Answer
A group from the University of Texas MD Anderson Cancer Center retrospectively reviewed their post–radical cystectomy surveillance protocol for 382 patients and concluded that a stage-specific approach was most appropriate. [13] With a median follow-up of 38 months, 25% of patients experienced recurrences, with a median time to recurrence of 12 months. The 4 most common sites of recurrence (in decreasing order of incidence) were the lung, pelvis, bone, and liver. Seventy-four percent of recurrences were asymptomatic, and 43 of the 72 asymptomatic recurrences were detected with chest radiography or liver function serum tests.
Only 5% of patients with pT1 disease had subsequent metastases, and all were identified with chest radiography or liver function tests. Among 10 patients who were found to have asymptomatic intra-abdominal recurrences based on CT scan findings, 9 had pT3 disease. Patients with pT2 and pT3 disease had recurrence rates of 20% and 40%, respectively. All recurrences in patients with pT2 or pT3 disease occurred within 24 months.
Based on these findings, the group recommended that surveillance should include the following:
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History
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Physical examination
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Chest radiography
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Liver function tests
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Alkaline phosphatase assessment
The group recommended scheduling surveillance according to the patient’s disease stage, as follows:
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pT1 disease - Annually
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pT2 disease - Every 6 months for 3 years, then annually
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pT3 disease - As with pT2 disease, but starting at 3 months, with CT scanning at 6, 12, and 24 months
All patients with transitional cell carcinoma (TCC), particularly those at higher risk of recurrence (eg, because of distal ureteral involvement at cystectomy, multiple recurrent bladder tumors, carcinoma in situ [CIS]), should undergo upper tract radiographic studies every 1-2 years.
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The classic appearance of carcinoma in situ as a flat, velvety patch. However, using special staining techniques such as 5-aminolevulinic acid, it has been shown that significant areas of carcinoma in situ are easily overlooked by conventional cystoscopy. Courtesy of Abbott and Vysis Inc.
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Papillary bladder tumors such as this one are typically of low stage and grade (Ta-G1). Courtesy of Abbott and Vysis Inc.
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Sessile lesions as shown usually invade muscle, although occasionally a tumor is detected at the T1-G3 stage prior to muscle invasion. Courtesy of Abbott and Vysis Inc.
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Flexible cystoscopes such as this one facilitate endoscopic tumor surveillance with minimal morbidity and excellent visualization of the urothelium. Courtesy of Olympus America Inc.
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The latest development in surveillance involves advances that integrate video chip technology on to the end of flexible cystoscopes. Courtesy of Olympus America Inc.
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Rigid cystoscopes such as this one allow biopsy collection via in-office fulguration of small tumors. Such fulguration may be performed using electrocautery or laser. Courtesy of Olympus America Inc.
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Resection of all visible tumors is possible using modern resectoscopes. Courtesy of Olympus America Inc.
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Photograph in which fluorescence in situ hybridization centromere staining identifies aneuploidy of chromosome 3. Multiple instances of overexpression of the chromosome (note the multiple red dots, which identify centromeres of this chromosome) prove aneuploidy.
