Follow-up after cystectomy: regularly scheduled, risk adjusted, or symptom guided? Patterns of recurrence, relapse presentation, and survival after cystectomy

• Published in: European journal of surgical oncology 2014-12, Vol.40 (12), p.1677-1685
• Main Authors: Nieuwenhuijzen, J A, de Vries, R R, van Tinteren, H, Bex, A, Van der Poel, H G, Meinhardt, W, Horenblas, S
• Format: Article
• Language: English
• Subjects: Adult; Aged; Aged, 80 and over; Chemotherapy, Adjuvant; Cystectomy; Female; Follow-Up Studies; Humans; Lymph Nodes - pathology; Lymphatic Metastasis; Male; Middle Aged; Neoadjuvant Therapy - methods; Neoplasm Recurrence, Local - diagnosis; Neoplasm Recurrence, Local - prevention & control; Neoplasm Recurrence, Local - therapy; Neoplasm Staging; Office Visits; Population Surveillance - methods; Radiotherapy, Adjuvant; Risk Assessment; Risk Factors; Salvage Therapy; Survival Analysis; Treatment Outcome; Urinary Bladder Neoplasms - diagnosis; Urinary Bladder Neoplasms - mortality; Urinary Bladder Neoplasms - pathology; Urinary Bladder Neoplasms - prevention & control; Urinary Bladder Neoplasms - surgery
• ISSN: 1532-2157
• DOI: 10.1016/j.ejso.2013.12.017

To evaluate the efficacy of follow-up based on the patterns of recurrence, relapse presentation and survival after cystectomy, and to define a risk adjusted follow-up schedule. The records of 343 patients with regular follow-up after cystectomy were reviewed for primary site of recurrence, accompanying symptoms, means of recurrence diagnosis, and clinicopathological factors. Based on Cox proportional hazard models, and the results of imaging studies low and high risk groups are identified and a risk adjusted follow-up protocol is proposed. The risk of a recurrence was related to increasing pT, tumour positive lymph nodes, tumour positive surgical margins, and pre-operative dilatation of the upper urinary tract, and low and high risk groups were defined consequently. 84% of all recurrences occurred within 2 years, with only one recurrence beyond 2 years in the low risk group. Although the minority of all patients (34%) is asymptomatic at time of recurrence, symptomatic recurrences were adversely associated with survival. CT-scans and chest X-rays accounted for 90% of the diagnostic tools to detect a recurrence in patients without symptoms. Asymptomatic patients may benefit from early treatment after disease recurrence. A risk adjusted follow-up strategy based on stage of disease and additional clinicopathological factors can dichotomise patients at high and low risk for recurrence. The small benefit in survival after early detection has to be confirmed in future studies, and weighed against the available treatment options of recurrences and their subsequent costs.