Biomedical subjects

Pierre I Karakiewicz

Publications and source records attributed to Pierre I Karakiewicz.

At least 37 records · Page 2Linked to original sources

PubMed2006

Zonal origin of localized prostate cancer does not affect the rate of biochemical recurrence after radical prostatectomy.

OBJECTIVE: To investigate whether transition zone (TZ) prostate cancers demonstrate different rates of biochemical recurrence after radical prostatectomy compared to peripheral zone (PZ) cancers. METHODS: In 1262 consecutive patients treated with radical prostatectomy, computerized planimetry defined tumour origin as either TZ tumours (>70% TZ location) or PZ. Kaplan-Meier and multivariate Cox regression models tested the association between zonal origin and the rate of biochemical recurrence (prostate-specific antigen >0.1ng/ml and rising). We used the Harrell's concordance index to quantify the accuracy of various Cox regression models. RESULTS: TZ prostate cancers were diagnosed in 115 patients (9.1%). Biochemical recurrence was recorded in 16 TZ and in 201 PZ prostate cancers patients. In multivariate Cox models, the rate of biochemical recurrence was not significantly different between TZ and PZ prostate cancers (p=0.4). Combined multivariate predictive accuracy of biochemical recurrence predictions was 81.2% accurate when zonal origin was included versus 81.0% when zonal origin was omitted. CONCLUSIONS: The zonal origin of prostate cancers does not affect the rate of biochemical recurrence after radical prostatectomy.

Humans↗

PubMed2006

Validation of a nomogram predicting the probability of lymph node invasion based on the extent of pelvic lymphadenectomy in patients with clinically localized prostate cancer.

OBJECTIVE: To develop a multivariate nomogram to predict the rate of lymph node invasion (LNI) in patients with clinically localized prostate cancer according to the extent of extended pelvic lymphadenectomy (PLND), which is associated with significantly higher rate of LNI. PATIENTS AND METHODS: The study comprised 781 consecutive patients (median age 66.6 years, range 45-85) treated with PLND and radical retropubic prostatectomy (RRP) for clinically localized prostate cancer. Their median (range) prostate-specific antigen (PSA) level was 7 (1.03-49.91) ng/mL, and their clinical stages were T1c in 433 (55.4%), T2 in 328 (42%) and T3 in 20 (2.6%). Biopsy Gleason sums were <or= 6 in 514 (65.8%), 7 in 204 (26.1%) and 8-10 in 63 (8.1%). Multivariate logistic regression models were used to test the association between predictors including PSA level, biopsy Gleason sum, clinical stage, number of nodes removed and the rate of LNI. Finally, regression coefficients were used to develop a nomogram, which was internally validated with 200 bootstrap re-samples. RESULTS: The median (range) number of lymph nodes removed was 14 (2-40); LNI was detected in 71 patients (9.1%). The univariate predictive accuracy for total PSA level, clinical stage, biopsy Gleason sum and number of total nodes removed and examined was 64.2%, 59.8%, 74% and 62.9%, respectively. Except for PSA (P = 0.2), all variables were statistically significant multivariate predictors of LNI at RRP (P <or= 0.001). A nomogram based on clinical stage, PSA level, biopsy Gleason sum and the number of total lymph nodes removed was 78.6% accurate, and 1.8% more accurate than a nomogram without the number of removed lymph nodes. CONCLUSIONS: The extent of PLND is directly related to the probability of LNI. The risk of LNI increases linearly, and is proportional to the number of nodes removed and examined. The effect of the increased probability of LNI is weighted more heavily in men with more advanced clinical stage and grade.

Aged↗

PubMed2006

Precystectomy nomogram for prediction of advanced bladder cancer stage.

OBJECTIVE: To evaluate precystectomy prediction of pT and pN stages at cystectomy. METHODS: Multivariate logistic regression analyses modelled variables of 726 evaluable patients treated with radical cystectomy and bilateral pelvic lymphadenectomy. The first set of models predicted pT(3-4) stage at cystectomy, and the second set predicted pN(1-3) stages at cystectomy. Transurethral resection (TUR) predictors consisted of 2002 T stage, 1973 WHO tumour grade, presence of carcinoma in situ, age, gender, and delivery of neo-adjuvant chemotherapy. The area under the ROC curve quantified nomogram accuracy. Two hundred bootstrap resamples were used to reduce overfit bias. RESULTS: At TUR, 11% of patients were staged as pT(3-4) versus 42% at cystectomy. Lymph node metastases were found in 24% of patients at cystectomy (pN(1-3)). The multivariate pT(3-4) nomogram was 75.7% accurate versus 71.4% for TUR T stage. The multivariate pN(1-3) nomogram was 63.1% accurate versus 61.0% for TUR T stage. CONCLUSION: Multivariate nomograms are not perfect, but they do predict more accurately than TUR T stage alone.

Adult↗

PubMed2006

A nomogram for staging of exclusive nonobturator lymph node metastases in men with localized prostate cancer.

OBJECTIVES: Some patients with localized prostate cancer are at risk of nonobturator lymph node invasion (NOLNI) and may require an extended pelvic lymph node dissection (ePLND). We explored the rate of exclusive NOLNI and developed a nomogram to predict it. MATERIAL AND METHODS: We mapped all ePLND specimens according to their anatomic location (obturator, external iliac, internal iliac lymph nodes) and assessed the location-specific rate of LNI in 565 patients. A multivariate logistic regression-based nomogram predicting NOLNI was then internally validated with 200 bootstrap resamples. RESULTS: Overall, 11.1% (63 of 565) had LNI and 21 (3.7%) had exclusive NOLNI. The nomogram predicting exclusive NOLNI was 80.2% accurate. The nomogram's negative predictive value was 99%, when it predicted 0-10% probability of NOLNI. This approach could allow the omission of an ePLND in 350 of 565 (61.9%) patients and still correctly stage 85.8% of NOLNI cases. CONCLUSIONS: Our nomogram-based approach offers the possibility of identifying men who are at virtually zero risk of exclusive NOLNI. In these men, an ePLND may be safely avoided.

Adult↗

PubMed2006

Discrepancy between clinical and pathologic stage: impact on prognosis after radical cystectomy.

OBJECTIVES: We compared clinical and pathologic staging in a large, contemporary, consecutive series of patients who were treated with radical cystectomy and pelvic lymphadenectomy, and determined the effect of stage discrepancy on outcomes. METHODS: We collected retrospective data from 778 consecutive patients with bladder transitional cell carcinoma who were treated with radical cystectomy and pelvic lymphadenectomy, and for whom the clinical and pathologic stage were available. RESULTS: Pathologic upstaging occurred in 42% of patients, and pathologic downstaging occurred in 22%. Forty percent of patients with non-muscle-invasive clinical stage had muscle-invasive pathologic stage. Thirty-six percent of patients with organ-confined clinical stage had non-organ-confined pathologic stage (> or =pT3N0 or pTanyN-positive). Patients with higher clinical stage were more likely to be upstaged to non-organ-confined disease (p<0.001). Patients were stratified into three groups: pathologically upstaged, same clinical and pathologic stage, and pathologically downstaged. When adjusted for the effects of standard postoperative features, upstaged patients were at a significantly higher risk of disease recurrence and bladder cancer-specific death than patients who had the same pathologic and clinical stage, who in turn were at significantly higher risk than downstaged patients. This observation remained true within each clinical stage strata. Within each pathologic stage strata, clinical stage did not substratify into different risk groups. CONCLUSIONS: Clinical to pathologic stage discrepancy is a relatively common finding after extirpative surgery for bladder cancer. Clinical outcomes after radical cystectomy are largely driven by pathologic stage. Better clinical staging is necessary to improve patient evaluation and management.

Adult↗

PubMed2006

Outcomes research: a methodologic review.

OBJECTIVES: We explored the history and conceptual trends of outcomes research. METHODS: We described different aspects of this field, after dividing it into conceptually distinct strata. RESULTS: Outcomes research can be divided into macro, meso and micro levels. Each level is further subdivided. Macro-level research targets cost and health care utilization, as well as racial, ethnic and geopolitical population health determinants. Meso-level studies address effectiveness, variability, disease impact, clinical modeling and program evaluation studies. Finally, micro-level studies address all aspects of direct patient-clinician decision-making. CONCLUSIONS: An explosion of outcomes research has occurred in the past decades. Wide access to information technology, data sharing and collaborative efforts between researchers represent some of the ingredients that did and will continue to fuel that growth.

Humans↗

PubMed2006

High incidence of prostate cancer detected by saturation biopsy after previous negative biopsy series.

OBJECTIVES: We explored the yield of saturation biopsy and developed a nomogram predicting the probability of prostate cancer (PCa) on the basis of saturation biopsy. MATERIALS AND METHODS: Between 2001 and 2004, saturation biopsies (average of 24 cores) were performed in 161 men with persistently elevated prostate specific antigen (PSA) level (median, 9 ng/ml). All had at least two previously negative, eight-core biopsy sessions. PCa predictors on saturation biopsy were integrated within multivariate nomograms. RESULTS: PCa detection was 41% (n=66 of 161). PSA density and transition zone volume were the most significant predictors of PCa on saturation biopsy. The accuracy of the nomogram with the best performance characteristics was 72%. CONCLUSIONS: Saturation biopsy may be indicated in men with a persistent suspicion of PCa. High-risk individuals can be identified accurately with our nomogram.

Adult↗

PubMed2006

High radical prostatectomy surgical volume is related to lower radical prostatectomy total hospital charges.

OBJECTIVE: To test the hypothesis that individual surgical volume (SV) is an independent predictor of radical prostatectomy (RP) total charges. METHODS: We used the Florida State Inpatient Data File. ICD-9 codes 60.5 (RP) and 185 (prostate cancer) identified all men treated with RP for prostate cancer between January 1 and December 31, 1998. Among 1,923,085 records, 3167 RPs were selected. SV represented the predictor. Total RP charges represented the outcome. Age, race, and comorbidity represented covariates. Univariate and multivariate linear regression models were used. RESULTS: All 3167 RPs were performed by 81 surgeons. SV ranged from 2 to 162 (mean, 68). Charges were 4755 dollars to 140,201 dollars (mean, 18,200 dollars). In the multivariate model, each SV increment corresponding to one RP reduced hospital charges by 25 dollars (p < or = 0.001). CONCLUSIONS: Redistribution of RPs from low to high SV users could result in significant savings. For example, 4 million dollars could be saved if 1000 RPs were redistributed from surgeons with an SV of 18 to surgeons with an SV of 200.

Adult↗

PubMed2006

Institutional variability in the accuracy of urinary cytology for predicting recurrence of transitional cell carcinoma of the bladder.

OBJECTIVE: To assess the contemporary inter-institutional accuracy of urinary cytology in predicting the recurrence of transitional cell carcinoma (TCC) of the bladder, in a large multi-institutional cohort from four continents, as cystoscopy and urinary cytology represent the 'gold standards' for surveillance of TCC recurrences, but the ability of cytology to predict recurrence varies. PATIENTS AND METHODS: Ten institutions contributed 2542 patients with a history of superficial TCC, of whom 898 had TCC recurrence. Age- and gender-adjusted logistic regression models were used to evaluate the association between urine cytology and TCC recurrence. The predictive accuracy derived from the logistic regression model was tested using the area under the receiver operating characteristic curve. The resulting predictive accuracy estimates were internally validated with 200 bootstrap re-samples. RESULTS: The mean (range across institutions) age of the patients was 65 (48-69) years and 75 (67-87)% were men. Cytology was positive in 19 (10-38)% of patients; recurrence was identified in 35 (27-54)% of patients. The sensitivity was 38-65% across institutions. Urinary cytology varied significantly in its ability to predict recurrence of bladder cancer. Institution-specific predictive accuracy adjusted for gender and age was 0.627-0.893. Stratifying by grade and stage only partly attenuated the discrepancies between centres. CONCLUSIONS: The variability of urinary cytology results was very appreciable among the 10 centres and ranged from poor (63%) to excellent (89%).

Aged↗

PubMed2006

Anatomic radical retropubic prostatectomy-long-term recurrence-free survival rates for localized prostate cancer.

Radical prostatectomy remains the mainstay for the treatment of localized prostate cancer. Long-term follow-up data showed excellent cancer control rates in several prostatectomy series. We report biochemical recurrence (BCR) outcomes after radical retropubic prostatectomy (RRP) in a European single center series of patients treated over a 13-year period. Between 1992 and 06/2005, 4,277 consecutive men underwent a RRP at the University Hospital Hamburg Eppendorf, Germany. Kaplan-Meier probabilities of BCR-free survival were determined for those patients with complete preoperative data, postoperative data, and follow-up information. Uni-and multivariate Cox regression models addressed PSA recurrence, defined as a PSA level > or = 0.1 ng/ml. Overall, BCR-free survival ranged between 84, 70 and 61% for 2, 5, and 8 years, respectively. In univariate and multivariate analyses, except for age and type of nerve-sparing technique, all traditional clinical and pathological variables represented statistically independent predictors of PSA recurrence-free survival (all P < or = 0.001). In organ-confined disease, the 10-year recurrence free survival rate was 80 and 30% in non-organ-confined cancers. Our findings confirm excellent long-term biochemical cancer-control outcomes after RRP. High grade prostate cancer at final pathology and seminal vesicle invasion proved to be the strongest risk factors of BCR after surgery.

Adult↗

PubMed2006

Tumor size improves the accuracy of TNM predictions in patients with renal cancer.

OBJECTIVES: Current staging for renal cancer (RC) does not directly rely on tumor size. We examined the increment in accuracy related to inclusion of pathologically determined tumor size in prediction of nodal metastases (N+), distant metastases (M+), and cancer-specific survival (CSS). METHODS: Partial or radical nephrectomy was performed in 2245 patients with clear cell histology. Pathologic stages were T1a in 566, T1b in 490, T2 in 303, T3 in 831, and T4 in 55 patients. Tumor size was 0.5-25 cm (mean, 6.8). Multivariate models relied on 1997 and 2002 TNM variables and addressed N+, M+ disease, and CCS. Their accuracy was compared according to either the presence or absence of tumor size. RESULTS: In all univariate and multivariate models, tumor size was a statistically significant predictor of all outcomes (p< or =0.001). In all multivariate models, tumor size added between 3.7% and 0.8% to predictive accuracy of either 1997 or 2002 TNM categories. CONCLUSIONS: Tumor size represents a highly significant, multivariate, and informative predictor of RC outcomes and may warrant inclusion in future TNM revisions.

Carcinoma, Renal Cell↗

PubMed2006

Validation of a nomogram predicting the probability of lymph node invasion among patients undergoing radical prostatectomy and an extended pelvic lymphadenectomy.

INTRODUCTION: Our goal was to develop and internally validate a nomogram for prediction of lymph node invasion (LNI) in patients with clinically localized prostate cancer undergoing extended pelvic lymphadenectomy (ePLND). METHODS: 602 consecutive patients (mean age 65.8 years) underwent an ePLND, where 10 or more nodes were removed. PSA was 1.1-49.9 (median 7.2). Clinical stages were: T1c in 55.6%, T2 in 41.4% and T3 in 3%. Biopsy Gleason sums were: 6 or less in 66%, 7 in 25.4%, 8-10 in 8.6%. Multivariate logistic regression models tested the association between all of the above predictors and LNI. Regression-based coefficients were used to develop a nomogram predicting LNI and 200 bootstrap resamples were used for internal validation. RESULTS: Mean number of lymph nodes removed was 17.1 (range 10-40). LNI was detected in 66 patients (11.0%). Univariate predictive accuracy for total PSA, clinical stage and biopsy Gleason sum was 63%, 58% and 73%, respectively. A nomogram based on clinical stage, PSA and Biopsy Gleason sum demonstrated bootstrap-corrected predictive accuracy of 76%. CONCLUSIONS: A nomogram based on pre-treatment PSA, clinical stage and biopsy Gleason sum can highly accurately predict LNI at ePLND.

Aged↗

PubMed2006

Comparative assessment of the 1992 and 2002 pathologic T3 substages for the prediction of biochemical recurrence after radical prostatectomy.

BACKGROUND: The objective of this study was to compare the ability of the 1992 American Joint Committee on Cancer (AJCC) TNM staging system for nonorgan-confined prostate carcinoma (PCa) (pathologic T3 [pT3a], pT3b,and pT3c) to predict biochemical recurrence (BCR) after radical prostatectomy with its revision from 1997/2002 (pT3a and pT3b). METHODS: The authors analyzed prospectively collected data from 971 consecutive patients with pT3 tumors who underwent radical prostatectomy alone at a single institution. According to the 1992 AJCC substages, 494 patients had pT3a PCa (51%), 85 patients had pT3b PCa (9%), 302 patients had pT3c PCa (31%) and 91 patients had pT3 PCa (9%) with metastatic lymph node invasion (LNI). Kaplan-Meier and Cox proportional hazards regression analyses were employed to assess the BCR rate using the preoperative prostate-specific antigen (PSA) level, surgical margin (SM) status, pathologic Gleason score, and LNI. The predictive accuracy of this "base" model was compared with models that added either the AJCC 1992 or the AJCC 1997/2002 staging definitions. RESULTS: BCR was observed in 345 patients (36%). The actuarial 5-year recurrence-free probability for patients with AJCC 1992 pT3a, pT3b, and pT3c PCa was 69%, 42%, and 33%, respectively, and differed significantly between men with pT3a tumors and men with pT3b tumors (log-rank test; P < 0.0005). In Cox regression analyses, the 1992 substages were associated significantly with BCR after controlling for PSA, SM status, Gleason grade, and LNI (P < 0.0005). The predictive accuracy of the base model (bootstrap-corrected concordance index, 0.739) was improved after addition of the 1992 TNM staging criteria (concordance index, 0.747). However, predictive accuracy was similar for the model that included the 1997/2002 substages (concordance index, 0.746). CONCLUSIONS: Substaging of pT3 tumors according to the less complex 1997/2002 pT3 classification improved the predictive accuracy of the BCR rate virtually to the same extent as the more detailed 1992 classification. Therefore, the current data favor the use of the 1997/2002 pT3 substaging system.

Biomarkers, Tumor↗

PubMed2006

Pre-treatment nomogram for disease-specific survival of patients with chemotherapy-naive androgen independent prostate cancer.

OBJECTIVE: Our objective was to develop a nomogram that predicts the probability of cancer-specific survival in men with untreated androgen-independent prostate cancer (AIPC). METHODS: AIPC was diagnosed in 129 consecutive patients between 1989 and 2002. No patient received cytotoxic chemotherapy. Univariate and multivariate Cox regression models were used to test the association between prostate-specific antigen (PSA) level at initiation of androgen deprivation, PSA doubling time (PSADT), PSA nadir on androgen deprivation therapy (ADT), time from ADT to AIPC, and AIPC-specific mortality. Multivariate regression coefficients were then used to develop a nomogram predicting AIPC-specific survival at 12-60 mo after AIPC diagnosis. Two-hundred bootstrap resamples were used to internally validate the nomogram. RESULTS: AIPC-specific mortality was recorded in 74 of 129 patients (57.4%). Other-cause mortality was recorded in 7 men (5.4%). Median overall survival was 52.0 mo (mean, 36.0 mo) and median AIPC-specific survival was 54.0 mo (mean, 35.0 mo). In univariate regression models, all variables were significant predictors of AIPC-specific survival (p < or = 0.02). In multivariate models, PSADT and time from androgen deprivation to AIPC remained statistically significant (p < or = 0.004). Bootstrap-corrected predictive accuracy of the nomogram was 80.9% versus 74.9% for our previous model. CONCLUSIONS: A nomogram predicting AIPC-specific survival is between 13% and 14% more accurate than previous nomograms and 6% more accurate than tree regression-based predictions obtained from the same data. Moreover, a nomogram approach combines several advantages, such as user-friendly interface and precise estimation of individual recurrence probability at several time points after AIPC diagnosis, which all patients deserve to know and all treating physicians need to know.

Aged↗

PubMed2006

The 2002 AJCC pT2 substages confer no prognostic information on the rate of biochemical recurrence after radical prostatectomy.

INTRODUCTION: We examined the prognostic value of AJCC pT2 substages in prediction of biochemical recurrence (BCR) after radical prostatectomy (RP), in European patients. METHODS: A cohort of 1726 RP patients with pT2N0 prostate cancer (PCa) was studied. Multivariate Cox regression models addressed the association between either the 1997 or 1992/2002 pT2 substages after controlling for total PSA, primary and secondary pathologic Gleason scores and surgical margin status and time to PSA recurrence (PSA >0.1 and rising) after RP. Regression coefficients were then used to test the predictive accuracy of multivariate models in a nomogram setting. RESULTS: PSA recurrence occurred in 80 (4.6%) patients. Mean and median times to recurrence were respectively 28.9 and 24.4 months. In univariate analyses, neither the 1997 (p = 0.48) nor the 1992/2002 pT2 substages (p = 0.054) were predictive of recurrence. In multivariate analyses the lack of significance persisted (1997 p = 0.709; 1992/2002 p = 0.124). When either the 1997 or 1992/2002 pT2 substages were added to a multivariate nomogram without pT2 substage information, its accuracy respectively decreased by 0.8% and 1.1%. CONCLUSION: Our data indicate that pT2 substages offer no incremental value relative to pre-treatment total PSA, surgical margin status and pathologic Gleason scores. Therefore, it might be postulated that it is sufficient to confirm organ confinement according to Partin's pathologic staging.

Analysis of Variance↗

PubMed2006

25-year prostate cancer control and survival outcomes: a 40-year radical prostatectomy single institution series.

PURPOSE: We report on 25-year cancer control and survival outcomes after radical prostatectomy in a single center series of patients treated during a 40-year period. MATERIALS AND METHODS: Between 1954 and 1994, 787 consecutive patients underwent radical prostatectomy at Virginia Mason Medical Center in Seattle, Washington. Kaplan-Meier 25-year probabilities of prostate cancer specific, overall, prostate specific antigen progression-free, local and distant progression-free survival were determined. Multivariate Cox regression models addressed prostate cancer specific mortality. RESULTS: Prostate cancer specific survival, overall survival, prostate specific antigen progression-free survival, local and distant progression-free survival ranged from 99.0% to 81.5%, 93.5% to 19.3%, 84.8% to 54.5%, 95.3% to 87.8% and 95.9% to 78.2%, respectively. In univariate analyses pathological stage, surgical margin status, pathological Gleason sum, delivery of hormonal therapy and radiotherapy represented statistically significant predictors of prostate cancer specific mortality (all p < or =0.001). In multivariate analyses only Gleason sum (p = 0.03) and delivery of hormonal therapy (p < 0.001) remained significant. CONCLUSIONS: This is one of the most mature radical prostatectomy series. It demonstrates that long-term biochemical cancer control outcomes after radical prostatectomy might be suboptimal. However, local and distant control outcomes are excellent, and cancer specific mortality is minimal even 25 years after surgery.

Adult↗

PubMed2006

Variability in the performance of nuclear matrix protein 22 for the detection of bladder cancer.

PURPOSE: We assessed variability in the diagnostic performance of NMP22 for detecting recurrence and progression in patients with Ta, T1, and/or CIS transitional cell carcinoma of the bladder in a large international cohort. MATERIALS AND METHODS: NMP22 voided urine levels were measured in 2,871 patients who underwent office cystoscopy for monitoring previous stage Ta, T1 and/or CIS transitional cell carcinoma at 12 participating institutions. RESULTS: Patient characteristics varied considerably among institutions. Overall 1,045 patients (36.4%) had recurrent transitional cell carcinoma (range across institutions 13.6% to 54.3%). Median NMP22 was 5.5 U/ml (range across institutions 2.5 to 18.8). Of the patients 33.5% had grade III tumors (range across institutions 20.6% to 54.0%) and 22.4% had muscle invasive tumors (range across institutions 3.2% to 38.2%). Area under the ROC curve for bladder TCC detection was 0.735 (95% CI 0.715 to 0.755, range across institutions 0.676 to 0.889). The manufacturer recommended cutoff of 10 U/ml detected 57% of cases with a 19% false-positive rate. AUC for grade III and stage T2 or greater disease was 0.806 (95% CI 0.780 to 831) and 0.864 (95% CI 0.839 to 0.890), respectively. For each NMP22 cutoff NMP22 had higher sensitivity for detecting grade III and stage T2 or greater bladder transitional cell carcinoma than for detecting any cancer. No optimal cutoffs for detecting any or aggressive bladder transitional cell carcinoma could be derived based on NMP22 values. CONCLUSIONS: There is a substantial degree of heterogeneity in the diagnostic performance of NMP22 applied to populations from different institutions. There is no clearly defined NMP22 cutoff but there is a continuum of risk for recurrence and progression.

Adult↗

PubMed2006

Nomogram for predicting disease recurrence after radical cystectomy for transitional cell carcinoma of the bladder.

PURPOSE: American Joint Committee on Cancer staging represents the gold standard for prediction of recurrence after radical cystectomy in patients with invasive bladder cancer. We tested the hypothesis that American Joint Committee on Cancer stage based predictions may be improved when pathological tumor and node stage information is combined with additional clinical and pathological variables within a prognostic nomogram. MATERIALS AND METHODS: We used Cox proportional hazards regression analysis to model variables of 728 patients with transitional cell carcinoma of the bladder treated with radical cystectomy and bilateral pelvic lymphadenectomy at 1 of 3 participating institutions. Standard predictors, pT and pN, were complemented by age, gender, tumor grade at cystectomy, presence of lymphovascular invasion, presence of carcinoma in situ in the cystectomy specimen, neoadjuvant chemotherapy, adjuvant chemotherapy and adjuvant radiotherapy. The concordance index was used to quantify the accuracy of regression coefficient based nomograms. A total of 200 bootstrap resamples were used to reduce overfit bias and for internal validation. Calibration plots were used to graphically explore the performance characteristics of the multivariate nomogram. RESULTS: Followup ranged from 0.1 to 183.4 months (median 24.9, mean 36.4). Recurrence was recorded in 249 (34.2%) patients with a median time to recurrence of 108 months (range 0.8 to 131.9). Actuarial recurrence-free probabilities were 69.6% (95% CI 65.8%-73.0%), 60.2% (55.8%-64.3%) and 52.9% (47.3%-58.1%) at 2, 5 and 8 years after cystectomy, respectively. Two-hundred bootstrap corrected predictive accuracy of American Joint Committee on Cancer stage based predictions was 0.748. Accuracy increased by 3.2% (0.780) when age, lymphovascular invasion, carcinoma in situ, neoadjuvant chemotherapy, adjuvant chemotherapy and adjuvant radiotherapy were added to pathological stage information and used within a nomogram. CONCLUSIONS: A nomogram predicting bladder cancer recurrence after cystectomy is 3.2% more accurate than American Joint Committee on Cancer stage based predictions. Moreover, a nomogram approach combines several advantages such as easy and precise estimation of individual recurrence probability at key points after cystectomy, which all patients deserve to know and all treating physicians need to know.

Adult↗