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Rutten VC, Salhi Y, Robbrecht GJ, de Wit R, van Leenders GJLH, Zuiverloon TCM, Boormans JL. The CHASIT study: sequential chemo-immunotherapy in patients with locally advanced urothelial cancer - a non-randomized phase II clinical trial. BMC Cancer 2023; 23:539. [PMID: 37312054 DOI: 10.1186/s12885-023-10963-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 05/16/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Patients with locally advanced irresectable or clinically node positive urothelial cancer (UC) have a poor outcome. Currently, these patients can only be cured by receiving induction chemotherapy and, if an adequate radiological response is obtained, radical surgical resection. Long-term survival, however, strongly depends on the absence of residual tumor in the surgical resection specimen, i.e. a pathological complete response (pCR). The reported pCR rate following induction chemotherapy in locally advanced or clinically node-positive UC is 15%. The 5-year overall survival rate for patients achieving a pCR is 70-80% versus 20% for patients who have residual disease or nodal metastases. This clearly demonstrates the unmet need to improve clinical outcome of these patients. Recently, the JAVELIN Bladder 100 study demonstrated an overall survival benefit of sequential chemo-immunotherapy in patients with metastatic UC. The CHASIT study aims to translate these findings to the induction setting by assessing the efficacy and safety of sequential chemo-immunotherapy in patients with locally advanced or clinically node-positive UC. In addition, patient biomaterials are collected to investigate biological mechanisms of response and resistance to chemo-immunotherapy. METHODS This multicenter, prospective phase II clinical trial includes patients with stage cT4NxM0 or cTxN1-N3M0 UC of the bladder, upper urinary tract or urethra. Patients who do not experience disease progression after 3 or 4 cycles of platinum-based chemotherapy are eligible for inclusion. Included patients receive 3 cycles of anti-PD-1 immunotherapy with avelumab followed by radical surgery. Primary endpoint is the pCR rate. It is hypothesized that sequential chemo-immunotherapy results in a pCR rate of ≥ 30%. To obtain a power of 80%, 64 patients are screened and 58 patients are included in the efficacy analysis. Secondary endpoints are toxicity, postoperative surgical complications, progression-free, cancer-specific and overall survival at 24 months. DISCUSSION This is the first study to assess the potential benefit of sequential chemo-immunotherapy in patients with locally advanced or node positive UC. If the primary endpoint of the CHASIT study is met, i.e. a pCR rate of ≥ 30%, a randomized controlled trial is foreseen to compare this new treatment regimen to standard care. TRIAL REGISTRATION NCT05600127 at Clinicaltrials gov, registered on 31/10/2022.
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Affiliation(s)
- V C Rutten
- Department of Urology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Y Salhi
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - G J Robbrecht
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - R de Wit
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - G J L H van Leenders
- Department of Pathology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - T C M Zuiverloon
- Department of Urology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - J L Boormans
- Department of Urology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands.
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Leonardo C, Flammia RS, Lucciola S, Proietti F, Pecoraro M, Bucca B, Licari LC, Borrelli A, Bologna E, Landini N, Del Monte M, Chung BI, Catalano C, Magliocca FM, De Berardinis E, Del Giudice F, Panebianco V. Performance of Node-RADS Scoring System for a Standardized Assessment of Regional Lymph Nodes in Bladder Cancer Patients. Cancers (Basel) 2023; 15:cancers15030580. [PMID: 36765540 PMCID: PMC9913205 DOI: 10.3390/cancers15030580] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/15/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Current cross-sectional imaging modalities exhibit heterogenous diagnostic performances for the detection of a lymph node invasion (LNI) in bladder cancer (BCa) patients. Recently, the Node-RADS score was introduced to provide a standardized comprehensive evaluation of LNI, based on a five-item Likert scale accounting for both size and configuration criteria. In the current study, we hypothesized that the Node-RADS score accurately predicts the LNI and tested its diagnostic performance. METHODS We retrospectively reviewed BCa patients treated with radical cystectomy (RC) and bilateral extended pelvic lymph node dissection, from January 2019 to June 2022. Patients receiving preoperative systemic chemotherapy were excluded. A logistic regression analysis tested the correlation between the Node-RADS score and LNI both at patient and lymph-node level. The ROC curves and the AUC depicted the overall diagnostic performance. In addition, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for different cut-off values (>1, >2, >3, >4). RESULTS Overall, data from 49 patients were collected. Node-RADS assigned on CT scans images, was found to independently predict the LNI after an adjusted multivariable regression analysis, both at the patient (OR 3.36, 95%CI 1.68-9.40, p = 0.004) and lymph node (OR 5.18, 95%CI 3.39-8.64, p < 0.001) levels. Node-RADS exhibited an AUC of 0.87 and 0.91 at the patient and lymph node levels, respectively. With increasing Node-RADS cut-off values, the specificity and PPV increased from 57.1 to 97.1% and from 48.3 to 83.3%, respectively. Conversely, the sensitivity and NPV decreased from 100 to 35.7% and from 100 to 79.1%, respectively. Similar trends were recorded at the lymph node level. Potentially, Node-RADS > 2 could be considered as the best cut-off value due to balanced values at both the patient (77.1 and 78.6%, respectively) and lymph node levels (82.4 and 93.4%, respectively). CONCLUSIONS The current study lays the foundation for the introduction of Node-RADS for the regional lymph-node evaluation in BCa patients. Interestingly, the Node-RADS score exhibited a moderate-to-high overall accuracy for the identification of LNI, with the possibility of setting different cut-off values according to specific clinical scenarios. However, these results need to be validated on larger cohorts before drawing definitive conclusions.
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Affiliation(s)
- Costantino Leonardo
- Department of Maternal Infant and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, 00161 Rome, Italy
| | - Rocco Simone Flammia
- Department of Maternal Infant and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, 00161 Rome, Italy
| | - Sara Lucciola
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University, 00161 Rome, Italy
| | - Flavia Proietti
- Department of Maternal Infant and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, 00161 Rome, Italy
| | - Martina Pecoraro
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University, 00161 Rome, Italy
| | - Bruno Bucca
- Department of Maternal Infant and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, 00161 Rome, Italy
| | - Leslie Claire Licari
- Department of Maternal Infant and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, 00161 Rome, Italy
| | - Antonella Borrelli
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University, 00161 Rome, Italy
| | - Eugenio Bologna
- Department of Maternal Infant and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, 00161 Rome, Italy
| | - Nicholas Landini
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University, 00161 Rome, Italy
| | - Maurizio Del Monte
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University, 00161 Rome, Italy
| | - Benjamin I. Chung
- Department of Urology, Standford University School of Medicine, Standford, CA 94305, USA
| | - Carlo Catalano
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University, 00161 Rome, Italy
| | - Fabio Massimo Magliocca
- Department of Anatomopathological, Oncology and Pathology, Sapienza University, 00161 Rome, Italy
| | - Ettore De Berardinis
- Department of Maternal Infant and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, 00161 Rome, Italy
| | - Francesco Del Giudice
- Department of Maternal Infant and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, 00161 Rome, Italy
- Department of Urology, Standford University School of Medicine, Standford, CA 94305, USA
- Correspondence: or ; Tel.: +39-0649975463; Fax: +39-0649978509
| | - Valeria Panebianco
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University, 00161 Rome, Italy
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Lim AH, Westerman ME, Korokovic A, Matulay JT, Narayan VM, Navai N. Efficacy of Surgery on the Primary Tumour in Patients with Metastatic Bladder Cancer: A Comprehensive Review. Bladder Cancer 2022. [DOI: 10.3233/blc-211529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: The benefit of surgery of the primary tumor in metastatic bladder cancer is unknown. OBJECTIVE: Perform a comprehensive contemporary literature review on the benefit of surgery of the primary tumor in metastatic bladder cancer. METHODS: Ovid MEDLINE, Ovid EMBASE, and Cochrane Library from January 1, 1990 to April 20, 2020 were queried for relevant articles published in English. Each article was evaluated by at least two content experts prior to inclusion which were blinded to the other’s evaluation. A third content expert was used when there was not a unanimous decision. Additional articles were added at the discretion of the authors. RESULTS: Long-term survival is possible in patients with initially unresectable and/or limited metastatic disease. Multi-modal therapy with chemotherapy and surgery have the most favorable outcomes when compared to single treatment modalities in selected populations. Patients who demonstrate a robust response to pre-surgical therapy are likely to benefit the most from consolidative surgery. Patients with distant metastatic disease may benefit from consolidative surgery; however, this benefit may only be seen in those with metastatic disease limited to one site. CONCLUSIONS: Surgery of the primary tumor in metastatic bladder cancer either in the setting of surgery alone, consolidative therapy or coupled with adjuvant therapy may be beneficial in well selected patients and should generally be limited to those who have a response to primary chemotherapy. Randomized clinical control trials are needed to further our understanding of the role of surgery in metastatic bladder cancer. Systematic Review Registration number: CRD42020182861
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Affiliation(s)
- Amy H. Lim
- Department of Urology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Mary E. Westerman
- Department of Urology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Andrea Korokovic
- Department of Urology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Justin T. Matulay
- Department of Urology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Vikram M. Narayan
- Department of Urology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Neema Navai
- Department of Urology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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Koerber SA, Fink CA, Dendl K, Schmitt D, Niegisch G, Mamlins E, Giesel FL. [Imaging of oligometastatic disease in selected urologic cancers]. Urologe A 2021; 60:1561-1569. [PMID: 34850260 DOI: 10.1007/s00120-021-01708-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Local treatment of the primary or metastatic sites in urologic malignancies is promising when compared to systemic therapy alone, leading to the definition of a potentially curative oligometastatic state. OBJECTIVES Comparison of imaging modalities regarding local and metastatic tumor sites in urologic cancers. METHODS Review of comparative trials addressing quality criteria of imaging modalities. RESULTS Depending on primary tumor and metastatic site, conventional imaging modalities such as computer tomography (CT) and bone scintigraphy still represent the standard of care in Germany. Due to superior quality criteria, hybrid-imaging techniques were widely adopted for oncological staging and particular due to the new PSMA-ligand (PSMA-PET/CT) in prostate cancer imaging. The development of new radioisotopes as well as their clinical application remains a focus of current research. CONCLUSIONS High-quality diagnostic imaging modalities lay the groundwork for a precise definition of an oligometastatic state. By enabling treatment of the entire tumor burden, a delay of systemic therapy, longer progression-free survival, or even curative treatment may become achievable.
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Affiliation(s)
- S A Koerber
- Klinik für Radioonkologie und Strahlentherapie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C A Fink
- Klinik für Radioonkologie und Strahlentherapie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - K Dendl
- Klinik für Nuklearmedizin, Universitätsklinikum Düsseldorf, Medizinische Fakultät, Heinrich-Heine-Universität, Moorenstraße 5, 40225, Düsseldorf, Deutschland.,Klinik für Nuklearmedizin, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - D Schmitt
- Klinik für Nuklearmedizin, Universitätsklinikum Düsseldorf, Medizinische Fakultät, Heinrich-Heine-Universität, Moorenstraße 5, 40225, Düsseldorf, Deutschland
| | - G Niegisch
- Klinik für Urologie, Medizinische Fakultät, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
| | - E Mamlins
- Klinik für Nuklearmedizin, Universitätsklinikum Düsseldorf, Medizinische Fakultät, Heinrich-Heine-Universität, Moorenstraße 5, 40225, Düsseldorf, Deutschland
| | - F L Giesel
- Klinik für Nuklearmedizin, Universitätsklinikum Düsseldorf, Medizinische Fakultät, Heinrich-Heine-Universität, Moorenstraße 5, 40225, Düsseldorf, Deutschland.
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Impact of preoperative chemotherapy on pathologic nodal status in muscle-invasive bladder cancer: optimal lymphadenectomy in the preoperative chemotherapy era. J Cancer Res Clin Oncol 2021; 148:2507-2515. [PMID: 34557987 DOI: 10.1007/s00432-021-03789-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/01/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To investigate the impact of preoperative chemotherapy (pCTX) on pathologic nodal (pN) status and evaluate the optimal lymphadenectomy method according to clinical nodal (cN) status in patients with muscle-invasive bladder cancer who received pCTX. MATERIALS AND METHODS We retrospectively reviewed 449 patients with muscle-invasive bladder cancer who underwent radical cystectomy. Among them, 139 (31.0%) received pCTX. We analyzed overall survival among three groups (cN-pCTX-, cN-pCTX+, and cN+pCTX+); the impact of lymphadenectomy extent according to the history of pCTX in cN- patients (n = 393); and the pN status which includes number of positive lymph nodes, and lymph node density in cN- patients who underwent extended lymphadenectomy (n = 222). RESULTS Overall survival was significantly dependent on cN status, and pCTX had no survival advantage although it decreased the percentage of pN+ patients and the number of positive lymph nodes in cN- patients. Lymph node density showed a significant prognostic effect on overall survival in Cox regression analysis both in cN- and cN+ patients. In cN- patients, there was no significant survival difference according to lymphadenectomy extent regardless of receiving pCTX. CONCLUSIONS pCTX can control micrometastases but not overt metastases, despite decreasing the number of positive lymph nodes in patients with muscle-invasive bladder cancer. Although extended lymphadenectomy is a reasonable diagnostic strategy in the pCTX era, standard dissection is as therapeutic as extended dissection in patients with cN- disease.
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Management of Clinically Regional Node-Positive Urothelial Carcinoma of the Bladder. Curr Oncol Rep 2021; 23:24. [PMID: 33559760 DOI: 10.1007/s11912-021-01018-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2021] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Clinically regional node-positive (cN+) urothelial carcinoma of the bladder requires a multi-modal management approach amidst growing recognition that it represents a spectrum of disease. Herein, we review the contemporary evidence for the natural history, evaluation, and management of clinically regional node-positive urothelial carcinoma of the bladder, highlighting recent changes in lymph node staging. RECENT FINDINGS Despite advances in techniques, cross-sectional imaging remains relatively insensitive for the detection of lymph node metastases. Recent changes to nodal staging that distinguish between cN1, cN2-3, and non-regional lymph node metastases reflect an increasing understanding that node-positive disease is heterogeneous and its management must be individualized according to nodal staging. Systemic therapy remains the initial management strategy, either alone or in conjunction with radiotherapy, with choice and sequencing of agents extrapolated from studies of metastatic disease. Consolidative radical cystectomy is an option for patients with disease response to upfront systemic therapy, and several series demonstrate a subset of patients with favorable oncologic outcomes. The comparative effectiveness of radiotherapy and radical cystectomy as local therapy remains an important evidence gap. Future studies that identify predictive biomarkers will help inform optimal choice of systemic therapy. The management of clinically regional node-positive disease requires a multimodal approach comprising both systemic and local therapy, tailored to the patient and to disease response. While choice of systemic therapy will be informed by ongoing studies in patients with metastatic disease, including the elucidation of predictive biomarkers, the comparative effectiveness of local therapies remains an important evidence gap.
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Le Goux C, Neuzillet Y, Rouanne M, Gachet J, Staub F, Hervé JM, Yonneau L, Abdou A, Ghoneim T, Théodore C, Lebret T. Prognosis of patients receiving induction chemotherapy for locally advanced or lymph node metastatic bladder cancer. JOURNAL OF CLINICAL UROLOGY 2020. [DOI: 10.1177/2051415819895865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Induction chemotherapy is recommended before surgery for unresectable muscle-invasive bladder cancer, locally advanced or lymph node disseminated disease. These patients’ prognoses cannot be extrapolated from data regarding neoadjuvant chemotherapy, which is performed in operable patients. Objective: We assessed the prognosis of patients undergoing induction chemotherapy for locally advanced or lymph node metastatic bladder cancer. Methods: We analysed patients with cT4NxM0 or cTxN+M0 bladder cancer treated by induction chemotherapy between 2006 and 2016. The tumour extension and node invasion was determined by imaging or histologically after upfront lymph node dissection. Clinical, biological, pathological and patient follow-up data were identified. Kaplan–Meier survival curves were compared by log rank test. Factors associated with the response to induction chemotherapy, operability of patients and survival were determined by multivariable logistic regression. Results: Among 70 patients included in the analysis, 51 (73%) showed response to induction chemotherapy. Progression-free and overall survival were improved in responder patients compared with non-responders ( P<0.0001 and P=0.025, respectively) and for patients who underwent surgery compared with non-operated patients (both P<0.001). On multivariable analysis, poor response was associated with chemotherapy other than methotrexate, vinblastine, doxorubicin and cisplatin ( P=0.016), operability with late response ( P=0.0024) and overall survival with surgery after induction chemotherapy ( P=0.0014). Conclusions: Surgery after induction chemotherapy with methotrexate, vinblastine, doxorubicin and cisplatin may improve prognosis with locally advanced or lymph node metastatic bladder cancer. Level of evidence: 4
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Affiliation(s)
- Constance Le Goux
- Service d’Urologie, Université de Versailles – Saint-Quentin-en-Yvelines, France
- Department of Urology, Hôpital Foch, France
| | - Yann Neuzillet
- Service d’Urologie, Université de Versailles – Saint-Quentin-en-Yvelines, France
- Department of Urology, Hôpital Foch, France
| | - Mathieu Rouanne
- Service d’Urologie, Université de Versailles – Saint-Quentin-en-Yvelines, France
- Department of Urology, Hôpital Foch, France
| | - Julie Gachet
- Service d’Urologie, Université de Versailles – Saint-Quentin-en-Yvelines, France
- Service d’Oncologie, Université de Versailles – Saint-Quentin-en-Yvelines, France
| | - Fabrice Staub
- Service d’Urologie, Université de Versailles – Saint-Quentin-en-Yvelines, France
- Service de Radiologie, Université de Versailles – Saint-Quentin-en-Yvelines, France
| | | | | | - Ali Abdou
- Department of Urology, Hôpital Foch, France
| | | | - Christine Théodore
- Service d’Urologie, Université de Versailles – Saint-Quentin-en-Yvelines, France
- Service d’Oncologie, Université de Versailles – Saint-Quentin-en-Yvelines, France
| | - Thierry Lebret
- Service d’Urologie, Université de Versailles – Saint-Quentin-en-Yvelines, France
- Department of Urology, Hôpital Foch, France
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Ghodoussipour S, Xu W, Tran K, Atkinson R, Cho D, Miranda G, Cai J, Bhanvadia S, Schuckman A, Daneshmand S, Djaladat H. Preoperative chemotherapy in clinically node positive muscle invasive bladder cancer: Radiologic variables can predict response. Urol Oncol 2020; 39:133.e1-133.e8. [PMID: 32900621 DOI: 10.1016/j.urolonc.2020.08.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 07/31/2020] [Accepted: 08/10/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To evaluate pathologic downstaging after radical cystectomy and pelvic lymph node dissection for clinically lymph node positive urothelial bladder cancer and to determine optimal preoperative imaging variables in predicting pathologic nodal status. METHODS We identified all patients with clinically lymph node positive urothelial bladder cancer who underwent radical cystectomy and extended pelvic lymph node dissection with intent to cure at our institution. Patients were stratified based on pathologic node status to determine clinical associations and survival outcomes. Pre and post-chemotherapy CT scans were reviewed to characterize lymph node size and morphology. We also sought to determine associations between post-chemotherapy radiology variables and pathologic response. RESULTS We identified 130 patients with clinically node positive bladder cancer, out of which 76 (58.5%) received induction chemotherapy. Thirty three (43.4%) had pathologic T downstaging following chemotherapy, compared to 7 (12.9%) patients who had surgery alone (P< 0.0001). A complete nodal response (pN0) occurred in 31 (40.8%) patients post-chemotherapy, while 6 (11.1%) of those who received cystectomy alone ended up being pN0 (P< 0.0001). Median overall survival and recurrence-free survival were shorter in patients with pN+ versus pN0 disease (1.9 years vs. 12.8 years, P= 0.016 and 1.2 years vs. 4.3 years, P= 0.013, respectively). Review of 29 post chemotherapy CT scans showed that patients with pathologic nodal involvement had a greater median number of enlarged nodes (3.5 vs. 1, P= 0.038) and a greater median size of largest node (8.5 mm vs. 6.0 mm, P= 0.021) on imaging compared to those with complete pN0. Each 1 mm increase in size of the largest node on post-chemotherapy CT scan increased the chance of having pN+ disease by 1.57 (95% CI 1.02-2.44, P= 0.043). Using a median node size of 8 mm as a cut-off to predict pN+ disease provided a sensitivity and specificity of 72% and 80%, respectively (c-index = 0.761, P= 0.014). The positive predictive value for this cut-off was 87% (95% CI 58%-98%) and negative predictive value was 62% (32%-85%). CONCLUSION Patients with clinically node positive bladder cancer may have significant pN0 after induction chemotherapy. Our data suggest a post-chemotherapy CT scan with an 8 mm nodal size cut-off may be a better predictor of pathologic nodal status than more traditional measures.
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Affiliation(s)
- Saum Ghodoussipour
- Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA.
| | - Willem Xu
- Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Khoa Tran
- Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Ryan Atkinson
- Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Diana Cho
- Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Gus Miranda
- Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Jie Cai
- Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Sumeet Bhanvadia
- Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Anne Schuckman
- Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Siamak Daneshmand
- Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Hooman Djaladat
- Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
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Aljabery F, Liedberg F, Häggström C, Ströck V, Hosseini A, Gårdmark T, Sherif A, Jerlström T, Malmström PU, Holmberg L, Hagberg O, Jahnson S. Management and outcome of muscle-invasive bladder cancer with clinical lymph node metastases. A nationwide population-based study in the bladder cancer data base Sweden (BladderBaSe). Scand J Urol 2019; 53:332-338. [DOI: 10.1080/21681805.2019.1681504] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Firas Aljabery
- Department of Clinical and Experimental Medicine, Division of Urology, Linköping University, Linköping, Sweden
| | - Fredrik Liedberg
- Department of Urology, Skåne University Hospital, Malmö, Sweden
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Christel Häggström
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Department of Biobank Research, Umeå University, Umeå, Sweden
| | - Viveka Ströck
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Urology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Abolfazl Hosseini
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Truls Gårdmark
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - Amir Sherif
- Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, Umeå, Sweden
| | - Tomas Jerlström
- Department of Urology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Per-Uno Malmström
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Lars Holmberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- School of Medicine, King´s College London, London, UK
| | - Oskar Hagberg
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Staffan Jahnson
- Department of Clinical and Experimental Medicine, Division of Urology, Linköping University, Linköping, Sweden
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Al-Alao O, Mueller-Leonhard C, Kim SP, Amin A, Tucci C, Kott O, Mega A, Golijanin D, Gershman B. Clinically node-positive (cN+) urothelial carcinoma of the bladder treated with chemotherapy and radical cystectomy: Clinical outcomes and development of a postoperative risk stratification model. Urol Oncol 2019; 38:76.e19-76.e28. [PMID: 31590968 DOI: 10.1016/j.urolonc.2019.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 08/05/2019] [Accepted: 09/04/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION AND OBJECTIVE Although node-positive (cN+) bladder cancer is considered Stage IV disease, a subset of patients is treated with chemotherapy and consolidative radical cystectomy (RC). We examined the clinical outcomes of such patients and developed a risk prediction model to facilitate risk-stratification and management. METHODS We identified adult patients with cTany cN1-3 M0 urothelial carcinoma of the bladder treated with chemotherapy followed by RC from 2006 to 2013 in the NCDB. The associations of clinicopathologic features with overall survival (OS) were evaluated using Cox regression, and a simplified risk score was developed. RESULTS A total of 491 patients received chemotherapy followed by RC. Median number of lymph nodes removed was 16 (interquartile range 9-25). At RC, 10% of patients were ypT0, and 35% were ypN0. Over a median follow-up of 18.7 months, 160 patients died of any cause. 1-, 5-, and 8-year OS were 69%, 34%, and 29%, respectively. On multivariable analysis, pT stage (hazard ratio [HR] 2.18; P = 0.003 for pT3, HR 2.65; P < 0.001 for pT4 vs. <pT2) and pN stage (HR 1.77; P = 0.02 for pN1; HR 2.58; P < 0.001 for pN2; HR 5.09; P < 0.001 for pN3 vs. pN0) were independently associated with worse OS. A risk score was developed based on pT and pN stages, with 5-year OS of 59%, 24%, and 10% for risk score groups of 0-1, 2, and ≥3 points. CONCLUSIONS Survival for patients with cN+ bladder cancer treated with chemotherapy and RC is highly variable, ranging from 10% to 59% at 5 years. A risk score can facilitate postoperative risk-stratification and selection of patients for adjuvant therapy.
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Affiliation(s)
- Osama Al-Alao
- Minimally Invasive Urology Institute, The Miriam Hospital, Providence, RI; Division of Urology, Rhode Island Hospital and The Miriam Hospital, Providence, RI
| | | | - Simon P Kim
- University of Colorado Anschutz Medical Center, Division of Urology, Aurora, CO
| | - Ali Amin
- Warren Alpert Medical School of Brown University, Providence, RI; Department of Pathology and Laboratory Medicine, The Miriam Hospital, Providence, RI
| | - Christopher Tucci
- Minimally Invasive Urology Institute, The Miriam Hospital, Providence, RI; Division of Urology, Rhode Island Hospital and The Miriam Hospital, Providence, RI
| | - Ohad Kott
- Minimally Invasive Urology Institute, The Miriam Hospital, Providence, RI; Division of Urology, Rhode Island Hospital and The Miriam Hospital, Providence, RI
| | - Anthony Mega
- Warren Alpert Medical School of Brown University, Providence, RI; Department of Hematology/Oncology, The Miriam Hospital, Providence, RI
| | - Dragan Golijanin
- Minimally Invasive Urology Institute, The Miriam Hospital, Providence, RI; Division of Urology, Rhode Island Hospital and The Miriam Hospital, Providence, RI; Warren Alpert Medical School of Brown University, Providence, RI
| | - Boris Gershman
- Division of Urologic Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
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11
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Warren M, Kolinsky M, Canil CM, Czaykowski P, Sridhar SS, Black PC, Booth CM, Kassouf W, Eapen L, Mukherjee SD, Blais N, Eigl BJ, Winquist E, Basappa NS, North SA. Canadian Urological Association/Genitourinary Medical Oncologists of Canada consensus statement: Management of unresectable locally advanced and metastatic urothelial carcinoma. Can Urol Assoc J 2019; 13:318-327. [PMID: 31059420 PMCID: PMC6788915 DOI: 10.5489/cuaj.6015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Mark Warren
- Department of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada
- Cancer Center, Bendigo Health, Bendigo, Australia
| | - Michael Kolinsky
- Department of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada
- University of Alberta, Edmonton, AB, Canada
| | - Christina M. Canil
- The Ottawa Hospital Cancer Center, Ottawa, ON Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Piotr Czaykowski
- Cancer Care Manitoba, Winnipeg, MB, Canada
- University of Manitoba, Winnipeg, MB, Canada
| | - Srikala S. Sridhar
- Division of Hematology and Medical Oncology, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Peter C. Black
- Department of Urological Sciences, University of British Columbia, Vancouver, BC, Canada
| | | | - Wassim Kassouf
- Department of Surgery, McGill University Health Center, Montreal, QC, Canada
| | - Libni Eapen
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Radiation Oncology, University of Ottawa, ON, Canada
| | | | - Normand Blais
- Division of Medical Oncology/Hematology, Centre Hospitalier de l’ Université de Montréal, Montreal, Quebec, Canada
| | - Bernhard J. Eigl
- BC Cancer, Vancouver, BC, Canada, University of British Columbia, BC, Canada
| | - Eric Winquist
- Division of Medical Oncology, Western University and London Health Sciences Center, London, ON, Canada
| | - Naveen S. Basappa
- Department of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada
- University of Alberta, Edmonton, AB, Canada
| | - Scott A. North
- Department of Medical Oncology, Cross Cancer Institute, Edmonton, AB, Canada
- University of Alberta, Edmonton, AB, Canada
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12
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Zabell J, Konety B. Is adjuvant chemotherapy better than neoadjuvant chemotherapy for those with node positive disease? Transl Androl Urol 2019; 7:S751-S752. [PMID: 30687616 PMCID: PMC6323291 DOI: 10.21037/tau.2018.08.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Joseph Zabell
- Department of Urology, University of Minnesota, Minneapolis, MN, USA
| | - Badrinath Konety
- Department of Urology, University of Minnesota, Minneapolis, MN, USA
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13
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Cattaneo F, Motterle G, Zattoni F, Morlacco A, Dal Moro F. The Role of Lymph Node Dissection in the Treatment of Bladder Cancer. Front Surg 2018; 5:62. [PMID: 30349822 PMCID: PMC6187970 DOI: 10.3389/fsurg.2018.00062] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 09/17/2018] [Indexed: 11/13/2022] Open
Abstract
Lymph node dissection (LND; PLND: pelvic LND) is an essential component of radical cystectomy (RC) for bladder cancer (BC). However, the optimal anatomical extent of LND and its potential therapeutic role are still controversial: as we will explain, the extent of LND dissection is a predictor of survival and local recurrence but what is an adequate extension is still unclear. Moreover, there is large uncertainty about the role of surgery in patients with clinically-positive nodes. In this review we will provide a synthesis of the available evidence on this highly debated topic. Overall, the studies presented in this work support the idea that extended lymphadenectomy could provide optimal diagnostic and possibly therapeutic results in cN- patients. In cN+ patients, post chemotherapy surgery may be considered especially in subjects who have a good response to CHT, although definitive evidence is still needed. Finally, the final results of randomized trials are eagerly awaited to draw definitive conclusions of the role of PLND in BC.
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Affiliation(s)
- Francesco Cattaneo
- Clinica Urologica, Dipartimento di Scienze Chirurgiche, Oncologiche e Gastroenterologiche, Università degli Studi di Padova, Padova, Italy
| | - Giovanni Motterle
- Clinica Urologica, Dipartimento di Scienze Chirurgiche, Oncologiche e Gastroenterologiche, Università degli Studi di Padova, Padova, Italy
| | - Filiberto Zattoni
- Clinica Urologica, Dipartimento di Scienze Chirurgiche, Oncologiche e Gastroenterologiche, Università degli Studi di Padova, Padova, Italy
| | - Alessandro Morlacco
- Clinica Urologica, Dipartimento di Scienze Chirurgiche, Oncologiche e Gastroenterologiche, Università degli Studi di Padova, Padova, Italy
| | - Fabrizio Dal Moro
- Clinica Urologica, Dipartimento di Scienze Chirurgiche, Oncologiche e Gastroenterologiche, Università degli Studi di Padova, Padova, Italy.,Clínica Urologica, Ospedale "Santa Maria della Misericordia", Università di Udine, Udine, Italy
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14
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Cha EK, Sfakianos JP, Sukhu R, Yee AM, Sjoberg DD, Bochner BH. Poor prognosis of bladder cancer patients with occult lymph node metastases treated with neoadjuvant chemotherapy. BJU Int 2018; 122:627-632. [PMID: 29633530 DOI: 10.1111/bju.14242] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To characterise the outcomes of neoadjuvant chemotherapy (NAC) pre-treated patients found to be lymph node (LN)-positive at the time of radical cystectomy and pelvic lymph node dissection (RC/PLND) for urothelial carcinoma of the bladder (UCB). PATIENTS AND METHODS Of 1484 patients treated with RC/PLND for UCB from 2000 to 2010, we analysed 198 patients with clinically non-metastatic (cN0M0) muscle-invasive UCB who were found to be LN-positive at RC/PLND. As patients not receiving perioperative chemotherapy were significantly older and comorbid, we compared LN-positive patients previously treated with NAC (32 patients) to LN-positive patients treated with adjuvant chemotherapy (AC, 49 patients) using Cox proportional hazards models. A sensitivity analysis was designed to account for the additional time to RC in NAC patients. RESULTS The 3-year recurrence-free survival estimate for LN-positive NAC patients was 26%, compared with 60% for LN-positive AC patients. LN-positive patients treated with NAC had significantly higher risks of disease recurrence and cancer-specific mortality in univariate analyses (hazard ratio [HR] 2.86, 95% confidence interval [CI] 1.58-5.19, P = 0.001 and HR 2.50, 95% CI 1.34-4.65, P = 0.004, respectively) and multivariable analyses adjusting for pathological stage and LN density (HR 3.11, 95% CI 1.59-6.07, P = 0.001 and HR 3.05, 95% CI 1.46-6.35, P = 0.003, respectively). Sensitivity analyses similarly demonstrated worse outcomes for NAC pre-treated LN-positive patients. CONCLUSION LN-positive patients previously treated with NAC have a poor prognosis, significantly worse than LN-positive patients subsequently treated with AC, and should be considered for protocols using sandwich chemotherapy approaches or novel agents. These results should be considered in the interpretation of and stratification for clinical trials.
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Affiliation(s)
- Eugene K Cha
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ranjit Sukhu
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alyssa M Yee
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bernard H Bochner
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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15
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Li R, Metcalfe M, Kukreja J, Navai N. Role of Radical Cystectomy in Non-Organ Confined Bladder Cancer: A Systematic Review. Bladder Cancer 2018; 4:31-40. [PMID: 29430505 PMCID: PMC5798530 DOI: 10.3233/blc-170130] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background: Currently, a diagnosis of non-organ confined bladder cancer (NOCBCa) confers a grave prognosis. The mainstay of treatment consists of systemic chemotherapy. However, it must be recognized that NOCBCa is a heterogeneous disease state with important clinical distinctions. While surgical extirpation has traditionally been regarded as overly aggressive for all NOCBCa patients, its utility as part of a multimodal treatment strategy in various clinical scenarios has not been thoroughly investigated. Objective: To perform a review of the literature regarding the role of radical cystectomy and pelvic lymph node dissection (RC-LND) in the setting of NOCBCa. Methods: Medline, and Pubmed electronic database were queried for English language articles from January 1990 to Nov 2016 on RC-LND for cT4, lymph node positive, and metastatic urothelial cancer. NOCBCa was separated into four distinct clinical scenarios: 1. Locally advanced/unresectable disease (cT4bN0M0); 2. Occult pelvic nodal disease (pN+) (cTxN0M0 and pTxN1-3Mx); 3. Clinical node positive disease (cN+) (cTxN1-3M0); and 4. Distant metastatic disease (TxNxM1). Evidence for the role of RC-LND in each of these clinical scenarios was summarized. Results: cT4b may be more effectively treated by presurgical chemotherapy (PSC) than other forms of NOCBCa. Although clinical response predicted improved survival, surgical factors, such as surgical margin status may also play a role in determining outcomes. In well selected patients, 5-year CSS may reach 60% after consolidative RC-LND. Survival in patients found to have pathologic nodal metastases without PSC was dictated not only by the histologically verified metastatic nodal disease burden, but also by the meticulousness of the lymph node dissection. In these patients, adjuvant chemotherapy may improve survival. On the other hand, in patients undergoing RC-LND after PSC, pathologic complete response (pCR) was the strongest predictor of improved CSS. The results of population based studies have suggested a therapeutic role by consolidative RC-LND in both patients with cN+ and metastatic BCa (mBCa). For the cN+ population, 5-year OS was 31% in patients undergoing RC-LND after PSC vs. 14% in those receiving chemotherapy alone. Similarly, consolidative intensive local therapy improved OS by approximately 5 months in patients with mBCa. Metastasectomy has also been shown to be effective in small retrospective series and may especially be useful in patients with solitary pulmonary lesions. Conclusions: Extirpative treatment of the primary tumor may be an important step in the management of de novo NOCBCa. The current retrospective and population based studies have demonstrated improved survival outcomes in patients with NOCBCa following RC-LND, especially in those with favorable response to PSC. With the advent of minimally invasive surgery and the enhanced post-surgical recovery protocols, RC-LND has not only been demonstrated to be feasible, but also tolerable in the setting of advanced BCa. Well designed, prospective trials are needed to definitively assess the value of surgical extirpation for NOCBCa patients.
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Affiliation(s)
- Roger Li
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael Metcalfe
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Janet Kukreja
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Neema Navai
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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16
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Abufaraj M, Dalbagni G, Daneshmand S, Horenblas S, Kamat AM, Kanzaki R, Zlotta AR, Shariat SF. The Role of Surgery in Metastatic Bladder Cancer: A Systematic Review. Eur Urol 2017; 73:543-557. [PMID: 29122377 DOI: 10.1016/j.eururo.2017.09.030] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/28/2017] [Indexed: 12/27/2022]
Abstract
CONTEXT The role of surgery in metastatic bladder cancer (BCa) is unclear. OBJECTIVE In this collaborative review article, we reviewed the contemporary literature on the surgical management of metastatic BCa and factors associated with outcomes to support the development of clinical guidelines as well as informed clinical decision-making. EVIDENCE ACQUISITION A systematic search of English language literature using PubMed-Medline and Scopus from 1999 to 2016 was performed. EVIDENCE SYNTHESIS The beneficial role of consolidation surgery in metastatic BCa is still unproven. In patients with clinically evident lymph node metastasis, data suggest a survival advantage for patients undergoing postchemotherapy radical cystectomy with lymphadenectomy, especially in those with measurable response to chemotherapy (CHT). Intraoperatively identified enlarged pelvic lymph nodes should be removed. Anecdotal reports of resection of pulmonary metastasis as part of multimodal approach suggest possible improved survival in well-selected patients. Cytoreductive radical cystectomy as local treatment has also been explored in patients with metastatic disease, although its benefits remain to be assessed. CONCLUSIONS Consolidative extirpative surgery may be considered in patients with clinically evident pelvic or retroperitoneal lymph nodal metastases but only if they have had a response to CHT. Surgery for limited pulmonary metastases may also be considered in very selected cases. Best candidates are those with resectable disease who demonstrate measurable response to CHT with good performance status. In the absence of data from prospective randomized studies, each patient should be evaluated on an individual basis and decisions made together with the patient and multidisciplinary teams. PATIENT SUMMARY Surgical resection of metastases is technically feasible and can be safely performed. It may help improve cancer control and eventually survival in very selected patients with limited metastatic burden. In a patient who is motivated to receive chemotherapy and to undergo extirpative surgical intervention, surgery should be discussed with the patient among other consolidation therapies in the setting of multidisciplinary teams.
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Affiliation(s)
- Mohammad Abufaraj
- Department of Urology, Medical University of Vienna, Vienna, Austria; Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan
| | - Guido Dalbagni
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Siamak Daneshmand
- Institute of Urology, University of Southern California/ Norris Comprehensive Cancer Center, Los Angeles, CA, USA
| | - Simon Horenblas
- Department of Surgical Oncology, Division of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Ashish M Kamat
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ryu Kanzaki
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Alexandre R Zlotta
- Department of Surgery, Division of Urology, University of Toronto, Mount Sinai Hospital and University Health Network, Toronto, ON, Canada
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna, Austria; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Urology, Weill Cornell Medical College, New York, NY, USA.
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17
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Abufaraj M, Gust K, Moschini M, Foerster B, Soria F, Mathieu R, Shariat SF. Management of muscle invasive, locally advanced and metastatic urothelial carcinoma of the bladder: a literature review with emphasis on the role of surgery. Transl Androl Urol 2016; 5:735-744. [PMID: 27785430 PMCID: PMC5071186 DOI: 10.21037/tau.2016.08.23] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Locally advanced (T3b, T4 and N1-N3) and metastatic urothelial bladder cancer (BCa) is a lethal disease with poor survival outcomes. Combination chemotherapy remains the treatment of choice in patients with metastatic disease and an important part of treatment in addition to radical cystectomy (RC) in patients with locally advanced tumour. Approximately half of patients who underwent RC for muscle invasive BCa relapse after surgery with either local recurrence or distant metastasis. This review focuses on the management of muscle invasive, locally advanced and metastatic BCa with emphasis on the role of surgery; to summarize the current knowledge in order to enhance clinical decision-making and counselling process.
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Affiliation(s)
- Mohammad Abufaraj
- Department of Urology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Kilian Gust
- Department of Urology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria; ; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria
| | - Marco Moschini
- Department of Urology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria; ; Department of Urology, Urological Research Institute, Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy
| | - Beat Foerster
- Department of Urology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria; ; Department of Urology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Francesco Soria
- Department of Urology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria; ; Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Studies of Torino, Turin, Italy
| | - Romain Mathieu
- Department of Urology, Rennes University Hospital, Rennes, France
| | - Shahrokh F Shariat
- Department of Urology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria; ; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria; ; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; ; Department of Urology, Weill Cornell Medical College, New York, NY, USA
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18
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Upper tract urothelial carcinoma topical issue 2016: treatment of metastatic cancer. World J Urol 2016; 35:367-378. [PMID: 27342991 DOI: 10.1007/s00345-016-1885-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 06/15/2016] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To review the management of metastatic upper tract urothelial carcinoma (UTUC) including recent advances in targeted and immune therapies as an update to the 2014 joint international consultation on UTUC, co-sponsored by the Société Internationale d'Urologie and International Consultation on Urological Diseases. METHODS A PubMed database search was performed between January 2013 and May 2016 related to the treatment of metastatic UTUC, and 54 studies were selected for inclusion. RESULTS The management of patients with metastatic UTUC is primarily an extrapolation from evidence guiding the management of metastatic urothelial carcinoma of the bladder. The first-line therapy for metastatic UTUC is platinum-based combination chemotherapy. Standard second-line therapies are limited and ineffective. Patients with UTUC who progress following platinum-based chemotherapy are encouraged to participate in clinical trials. Recent advances in genomic profiling present exciting opportunities to guide the use of targeted therapy. Immunotherapy with checkpoint inhibitors has demonstrated extremely promising results. Retrospective studies provide support for post-chemotherapy surgery in appropriately selected patients. CONCLUSIONS The management of metastatic UTUC requires a multi-disciplinary approach. New insights from genomic profiling using targeted therapies, novel immunotherapies, and surgery represent promising avenues for further therapeutic exploration.
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19
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Ho PL, Willis DL, Patil J, Xiao L, Williams SB, Melquist JJ, Tart K, Parikh S, Shah JB, Delacroix SE, Navai N, Siefker-Radtke A, Dinney CP, Pisters LL, Kamat AM. Outcome of patients with clinically node-positive bladder cancer undergoing consolidative surgery after preoperative chemotherapy: The M.D. Anderson Cancer Center Experience. Urol Oncol 2016; 34:59.e1-8. [DOI: 10.1016/j.urolonc.2015.08.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 07/28/2015] [Accepted: 08/24/2015] [Indexed: 01/31/2023]
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20
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Urakami S, Okaneya T. Editorial Comment to Effect of preoperative chemotherapy on survival of patients with upper urinary tract urothelial carcinoma clinically involving regional lymph nodes. Int J Urol 2015; 23:158-9. [PMID: 26663568 DOI: 10.1111/iju.13030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Shinji Urakami
- Department of Urology, Toranomon Hospital, Tokyo, Japan.
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21
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Delacroix S, Lawrentschuk N, Kamat AM. The role of radical cystectomy in patients with unresectable or regionally metastatic urothelial carcinoma of the bladder. Bladder Cancer 2015. [DOI: 10.1002/9781118674826.ch17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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22
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Zargar-Shoshtari K, Zargar H, Lotan Y, Shah JB, van Rhijn BW, Daneshmand S, Spiess PE, Black PC. A Multi-Institutional Analysis of Outcomes of Patients with Clinically Node Positive Urothelial Bladder Cancer Treated with Induction Chemotherapy and Radical Cystectomy. J Urol 2015. [PMID: 26205531 DOI: 10.1016/j.juro.2015.07.085] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE Selected patients with bladder cancer with pelvic lymphadenopathy (cN1-3) are treated with induction chemotherapy followed by radical cystectomy. However, the data on clinical outcomes in these patients are limited. In this study we assess pathological and survival outcomes in patients with cN1-3 disease treated with induction chemotherapy and radical cystectomy. MATERIALS AND METHODS Data were collected on patients from 19 North American and European centers with cT1-4aN1-N3 urothelial carcinoma who received chemotherapy followed by radical cystectomy between 2000 and 2013. The primary end points were pathological complete (pT0N0) and partial (pT1N0 or less) response rates, with overall survival as a secondary end point. Logistic regression and Cox proportional hazard ratios were used for multivariate analysis of factors predicting these outcomes. RESULTS The total of 304 patients had clinical evidence of lymph node involvement (cN1-N3). Methotrexate/vinblastine/doxorubicin/cisplatin was used in 128 (42%), gemcitabine/cisplatin in 132 (43%) and other regimens in 44 (15%) patients. The pN0 rate was 48% (cN1-56%, cN2-39%, cN3-39%, p=0.03). The complete and partial pathological response rates for the entire cohort were 14.5% and 27%, respectively. The estimated median overall survival time for the cohort was 22 months (IQR 8.0, 54). On Cox regression analysis overall survival was associated with pN0, negative surgical margins, removal of 15 or more pelvic nodes and cisplatin therapy. CONCLUSIONS Complete pathological nodal response can be achieved in a proportion of patients with cN1-3 disease receiving induction chemotherapy. The best survival outcomes are observed in male patients on cisplatin regimens with subsequent negative radical cystectomy margins and complete nodal response (pN0) with excision of 15 or more pelvic nodes.
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Affiliation(s)
- Kamran Zargar-Shoshtari
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Homayoun Zargar
- Vancouver Prostate Centre, Vancouver, British Columbia, Canada
| | - Yair Lotan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jay B Shah
- Department of Urology, MD Anderson Cancer Center, Houston, Texas
| | - Bas W van Rhijn
- Department of Urology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Siamak Daneshmand
- USC/Norris Comprehensive Cancer Center, Institute of Urology, University of Southern California, Los Angeles, California
| | - Philippe E Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Peter C Black
- Vancouver Prostate Centre, Vancouver, British Columbia, Canada.
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23
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van de Putte EEF, Mertens LS, Meijer RP, van der Heijden MS, Bex A, van der Poel HG, Kerst JM, Bergman AM, Horenblas S, van Rhijn BWG. Neoadjuvant induction dose-dense MVAC for muscle invasive bladder cancer: efficacy and safety compared with classic MVAC and gemcitabine/cisplatin. World J Urol 2015; 34:157-62. [PMID: 26184106 DOI: 10.1007/s00345-015-1636-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 07/06/2015] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To investigate the efficacy and safety of neoadjuvant induction dose-dense MVAC (dd-MVAC) for muscle invasive bladder cancer (MIBC). Results of the 2-week-per-cycle regimen were compared with classic MVAC (4 weeks per cycle) and gemcitabine/cisplatin (GC, 3 weeks per cycle). METHODS We included 166 patients with non-organ-confined MIBC, who received neoadjuvant induction dd-MVAC (80), classic MVAC (35), or GC (51) between 1990 and 2014. Complete pathological response (pCR) was defined as no evidence of residual tumor in cystectomy and lymphadenectomy specimens (ypT0N0). pCR and toxicity rates were compared among regimens. RESULTS pCR was found in 29% of dd-MVAC-treated patients, which was not significantly different from classic MVAC (20%, p = 0.366) and GC (32%, p = 0.845). Grade 3-4 toxicity rates related to dd-MVAC and GC (44%) were similar (p = 0.202), whereas the toxicity rate for classic MVAC (55%) was significantly higher than for dd-MVAC (32%) uncorrected (p = 0.026) and corrected for patient and tumor characteristics (OR 2.84, p = 0.037). CONCLUSIONS Neoadjuvant induction dd-MVAC resulted in pathological response rates similar to classic MVAC and GC treatment in patients with non-organ-confined MIBC. The shorter cycle duration compared with classic MVAC and GC and the significantly lower toxicity rate compared with classic MVAC indicate that dd-MVAC should be the preferred option for neoadjuvant induction treatment.
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Affiliation(s)
- Elisabeth E Fransen van de Putte
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
| | - Laura S Mertens
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Richard P Meijer
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.,Department of Urology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michiel S van der Heijden
- Department of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Axel Bex
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Henk G van der Poel
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - J Martijn Kerst
- Department of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Andries M Bergman
- Department of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Simon Horenblas
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Bas W G van Rhijn
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
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Urakami S, Yuasa T, Yamamoto S, Sakura M, Tanaka H, Hayashi T, Uehara S, Inoue Y, Fujii Y, Masuda H, Fukui I, Yonese J. Clinical response to induction chemotherapy predicts improved survival outcome in urothelial carcinoma with clinical lymph nodal metastasis treated by consolidative surgery. Int J Clin Oncol 2015; 20:1171-8. [DOI: 10.1007/s10147-015-0839-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 04/27/2015] [Indexed: 11/24/2022]
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Numahata K, Hoshi S, Hoshi K, Yasuno N, Kubo M, Sasagawa I, Ohta S. Remarkable response to neoadjuvant therapy with methotrexate, vinblastine, adriamycin, and Cisplatin for undifferentiated bladder carcinoma: a case report and literature review. Case Rep Oncol 2014; 7:746-50. [PMID: 25520650 PMCID: PMC4264512 DOI: 10.1159/000369004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We report a case of primary undifferentiated bladder carcinoma, which revealed a remarkable response to methotrexate, vinblastine, adriamycin, and cisplatin (MVAC) therapy. A 46-year-old Japanese woman presented at the hospital with the chief complaints of gross hematuria and pain during urination. Cystoscopy revealed a large smooth-surfaced tumor in the urinary bladder. The histopathological diagnosis was undifferentiated carcinoma. The patient then received 3 courses of MVAC over a 3-month period. Hydronephrosis disappeared after the first course, and the tumor shrank rapidly. After completion of the third MVAC course, radical cystectomy and ileal conduit surgery were performed. After 7 years, the patient has still had no recurrences or metastases. We retrospectively review the relative efficacy of the two popular chemotherapeutic regimens in the management of muscle-invasive bladder cancer in patients who had had radical cystectomy.
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Affiliation(s)
- Kenji Numahata
- Department of Urology, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Senji Hoshi
- Department of Urology, Yamagata Prefectural Central Hospital, Yamagata, Japan ; Department of Urology, Yamagata Tokushukai Hospital, Yamagata, Japan
| | - Kiyotsugu Hoshi
- Department of Urology, Yamagata Tokushukai Hospital, Yamagata, Japan
| | | | - Maiko Kubo
- Clinical Pathophysiology, Faculty of Pharmaceutical Sciences, Josai University, Sakado, Japan
| | - Isoji Sasagawa
- Department of Urology, Yamagata Tokushukai Hospital, Yamagata, Japan
| | - Shoichiro Ohta
- Kan-etsu Hospital, Saitama, Josai University, Sakado, Japan ; Clinical Pathophysiology, Faculty of Pharmaceutical Sciences, Josai University, Sakado, Japan
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Correlation of Pathologic Complete Response with Survival After Neoadjuvant Chemotherapy in Bladder Cancer Treated with Cystectomy: A Meta-analysis. Eur Urol 2014; 65:350-7. [DOI: 10.1016/j.eururo.2013.06.049] [Citation(s) in RCA: 193] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 06/25/2013] [Indexed: 11/17/2022]
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Mertens LS, Meijer RP, Meinhardt W, van der Poel HG, Bex A, Kerst JM, van der Heijden MS, Bergman AM, Horenblas S, van Rhijn BW. Occult lymph node metastases in patients with carcinoma invading bladder muscle: incidence after neoadjuvant chemotherapy and cystectomy vs after cystectomy alone. BJU Int 2014; 114:67-74. [DOI: 10.1111/bju.12447] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Laura S. Mertens
- Department of Urology; Antoni van Leeuwenhoek Hospital; Amsterdam The Netherlands
| | - Richard P. Meijer
- Department of Urology; Antoni van Leeuwenhoek Hospital; Amsterdam The Netherlands
- Department of Urology; University Medical Center; Utrecht The Netherlands
| | - Wim Meinhardt
- Department of Urology; Antoni van Leeuwenhoek Hospital; Amsterdam The Netherlands
| | - Henk G. van der Poel
- Department of Urology; Antoni van Leeuwenhoek Hospital; Amsterdam The Netherlands
| | - Axel Bex
- Department of Urology; Antoni van Leeuwenhoek Hospital; Amsterdam The Netherlands
| | - J. Martijn Kerst
- Department of Medical Oncology; The Netherlands Cancer Institute; Antoni van Leeuwenhoek Hospital; Amsterdam The Netherlands
| | - Michiel S. van der Heijden
- Department of Medical Oncology; The Netherlands Cancer Institute; Antoni van Leeuwenhoek Hospital; Amsterdam The Netherlands
| | - Andries M. Bergman
- Department of Medical Oncology; The Netherlands Cancer Institute; Antoni van Leeuwenhoek Hospital; Amsterdam The Netherlands
| | - Simon Horenblas
- Department of Urology; Antoni van Leeuwenhoek Hospital; Amsterdam The Netherlands
| | - Bas W.G. van Rhijn
- Department of Urology; Antoni van Leeuwenhoek Hospital; Amsterdam The Netherlands
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Siefker-Radtke AO. Surgical consolidation of initially unresectable urothelial carcinoma: an incremental opportunity to cure. Expert Rev Anticancer Ther 2014; 9:1701-3. [DOI: 10.1586/era.09.146] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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29
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Surgical and Chemotherapeutic Management of Regional Lymph Nodes in Bladder Cancer. J Urol 2012; 188:1081-8. [DOI: 10.1016/j.juro.2012.06.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Indexed: 11/22/2022]
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Mertens LS, Meijer RP, Kerst JM, Bergman AM, van Tinteren H, van Rhijn BWG, Horenblas S. Carboplatin based induction chemotherapy for nonorgan confined bladder cancer--a reasonable alternative for cisplatin unfit patients? J Urol 2012; 188:1108-13. [PMID: 22901581 DOI: 10.1016/j.juro.2012.06.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE We investigated induction carboplatin based chemotherapy in patients with nonorgan confined urothelial carcinoma who were considered unfit for cisplatin. A comparison was made with patients who received induction cisplatin based combination chemotherapy. MATERIALS AND METHODS We identified 167 patients with nonorgan confined urothelial carcinoma who received induction cisplatin based combination chemotherapy (126) or gemcitabine and carboplatin (41) at our hospital between 1990 and 2010. Of the patients 124 completed 4 cycles of cisplatin based combination chemotherapy or gemcitabine and carboplatin. Clinical response (ycTNM) was evaluated according to RECIST (Response Evaluation Criteria in Solid Tumors) 1.1. Radical cystectomy and bilateral extended pelvic lymph node dissection were performed in 106 patients. A pathological complete response was defined as no evidence of disease (ypT0N0). Disease specific survival was analyzed using the Kaplan-Meier method. Multivariate analysis was performed. RESULTS Complete clinical response rates did not differ significantly among the treatment groups. A pathological complete response was seen in 33.7% of specimens in the cisplatin based combination chemotherapy group vs 30.3% in the gemcitabine and carboplatin group (p = 0.808). We found no significant difference in disease specific survival between patients who started cisplatin based combination chemotherapy and those who started gemcitabine and carboplatin. For patients who completed 4 cycles and underwent radical cystectomy there was also no significant difference in disease specific survival between the groups. On multivariate analysis a pathological complete response was the only variable significantly associated with disease specific survival (p <0.045). CONCLUSIONS Induction gemcitabine and carboplatin for nonorgan confined urothelial carcinoma achieves clinical and pathological response rates, and survival outcomes comparable to those of the cisplatin based combination chemotherapy schemes. Our data suggest that a carboplatin based regimen can be considered a reasonable alternative for cisplatin unfit patients in the preoperative setting.
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Affiliation(s)
- Laura S Mertens
- Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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31
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Scosyrev E, Messing EM, van Wijngaarden E, Peterson DR, Sahasrabudhe D, Golijanin D, Fisher SG. Neoadjuvant gemcitabine and cisplatin chemotherapy for locally advanced urothelial cancer of the bladder. Cancer 2011; 118:72-81. [PMID: 21720989 DOI: 10.1002/cncr.26238] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 01/18/2011] [Accepted: 02/23/2011] [Indexed: 11/10/2022]
Abstract
BACKGROUND The purpose of this study was to investigate the effect of neoadjuvant chemotherapy with gemcitabine and cisplatin (GC) on pathologic down-staging of patients with locally advanced urothelial cancer (UC) of the bladder. METHODS This was a retrospective cohort study of patients treated with radical cystectomy (RC) for clinical stage cT2-T4, N any, M0 bladder UC at Strong Memorial Hospital from 1999 to 2009. The primary exposure variable was use of neoadjuvant chemotherapy (GC vs none). The primary outcome was stage pT0 at RC. Secondary outcomes included other down-staging end points in the bladder (<pT1, <pT2, <pT3), nodal status, and surgical margins. Linear probability models were used to estimate the effect of neoadjuvant GC on tumor down-staging with adjustment for clinical staging variables. RESULTS A total of 160 eligible patients were identified, of whom 25 were treated with neoadjuvant GC before RC (GC + RC) and 135 without neoadjuvant chemotherapy (RC only). Stage pT0 at cystectomy was found in 20% of patients in the GC + RC group and in 5% of patients in the RC group (adjusted risk difference [aRD] = 16%, P = .03). For other down-staging end points, the estimated treatment effect was as follows (all point estimates favoring chemotherapy): <pT1 aRD = 30% (P = .005); <pT2 aRD = 30% (P = .004); <pT3 aRD = 31% (P = .008); margins aRD = 8% (P = .41); nodes aRD = 4% (P = .74). CONCLUSIONS Neoadjuvant GC was found to be capable of down-staging UC in the bladder; however, no effect on disease in nodes was seen in this study.
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Affiliation(s)
- Emil Scosyrev
- Department of Urology, University of Rochester, Rochester, New York, USA
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de Vries RR, Nieuwenhuijzen JA, Meinhardt W, Bais EM, Horenblas S. Long-term survival after combined modality treatment in metastatic bladder cancer patients presenting with supra-regional tumor positive lymph nodes only. Eur J Surg Oncol 2008; 35:352-5. [PMID: 18722076 DOI: 10.1016/j.ejso.2008.07.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2008] [Revised: 07/01/2008] [Accepted: 07/03/2008] [Indexed: 10/21/2022] Open
Abstract
AIMS To evaluate if combined treatment should be offered to bladder cancer patients presenting with supra-regional lymph node metastases only and a clinical complete or partial response after chemotherapy. PATIENTS AND METHODS We identified 14 patients with supra-regional lymph node metastases out of 394 patients with transitional cell carcinoma (TCC) treated in our institute with cystectomy and regional and supra-regional lymph node dissection between 1987 and 2007. Prior to cystectomy, neoadjuvant chemotherapy had been given. The patients received a total of four cycles of platinum-based chemotherapy. RESULTS Five patients had a CR, nine patients had a PR after neoadjuvant chemotherapy. Histopathological proof of complete response in the bladder was confirmed in all five cases. One of these five patients had a CR in the bladder but pelvic lymph nodes still contained vital tumor. Five patients had no tumor in the lymph nodes, whereas four had tumor in the lymph nodes. Eleven patients died due to bladder cancer, seven of them within 1 year after cystectomy. The 3- and 5-year disease-specific survival rates were 36% (95% CI: 10-60%) and 24% (95% CI: 0-49%). Mean follow-up was 2.5 years. CONCLUSIONS Combination therapy consisting of neoadjuvant chemotherapy and surgery in selected patients with tumor positive supra-regional lymph nodes only can result in durable long-term survival rates (24% 5-year survival). Response evaluation after neoadjuvant chemotherapy might play a decisive role in the selection of patients undergoing subsequent surgical removal of all known tumor sites.
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Affiliation(s)
- R R de Vries
- Department of Urology, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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Shang D, Liu Y, Matsui Y, Ito N, Nishiyama H, Kamoto T, Ogawa O. Demethylating Agent 5-Aza-2′-Deoxycytidine Enhances Susceptibility of Bladder Transitional Cell Carcinoma to Cisplatin. Urology 2008; 71:1220-5. [DOI: 10.1016/j.urology.2007.11.029] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2007] [Revised: 10/20/2007] [Accepted: 11/08/2007] [Indexed: 11/25/2022]
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Als AB, Sengelov L, von der Maase H. Long-Term Survival after Gemcitabine and Cisplatin in Patients with Locally Advanced Transitional Cell Carcinoma of the Bladder: Focus on Supplementary Treatment Strategies. Eur Urol 2007; 52:478-86. [PMID: 17383078 DOI: 10.1016/j.eururo.2007.03.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2006] [Accepted: 03/07/2007] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The objective was to evaluate response and survival, as well as efficacy of subsequent supplementary treatment and follow-up strategy in patients with locally advanced transitional cell carcinoma of the bladder following combination chemotherapy with gemcitabine and cisplatin (GC). METHODS A total of 84 patients with locally advanced (T4b, Nx, M0 or Tx, N2-3, M0) received GC. After chemotherapy, the strategy was close surveillance in patients with complete response, and supplementary radical cystectomy or radiotherapy whenever possible in patients with partial response. RESULTS A total of 25 patients (29.8%) with complete response to chemotherapy were followed by close surveillance. This group achieved a median overall survival of 47.6 mo. Another 25 patients had partial response to chemotherapy. Of these patients, 16 had supplementary treatment, with 10 achieving "no evidence of disease" (NED). Thus, a total of 35 patients achieved NED with a median overall survival of 48.7 mo versus 10.2 mo in patients not achieving NED (hazard ratio=0.10; 95%CI, 0.05-0.20; p<0.0001). The rate of NED was higher in the group of patients who had a cystectomy compared with the group who received radiotherapy as supplementary treatment. CONCLUSIONS In patients with locally advanced bladder cancer, NED following chemotherapy alone or chemotherapy plus supplementary cystectomy or radiotherapy is essential to achieve long-term survival. Patients with a partial response should be offered radical cystectomy whenever possible, which seems to be superior to radiotherapy. Close surveillance may be an alternative to immediate cystectomy in patients with complete response following chemotherapy.
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Affiliation(s)
- Anne Birgitte Als
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark.
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Abstract
The 30-45% failure rate after radical cystoprostatectomy mandates that we explore and optimize multimodal therapy to achieve better disease control in these patients. Cisplatin-based multi-agent combination chemotherapy has been used with success in metastatic disease and has therefore also been introduced in patients with high-risk but non-metastatic bladder cancer. There is now convincing evidence that chemotherapy given pre-operatively can improve survival in these patients. In this review we establish the need for peri-operative chemotherapy in bladder cancer patients and summarize the evidence for the efficacy of neoadjuvant chemotherapy. The advantages and disadvantages of neoadjuvant versus adjuvant chemotherapy are discussed, and the main shortcomings of both--treatment-related toxicity and the inability to prospectively identify likely responders--are presented. Finally, a risk-adapted approach to neoadjuvant chemotherapy is presented, whereby the highest risk patients are offered treatment while those unlikely to benefit are spared the treatment-related toxicity.
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Affiliation(s)
- Peter C Black
- Department of Urology, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1373, Houston, TX 77030, USA
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36
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Bibliography. Current world literature. Bladder cancer. Curr Opin Urol 2006; 16:386-9. [PMID: 16905987 DOI: 10.1097/01.mou.0000240314.93453.d4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Duffau H, Taillandier L, Capelle L. Radical surgery after chemotherapy: a new therapeutic strategy to envision in grade II glioma. J Neurooncol 2006; 80:171-6. [PMID: 16645710 DOI: 10.1007/s11060-006-9168-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2006] [Accepted: 03/29/2006] [Indexed: 10/24/2022]
Abstract
While surgery is proned in low-grade glioma (LGG), the invasion of functional areas frequently prevents a complete resection. We report the first case of a patient operated on for a left frontal LGG, diagnosed because of seizures, with partial resection due to an invasion of the controlateral hemisphere. Chemotherapy enabled a regression of this controlateral extension. Postchemotherapy surgery performed with intraoperative functional mapping then allowed a complete resection, without sequelae. The patient has a normal socio-professional life, with no seizure. No other treatment was given. There was no recurrence, with a follow-up of 2 years since the second surgery (3.5 years since the first symptom). We propose a new therapeutic strategy in unresectable LGG, with preoperative chemotherapy, to make a radical surgery possible in a second step, while preserving the quality of life.
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Affiliation(s)
- Hugues Duffau
- Department of Neurosurgery, UMR-S678, Inserm/UPMC, Hôpital Salpêtrière, 75651, Paris, Cedex 13, France.
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