factor HG-AVB episode(s) during the one year follow up No HG-AVB episode during the one year follow up p value RBBB before TAVI (%) 41 34 0,346 Low implantation (>6mm) (%) 59 37 0,156 Use of Autoexpansive Valve (%) 62 62 0,990 Oversizing (%) 19 6 0,022 HG-AVB per TAVI (%) 56 30 0,001 HG-AVB D0-D1 (%) 53 24 0,001 HG-AVB D2-D7 (%) 68 34 0,001 New or wiser LBBB and improvement of PR interval after TAVI (%) 30 39 0,253 Influence of predefined factors on the Primary Endpoint. Conclusion The analysis of the SafeR® algorithm files in patients implanted with a PM after TAVI show a high incidence of HG-AVB during the one year follow up. In multivariate analysis, only HG-AVB occurring between D2 and D7 significantly influence the PE, confirming that AV conduction disorders occurring during the first 24 hours may spontaneously normalize. Acknowledgement/Funding Microport CRM

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Comparison of Surgical Outcomes and Recurrence Rates of Cystic and Solid Vestibular Schwannomas

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-1697039 ◽

2019 ◽

Author(s):

Rami O. Almefty ◽

David S. Xu ◽

Michael A. Mooney ◽

Andrew Montoure ◽

Komal Naeem ◽

...

Keyword(s):

Multivariate Analysis ◽

Facial Nerve ◽

Tumor Progression ◽

Clinical Outcomes ◽

Univariate Analysis ◽

Growth Patterns ◽

Vestibular Schwannomas ◽

Tumor Control ◽

Tumor Diameter ◽

Cystic Tumors

Abstract Objective Cystic vestibular schwannomas (CVSs) are anecdotally believed to have worse clinical and tumor-control outcomes than solid vestibular schwannomas (SVSs); however, no data have been reported to support this belief. In this study, we characterize the clinical outcomes of patients with CVSs versus those with SVSs. Design This is a retrospective review of prospectively collected data. Setting This study is set at single high-volume neurosurgical institute. Participants We queried a database for details on all patients diagnosed with vestibular schwannomas between January 2009 and January 2014. Main Outcome Measures Records were retrospectively reviewed and analyzed using univariate and multivariate analyses to study the differences in clinical outcomes and tumor progression or recurrence. Results Of a total of 112 tumors, 24% (n = 27) were CVSs and 76% (n = 85) were SVSs. Univariate analysis identified the extent of resection, Koos grade, and tumor diameter as significant predictors of recurrence (p ≤ 0.005). However, tumor diameter was the only significant predictor of recurrence in the multivariate analysis (p = 0.007). Cystic change was not a predictor of recurrence in the univariate or multivariate analysis (p ≥ 0.40). Postoperative facial nerve and hearing outcomes were similar for both CVSs and SVSs (p ≥ 0.47). Conclusion Postoperative facial nerve outcome, hearing, tumor progression, and recurrence are similar for patients with CVSs and SVSs. As CVS growth patterns and responses to radiation are unpredictable, we favor microsurgical resection over radiosurgery as the initial treatment. Our data do not support the commonly held belief that cystic tumors behave more aggressively than solid tumors or are associated with increased postoperative facial nerve deficits.

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Neoadjuvant chemotherapy for invasive bladder cancer: prognostic factors for survival of patients treated with M-VAC with 5-year follow-up.

Journal of Clinical Oncology ◽

10.1200/jco.1994.12.7.1394 ◽

1994 ◽

Vol 12 (7) ◽

pp. 1394-1401 ◽

Cited By ~ 113

Author(s):

P K Schultz ◽

H W Herr ◽

Z F Zhang ◽

D F Bajorin ◽

A Seidman ◽

...

Keyword(s):

Bladder Cancer ◽

Multivariate Analysis ◽

Prognostic Factors ◽

Neoadjuvant Chemotherapy ◽

Univariate Analysis ◽

Invasive Bladder Cancer ◽

Pathologic Stage ◽

Muscle Invasive ◽

Extravesical Disease

PURPOSE To determine survival in patients with muscle-invasive bladder cancer treated with neoadjuvant chemotherapy and to analyze prechemotherapy and postchemotherapy factors for prognostic significance. PATIENTS AND METHODS The survival of 111 patients with T2-4N0M0 bladder cancer treated with neoadjuvant methotrexate, vinblastine, doxorubicin, and cisplatin (M-VAC) was assessed. Prechemotherapy and postchemotherapy factors were analyzed for correlation with survival. Factors found to be significant on univariate analysis were subjected to multivariate analysis using Cox's proportional hazards model. RESULTS The median follow-up duration was 5.3 years. Initial tumor (T) stage (P = .0001), presence of ureteral obstruction (P = .0074), and presence of a palpable mass (P = .0039) were the only pretreatment factors found to be significant on univariate analysis. Postchemotherapy surgery was performed in 81 patients. In these cases, postchemotherapy clinical stage and pathologic stage were significant factors on univariate analysis. In the multivariate analysis, the initial prechemotherapy T stage and the postchemotherapy pathologic stage (pT stage) were the only two factors to demonstrate independent significance. An association between downstaging postchemotherapy and survival was observed for patients with extravesical disease (T < or = 3B) at the start of treatment. In this subset, the 5-year survival rate was 54% for patients with downstaging versus 12% for those without downstaging. This association was not observed for patients with bladder-confined disease (T < or = 3A) at presentation. CONCLUSION The stage of bladder cancer at presentation and at postchemotherapy pathologic staging are independent prognostic factors for long-term survival in patients treated with neoadjuvant chemotherapy. Downstaging after neoadjuvant chemotherapy was associated with improved survival in patients with muscle-invasive bladder cancers, but only for those with extravesical disease (T > or = 3B) pretreatment. Randomized comparisons will be required to assess the impact of chemotherapy on overall survival.

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