Nomogram Predicting Bladder Cancer-specific Mortality After Neoadjuvant Chemotherapy and Radical Cystectomy for Muscle-invasive Bladder Cancer: Results of an International Consortium.

BACKGROUND: Cisplatin-based neoadjuvant chemotherapy (NAC) for muscle-invasive bladder cancer (MIBC) is associated with improved overall and cancer-specific survival. The post-NAC pathological stage has previously been reported to be a major determinant of outcome. OBJECTIVE: To develop a postoperative nomogram for survival based on pathological and clinical parameters from an international consortium. DESIGN, SETTING, AND PARTICIPANTS: Between 2000 and 2015, 1866 patients with MIBC were treated at 19 institutions in the USA, Canada, and Europe. Analysis was limited to 640 patients with adequate follow-up who had received three or more cycles of NAC. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: A nomogram for bladder cancer-specific mortality (BCSM) was developed by multivariable Cox regression analysis. Decision curve analysis was used to assess the model's clinical utility. RESULTS AND LIMITATIONS: A total of 640 patients were identified. Downstaging to non-MIBC (ypT1, ypTa, and ypTis) occurred in 271 patients (42 %), and 113 (17 %) achieved a complete response (ypT0N0). The 5-yr BCSM was 47.2 % (95 % confidence interval [CI]: 41.2-52.6 %). On multivariable analysis, covariates with a statistically significant association with BCSM were lymph node metastasis (hazard ratio [HR] 1.90 [95% CI: 1.4-2.6]; p < 0.001), positive surgical margins (HR 2.01 [95 % CI: 1.3-2.9]; p < 0.001), and pathological stage (with ypT0/Tis/Ta/T1 as reference: ypT2 [HR 2.77 {95 % CI: 1.7-4.6}; p < 0.001] and ypT3-4 [HR 5.9 {95 % CI: 3.8-9.3}; p < 0.001]). The area under the curve of the model predicting 5-yr BCSM after cross validation with 300 bootstraps was 75.4 % (95 % CI: 68.1-82.6 %). Decision curve analyses showed a modest net benefit for the use of the BCSM nomogram in the current cohort compared with the use of American Joint Committee on Cancer staging alone. Limitations include the retrospective study design and the lack of central pathology. CONCLUSIONS: We have developed and internally validated a nomogram predicting BCSM after NAC and radical cystectomy for MIBC. The nomogram will be useful for patient counseling and in the identification of patients at high risk for BCSM suitable for enrollment in clinical trials of adjuvant therapy. PATIENT SUMMARY: In this report, we looked at the outcomes of patients with muscle-invasive bladder cancer in a large multi-institutional population. We found that we can accurately predict death after radical surgical treatment in patients treated with chemotherapy before surgery. We conclude that the pathological report provides key factors for determining survival probability.

Influences on length of stay in an enhanced recovery programme after colonic surgery.

AIM: Enhanced recovery after surgery (ERAS) programmes have been shown to accelerate and enhance functional recovery after colonic surgery. We analysed prospectively collected data to investigate potentially modifiable factors that may influence the length of stay (LOS) in the ERAS setting at a single institution. METHOD: Between October 2005 and November 2008, prospective data were collected on consecutive patients who underwent elective colonic surgery without a stoma. Patients with rectal cancer, those unable to participate in preoperative ERAS components because of their inability to communicate effectively in English, those with cognitive impairment and those with an American Society of Anesthesiologists (ASA) grade of ≥ 4 were excluded. Statistical analyses were performed using the Mann-Whitney U-test and Cox regression modelling. RESULTS: A total of 100 (79 malignancies) patients underwent elective colon resection during the study period. There were 57 right-sided, 41 left-sided and two total colectomies. The median age of the patients was 67.5 (range 31-92) years and the median day stay was 4 (range 3-46) days. Factors with significant correlations for reduced LOS were female gender, the surgeon, operative severity, high-dependency unit (HDU) admission and incision type favouring laparoscopic and transverse approaches. Age, operation site, indication for surgery and body mass index were not significant predictors of hospital stay. Gender, operative severity, HDU admission and surgeon did not have any independent correlation with LOS; in contrast to the ASA score and the type of incision, which did. CONCLUSION: Lower ASA score, transverse incision laparotomy and laparoscopy correlated independently with reduced postoperative LOS within the ERAS setting.

Randomized clinical trial of the effect of glucocorticoids on peritoneal inflammation and postoperative recovery after colectomy.

BACKGROUND: Recent data have suggested a relationship between postoperative fatigue and the peritoneal cytokine response after surgery. The aim of this study was to test the hypothesis that preoperative administration of glucocorticoids before surgery would decrease fatigue and enhance recovery, by reducing the peritoneal production of cytokines. METHODS: In a double-blind randomized controlled study, patients undergoing elective, open colonic resection were administered 8 mg dexamethasone or normal saline. Patients were treated within an enhanced recovery after surgery programme. Primary outcomes were cytokine levels in peritoneal drain fluid and fatigue as measured by the Identity-Consequence Fatigue Scale (ICFS). RESULTS: Baseline parameters were similar for 29 patients in the dexamethasone group and 31 in the placebo group. Patients who received dexamethasone had lower ICFS scores on days 3 and 7. Dexamethasone was associated with significantly lower peritoneal fluid interleukin (IL) 6 and IL-13 concentrations on day 1, and these correlated with changes in the ICFS score. There was no significant increase in adverse events in the dexamethasone group. CONCLUSION: Preoperative administration of dexamethasone resulted in a significant reduction in early postoperative fatigue, associated with an attenuated early peritoneal cytokine response. Peritoneal production of cytokines may therefore be important in postoperative recovery. REGISTRATION NUMBER: ACTRN12607000066482 (http://www.anzctr.org.au/).