Bladder-sparing approaches to invasive disease

Concurrent carbogen and nicotinamide with radiation therapy in muscle invasive bladder cancer: A report on feasibility in the Australian setting

INTRODUCTION

The incidence of bladder cancer increases with age, and elderly patients with muscle invasive bladder cancer (MIBC) are significantly undertreated. Bladder preservation trimodality therapy (BPTT) is an alternative to radical cystectomy in the curative setting. The use of concurrent carbogen and nicotinamide (CON) with radiation therapy (RT) as radiosensitisers have shown significant improvement in the overall survival and local relapse in the UK BCON Trial and is part of the standard of care for patients with MIBC in the UK. This is the first study in the Australian setting to demonstrate the feasibility in setting up a CON radiation oncology department.

METHODS

Based on the UK BCON trial, circuit systems for carbogen gas delivery were set up in consultation with the anaesthetics and respiratory teams. TGA exemption was obtained for 98% oxygen and 2% carbon dioxide carbogen gas mixture and delivery apparatus for each patient. Seven patients with histological locally advanced bladder cancer were recruited into this study.

RESULTS

The establishment of a CON department took approximately 24 months. Development of trial protocol was based on the equipment availability in Australia and proper transport, storage and handling of the equipment was guided by local occupational, health and safety (OHS) regulations. All patients received full of dose of CON. Increased urinary frequency, urgency and diarrhoea were the most commonly reported acute bladder and bowel toxicities.

CONCLUSIONS

This is the first study in Australia to demonstrate the feasibility of concurrent CON with radiation therapy. It is a safe and cost-effective treatment that provides a new therapeutic option in the treatment of patients with MIBC, particularly those with limited treatment options.

Elderly patients undergoing cystectomy, comparing preoperative American Society of Anesthesiology and Eastern Cooperative Oncology Group scores and operative approaches

Objective:

To evaluate preoperative scoring systems and operative management and their relation to complications in patients older than 75 years undergoing cystectomy at two academic institutions.

Methods:

In total, 212 patients aged 75–95 years with muscle invasive bladder cancer underwent cystectomy at the University of Utah and Central Hospital of Bolzano, Italy. The rates of Grade 3 Clavien-Dindo complications and above in radical cystectomy patients (n = 199) were compared using Eastern Cooperative Oncology Group Scores and American Society of Anesthesiologists Physical Status Classification. The rates of Grade 3 Clavien-Dindo complications and above were also compared by urinary diversion type. Logistic regression was used to control for source institution.

Results:

In total, 199 cases were included in the primary analysis. Neither of the preoperative scoring systems were predictive for identification of radical cystectomy patients with ⩾Grade 3 Clavien-Dindo complications. In secondary analysis (n = 212, including partial cystectomy), none of the urinary diversion types associated with radical cystectomy had a significantly different rate of complications. However, partial cystectomy (n = 13) had a significantly lower rate of complications.

Conclusion:

Complication rates among elderly patients undergoing cystectomy for muscle invasive bladder cancer were very high. For patients who are approved for surgery after the history and physical exam, none of our objective metrics adequately predicted operative risk. A unique diversion procedure described by the Bolzano group, uretero-ureterocutaneostomy, had equivalent complication rates to the more common diversion procedures. It also appears based on outcomes in this cohort that partial cystectomy is a particularly favorable option within the elderly population in terms of perioperative morbidity.

Current clinical practice guidelines on chemotherapy and radiotherapy for the treatment of non-metastatic muscle-invasive urothelial cancer: a systematic review and critical evaluation by the Hellenic Genito-Urinary Cancer Group (HGUCG)

Radical cystectomy is the treatment of choice in localized muscle-invasive urothelial cancer. Nevertheless, relapses are frequent and systemic chemotherapy has been employed in order to reduce this risk. In addition, bladder preservation strategies are appealing. During the last decade, there has been a difficulty in conducting and completing large-scale trials in urothelial cancer. This has resulted in relatively few changes in the existing guidelines. Recent studies have created renewed interest in certain fields, such as the role of chemo-radiotherapy and management of unfit patients. In addition, application of certain guidelines has been limited in everyday practice. We conducted a systematic review of the existing guidelines and recent randomized trials not included in these guidelines, and developed a treatment algorithm, regarding non-surgical therapies for non-metastatic, muscle-invasive urothelial cancer based predominantly on patients' fitness for the available therapeutic modalities.

Transurethral resection and degeneration of bladder tumour

INTRODUCTION

We evaluate the efficacy and safety of transurethral resection and degeneration of bladder tumour (TURD-Bt).

METHODS

In total, 56 patients with bladder tumour were treated by TURD-Bt. The results in these patients were compared with 32 patients treated by current transurethral resection of bladder tumour (TUR-Bt). Patients with or without disease progressive factors were respectively compared between the 2 groups. The factors included recurrent tumour, multiple tumours, tumour ≥3 cm in diameter, clinical stage T2, histological grade 3, adenocarcinoma, and ureteral obstruction or hydronephrosis.

RESULTS

Follow-up time was 48.55 ± 23.74 months in TURD-Bt group and 56.28 ± 17.61 months in the TUR-Bt group (p > 0.05). In patients without progressive factors, no tumour recurrence was found and overall survival was 14 (100%) in the TURD-Bt group; 3 (37.50%) patients had recurrence and overall survival was 5 (62.5%) in the TUR-Bt group. In patients with progressive factors, 8 (19.05%) patients had tumour recurrence, overall survival was 32 (76.19%) and cancer death was 3 (7.14%) in TURD-Bt group; 18 (75.00%) patients had tumour recurrence (p < 0.05), overall survival was 12 (50.00%) (p < 0.01) and cancer death was 8 (33.33%) (p < 0.05) in TUR-Bt group. No significant complication was found in TURD-Bt group.

CONCLUSION

This study suggests that complete resection and degeneration of bladder tumour can be expected by TURD-Bt. The surgical procedure is safe and efficacious, and could be predictable and controllable before and during surgery. We would conclude that for bladder cancers without lymph node metastasis and distal metastasis, TURD-Bt could be performed to replace radical TUR-Bt and preserve the bladder.

Radiotherapy With Concurrent Carbogen and Nicotinamide in Bladder Carcinoma

Purpose

Phase II clinical studies suggest that hypoxic modification with carbogen and nicotinamide (CON) may increase the efficacy of radiotherapy (RT).

Patients and Methods

Three hundred thirty-three patients with locally advanced bladder carcinoma were randomly assigned to RT alone versus RT with CON. A schedule of either 55 Gy in 20 fractions in 4 weeks or 64 Gy in 32 fractions in 6.5 weeks was used. The primary end point was cystoscopic control at 6 months (CC6m) and secondary end points were overall survival (OS), local relapse-free survival (RFS), urinary and rectal morbidity.

Results

CC6m was 81% for RT + CON and 76% for RT alone (P = .3); however, just more than half of patients underwent cystoscopy at that time. Three-year estimates of OS were 59% and 46% (P = .04) and 3-year estimates of RFS were 54% and 43% (P = .06) for RT + CON versus RT alone. Risk of death was 14% lower with RT + CON (P = .04). In multivariate comparison, RT + CON significantly reduced the risk of relapse (P = .05) and death (P = .03). There was no evidence that differences in late urinary or GI morbidity between treatment groups or between fractionation schedules were significant.

Conclusion

RT + CON produced a small nonsignificant improvement in CC6m. Differences in OS, risk of death, and local relapse were significantly in favor of RT + CON. Late morbidity was similar in both trial arms. Results indicate a benefit of adding CON to radical RT.

Bladder cancer

PURPOSE OF REVIEW

To review the diagnosis and management of all stages of bladder cancer with an emphasis on studies and developments within the last year.

RECENT FINDINGS

Cystoscopy remains the mainstay in the detection and surveillance of bladder cancer, though fluorescent light may enhance detection as well as prolong recurrence-free survival. Urine cytology remains the gold standard for diagnosis and surveillance of bladder cancer; however, there are continued efforts in the development of urinary bladder cancer markers. Transurethral resection and instillation of perioperative chemotherapy remains the treatment of choice for superficial bladder cancer in most patients. Data supports the use of intravesical Bacillus Calmette-Guerin (including a maintenance regimen) for those at high risk for disease progression. Radical cystectomy with thorough pelvic lymphadenectomy remains the gold standard for management of muscle invasive disease. Research on the use of laparoscopy, robot-assisted laparoscopy, the effect on patient's health-related quality of life, and the potential role for bladder preservation strategies is ongoing. The value of neoadjuvant versus adjuvant chemotherapy around the time of cystectomy is still debated, though the best level-one evidence supports the use of neoadjuvant methotrexate, vinblastine, doxorubicin, and cisplatin followed by cystectomy. Platinum-based chemotherapeutic agents are most commonly used in the community setting. Work is ongoing to develop new regimens, especially in patients who cannot take cisplatin. Research in the development of targeted therapies alone or in combination with chemotherapeutic regimens continues and will hopefully broaden our treatment strategy for patients with advanced/metastatic disease.

SUMMARY

We are encouraged by the progress in bladder cancer diagnosis and management; however, continued research is needed in order to improve the lives of our patients with this disease.

The value of bladder-conserving strategies in muscle-invasive bladder carcinoma compared with radical surgery

PURPOSE OF REVIEW

Patients with muscle-invasive bladder cancer will practically all develop progression, often associated with severe side effects including pain, dysuria or macrohematuria. Recent reports demonstrate multimodality bladder-sparing approaches as primary treatment for muscle-invasive bladder cancer.

RECENT FINDINGS

Bladder-conserving strategies include thorough transurethral resection of the bladder tumor, external beam radiation therapy and chemotherapy. It has been shown that survival rates are similar to those of radical cystectomy series; additionally, a substantial number of patients survive with an intact bladder. The high costs, close cooperation between clinical specialists and a highly compliant patient need to be taken into consideration, however.

SUMMARY

Nowadays, the good long-term results after radical cystectomy with the creation of an orthotopic neobladder make the substantial advantage of a bladder-preserving strategy questionable when the patient's quality of life is addressed. Multimodality bladder-conserving strategies are a therapeutic option for selected patients; however, radical cystectomy remains the gold standard of treatment.

Bladder cancer

PURPOSE OF REVIEW

This article reviews the diagnosis and management of bladder cancer with an emphasis on studies and developments over the past year.

RECENT FINDINGS

Cystoscopy remains the mainstay in the detection and surveillance of bladder cancer, though efforts continue in the development of urinary bladder cancer markers. Superficial bladder cancer continues to be managed predominantly through transurethral resection with perioperative instillation of chemotherapy recommended for most patients. Intravesical bacille Calmette-Guerin (including a maintenance regimen) should be used for those at high risk for progression. Muscle invasive disease continues to be managed by radical cystectomy. Research continues on the use of laparoscopy, the effect on patient's health-related quality of life, and the potential role for bladder preservation strategies. The role of neoadjuvant versus adjuvant chemotherapy around the time of cystectomy remains to be resolved. The mainstays of chemotherapy remain methotrexate, vinblastine, doxorubicin, and cisplatin, and gemcitabine and cisplatin, but work is ongoing to develop new regimens, especially in patients who cannot take cisplatin.

SUMMARY

Although great strides continue to be made each year in the diagnosis and management of bladder cancer considerably more work needs to be done in order to improve the lives of our patients with this disease.