Total Cystectomy Versus Bladder Preservation Therapy for Locally Invasive Bladder Cancer: Effect of Combined Therapy Using Balloon-Occluded Arterial Infusion of Anticancer Agent and Hemodialysis With Concurrent Radiation

Our Experience of OSAKA Regimen (Bladder Preservation) in Patients with Advanced Bladder Cancer

Introduction and Objectives

OSAKA regimen is a novel bladder preservation therapy involving balloon-occluded selective arterial infusion of radio-sensitizing chemotherapeutic agent with concurrent hemodialysis (HD), followed by radiation therapy. Objectives are to study the feasibility of this novel regimen in patients with advanced cancer bladder (Ca Bladder).

Methods

Two patients having advanced Ca Bladder with cisplatin ineligibility and poor performance status were managed with OSAKA regimen. Patients undergo super selective catheterisation of the anterior division of the internal iliac artery, followed by concurrent instillation of cisplatin (100 mg) via microcatheters and hemodialysis. Within 72 h, definitive radiation therapy is given. Image-guided radiation therapy (IGRT) with Helical Tomo using an Accuracy Radixact Tomography machine was used. 60 Gray/30 fractions is given to the bladder and nodes (50 Gray to bladder and nodes plus margin, with a boost of 10 Gray to bladder plus margin). Response is monitored by 3 monthly fluorodeoxyglucose positron emission tomography (FDG PET) imaging.

Results

Our first patient tolerated the procedure well and showed a complete response at 3 months of FDG PET imaging, but unfortunately, 1 year of FDG PET showed bony metastases, and the patient was managed accordingly. Our second patient also tolerated the regimen well, showed a complete response at 3 and 12 months of FDG PET imaging, and is under follow-up.

Conclusions

The OSAKA regimen, as a bladder preservation strategy, is feasible and safe in selective advanced Ca Bladder patients.

Comparing trimodal therapy with radical cystectomy in muscle-invasive bladder cancer: an updated meta-analysis

BACKGROUND

We conducted this meta-analysis to compare the two muscle-invasive bladder cancer (MIBC) treatment modalities in terms of cancer-specific survival (CSS) and other outcome indicators.

METHOD

A systematic review and meta-analysis were performed in accordance with the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. The search was conducted using various academic databases including Scopus, PubMed, Cochrane database, EMBASE, Chinese biomedical literature database, Wan fang databases, and China National Knowledge Internet databases between 1966 and December 2023. This review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) No. (CRD42023398977).

RESULT

This study included a total of 54,816 patients diagnosed with bladder cancer from 14 studies, of which 6,228 patients were assigned to the trimodal therapy (TMT) group and 48,588 patients were assigned to the radical cystectomy (RC) group. Based on the results, the RC group exhibited a higher rate of survival than the TMT group [pooled hazard ratio (HR) = 1.23, 95% CI: 1.18-1.28, Z = 1.46, P < 0.001]. In terms of CSS, patients in the RC group had a longer CSS compared with those in the TMT group (pooled HR = 1.47, 95% CI: 1.29-1.67, Z = 5.893, P < 0.001). Compared with RC, TMT is significantly associated with an increased risk of both types of mortality (pooled HR: 1.30, P < 0.001).

CONCLUSION

Overall, the findings of this meta-analysis suggest that RC treatment may be associated with improved overall survival. Moreover, it was observed that cancer-specific survival was significantly prolonged among patients in the RC group as opposed to those who received TMT. In addition, it was shown that patients who received TMT exhibited a higher risk of all-cause mortality when compared with those who underwent RC.

Detection of the Vesical Arteries Using Three-dimensional Digital Subtraction Angiography Relevant to Intra-arterial Infusion Chemotherapy for Bladder Cancer Using Double-balloon Catheters

Purpose

This study aims to assess and measure the origin of the superior vesical artery and its distance from the anterior trunk of the internal iliac artery, to which the anticancer drug is infused via double-balloon-occluded arterial infusion bladder-preserving therapy for locally invasive bladder cancer.

Material and Methods

The 160 pelvic sides of 80 patients were analyzed. Double-balloon catheters were bilaterally introduced into the contralateral superior gluteal artery via the internal iliac arteries using a bilateral transfemoral approach. The proximal balloon is placed at the internal iliac artery, proximally from superior gluteal artery bifurcation, whereas the distal balloon at the origin of the superior gluteal artery to isolate the anterior trunk of the internal iliac artery discharging to the targeted vesical arteries between the balloons. The side hole between the distal and proximal balloons was adjusted at the origin of the anterior trunk of the internal iliac artery to allow clear visualization of the angiographic flow into the bladder. After the distal and proximal balloons were inflated, three-dimensional rotational digital subtraction angiography was performed by simultaneous contrast injection from one extension tube connected to bilateral catheters. The distance (X) between the origins of anterior trunk of the internal iliac artery and superior vesical artery was measured on three-dimensional digital subtraction angiography images, and the origin of the inferior vesical artery was investigated.

Results

All superior vesical artery originated from anterior trunk of the internal iliac artery. The mean x was 7.2 mm (range 1.0-22.0 mm). All inferior vesical arterys branched from anterior trunk of the internal iliac artery or its branches.

Conclusions

Superior vesical artery commonly originates from the proximal portion of anterior trunk of the internal iliac artery close to superior gluteal artery bifurcation.

Trimodal Therapy vs. Radical Cystectomy for Muscle-Invasive Bladder Cancer: A Meta-Analysis

Background: To compare the difference between trimodal therapy (TMT) and radical cystectomy (RC) in treating muscle-invasive bladder cancer, we performed a meta-analysis for data from the following database.

Methods: We searched PubMed, Chinese biomedicine literature database, the Cochrane Library, China National Knowledge Internet databases, Wanfang databases, and Google Scholar up to December 2019. The main outcome measures assessed were overall survival (OS), cancer-specific survival (CSS), mortality, and Charlson comorbidity score (CCS). Two authors independently evaluated the study quality and extracted data. All data were analyzed using Review Manager (version 5.3).

Results: After database retrieval, article selection, data extraction, and quality assessment, nine articles comprising 5,721 cases from the TMT group and 48,262 cases from the RC group were included in this study. The data showed that there was no statistical difference between TMT and RC at <10 years OS [pooled hazard ratio (HR) = 1.26, 95% confidence interval (CI): 0.92–1.73, Z = 1.46, P = 0.14], while OS of the RC group was higher than that of the TMT group at more than 10 years (pooled HR = 1.34, 95% CI: 1.18–1.54, Z = 4.33, P < 0.0001). As for CSS, compared with the TMT group, the patients in the RC group had longer CSS (pooled HR = 1.50, 95% CI: 1.29–1.76, Z = 5.15, P < 0.00001). Compared with RC, TMT is linked to an obvious increase in all-cause mortality and bladder-specific cancer mortality (pooled HR = 1.30, 95% CI: 1.16–1.46, Z = 4.55, P < 0.00001; pooled HR = 1.32, 95% CI: 1.15–1.51, Z = 3.92, P < 0.0001). The bladder cancer patients belonging to CCS “0” score preferred RC [pooled relative risk (OR) = 0.94, 95% CI: 0.89–0.98, Z = 2.79, P = 0.005], while CCS “2” score's patients were prone to TMT (pooled OR = 1.40, 95% CI: 1.29–1.53, Z = 7.73, P < 0.00001).

Conclusions: Overall, this meta-analysis suggests that the efficacy of TMT is non-inferior to that of RC at <10-year OS, and RC is superior to TMT at more than 10-year OS. Therefore, TMT may be a reasonable treatment option in well-selected patients who are unsuitable for surgery or are not willing to experience surgery. In the future, more high-quality, large-sample randomized controlled trials (RCTs) are needed to verify the results.

Neoadjuvant intra-arterial chemotherapy using an original four-lumen double-balloon catheter for locally advanced uterine cervical cancer

OBJECTIVE

We report a balloon-occluded arterial infusion therapy with an original four-lumen double-balloon catheter (4L-DB) which allows for the efficient injection of an anticancer agent at a high concentration to the target spot for patients with locally advanced uterine cervical cancer.

METHODS

One hundred and forty-three patients with locally advanced cervical cancer treated with neoadjuvant intra-arterial chemotherapy (NAIAC) or a primary radical hysterectomy (PRH) were retrospectively assessed. The patients in the NAIAC group received irinotecan 70 mg/m2 intravenously on day 1 and 8 and cisplatin 70 mg/m2 intra-arterially using the 4L-DB on day 2 of a 21-day course, and two courses were performed in principle. The radical hysterectomy was performed within 6 weeks after NAIAC.

RESULTS

Ninety-four patients were treated with NAIAC, and 49 patients undertook a PRH. The response rate of NAIAC on MRI was 92.6%. Fourteen patients (14.6%) had no evidence of cancer cells on pathologic diagnoses. The NAIAC group had a longer disease-free survival than the PRH group (p=0.02); however, the overall survival was not significantly different. The relative risk (RR) for recurrence was higher in patients with lymph node metastasis (RR, 4.31; 95% CI, 2.23-8.43) and lower in those who underwent NAIAC (RR, 0.30; 95% CI, 0.14-0.68).

CONCLUSION

Our results with NAIAC using the 4L-DB catheter in locally advanced cervical cancer indicates beneficial effects on primary lesions and improves disease-free survival.

Muscle-invasive bladder cancer organ-preserving therapy: systematic review and meta-analysis

PURPOSE

To determine the effectiveness and harms of bladder-preserving trimodal therapy (TMT) as a first-line treatment versus radical cystectomy (RC) plus radical pelvic lymphadenectomy in the treatment of muscle-invasive bladder cancer in terms of overall survival.

METHODS

We included parallel clinical trials and prospective and retrospective cohort studies that included patients older than 18 years old, diagnosed with muscle-invasive bladder cancer, who underwent TMT compared with RC. The planned comparison was TMT versus RC plus pelvic lymphadenectomy as first-line treatment. The primary outcome was overall survival (OS) and secondary outcomes were salvage cystectomy and cancer-specific survival and progression-free survival. A search strategy was designed for MEDLINE, CENTRAL, Embase, and LILACS. We saturated information with conference abstracts, in progress clinical trials, literature published in non-indexed journals, and other sources of gray literature. Standardized tools assessed the risk of bias independently. We performed the statistical analysis in R v3.4.1 and effect sizes were reported in terms of hazard ratios (HR) and the corresponding 95% confidence intervals (95%CI). Accordingly, we used a random effect model due to the statistical heterogeneity found in included studies.

RESULTS

We found 2682 records with the search strategies and, finally, 11 studies were included in the quantitative analysis. The summary HR for OS was 1.06 95%CI (0.85-1.31) I2 = 77%, showing no statistical difference. Regarding cancer-specific survival, the summary HR was 1.23 95%CI (1.04-1.46) I2 = 14%. On the other side, for the progression-free survival, the summary HR was 1.11 95%CI (0.63-1.95) I2 = 78%. Only one study described HR for adverse events (1.37 95%CI 1.16-1.59).

CONCLUSION

We found no differences in overall survival and progression-free survival between these two interventions. Nonetheless, we found that cancer-specific survival favored patients who received radical cystectomy.

Detectability of residual invasive bladder cancer in delayed 18F-FDG PET imaging with oral hydration using 500 mL of water and voiding-refilling

OBJECTIVE

2-Fluorine-18-fluoro-2-deoxy-D-glucose positron emission tomography (¹⁸F-FDG PET) imaging is not considered useful for assessing bladder cancer due to the physiological uptake of ¹⁸F-FDG in the bladder. Despite reports of the detection of bladder cancer by washing out ¹⁸F-FDG from the bladder, such methods are invasive and impractical in the routine practice. The purpose of this study was to evaluate prospectively the utility of oral hydration with 500 mL of water and voiding-refilling, a minimally invasive method that we introduced to enable detection of residual invasive bladder cancer on delayed ¹⁸F-FDG PET imaging.

METHODS

From January 2015 to December 2017, 267 consecutive patients with bladder cancer underwent ¹⁸F-FDG PET/computed tomography scans. Among these patients, 25 (19 men and 6 women; mean age, 72.0 ± 11.3 years) were newly diagnosed as having muscle-invasive bladder cancer by transurethral resection of bladder tumor and T3b or T4 by magnetic resonance imaging (MRI). All patients were orally hydrated with only 500 mL of water and were then instructed to void frequently for 60 min before early ¹⁸F-FDG PET imaging. After the scans, they were instructed to hold their urine for 60 min. Then, delayed imaging was performed. Two radiologists evaluated the early and delayed ¹⁸F-FDG PET images to determine whether residual invasive bladder cancer could be detected. The maximum standardized uptake values (SUVmax) of the bladder urine and residual tumor site were also measured on early and delayed images. The maximum diameter of the primary bladder tumor was measured on MRI.

RESULTS

The sensitivity for detecting residual invasive bladder cancer on early and delayed imaging were 24.0 and 92.0%, respectively (P < 0.001). The SUVmax of the bladder urine on the early and delayed imaging were 34.7 ± 29.7 and 16.0 ± 10.7 (mean ± SD), respectively. The SUVmax of the residual tumor site on the early and delayed imaging were range 15.65-30.83 and 10.06-45.70, respectively.

CONCLUSION

Delayed ¹⁸F-FDG PET imaging with oral hydration using only 500 mL of water and voiding-refilling is useful for detecting residual invasive bladder cancer.

Can bladder preservation therapy come to the center stage?

Decision-making in urological cancer care requires a multidisciplinary approach for refinement, but its impact on urothelial carcinoma of the bladder has not been fully addressed for the past three decades, except for the latest immunological checkpoint inhibitor approved by the U.S. Food and Drug Administration for metastatic muscle-invasive bladder cancer that is resistant to platinum-based chemotherapy. For the time being, radical cystectomy is the gold standard of curative therapy for muscle-invasive bladder cancer. Trimodal therapy that combines chemotherapy for the purpose of radiation sensitization, external beam radiotherapy and transurethral resection of bladder tumor has emerged as a potential alternative treatment option that preserves the bladder. In lack of randomized studies for bladder preservation therapy compared with surgery, the principles of management of urothelial carcinoma of the bladder have evolved in recent times, with an emphasis on bladder preservation. A number of bladder preservation techniques are available to the surgeon; however, appropriately selected patients with muscle-invasive bladder cancer should be offered the opportunity to discuss various treatment options, including organ-sparing trimodal therapy. The aim of the present study was to compare the primary outcomes of the available treatment methods and identify the sources of variance among studies. A review of various bladder preservation techniques in vogue for the management of urothelial carcinoma of the bladder is discussed.

Novel Software-Assisted Hemodynamic Evaluation of Pelvic Flow During Chemoperfusion of Pelvic Arteries for Bladder Cancer: Double- Versus Single-Balloon Technique

PURPOSE

Approximately 83 % of patients with bladder cancer have achieved a complete response after undergoing a novel bladder preservation therapy involving balloon-occluded intra-arterial infusion chemotherapy (BOAI) using a four-lumen double-balloon catheter, known as the Osaka Medical College regimen. This study aimed to show the quantitative difference in hemodynamics of the bladder arteries using syngo iFlow (Siemens Healthcare, Erlangen, Germany), which provides an automatic tool for quantitative blood flow analysis between double BOAI (D-BOAI) and conventional single BOAI (S-BOAI).

MATERIALS AND METHODS

Fifty patients were included. The catheters were introduced into both posterior trunks of the internal iliac arteries via contralateral femoral artery access. A side hole between the distal and proximal balloons was placed at the origin of each bladder artery to allow clear visualization of angiographic flow of the injected agent into the urinary bladder. Digital subtraction angiography was used during analysis with the syngo iFlow to evaluate the hemodynamics of the contrast medium in the pelvic arteries during BOAI. The comparative change in the amount of contrast medium in the bladder arteries between D-BOAI and S-BOAI was assessed using syngo iFlow.

RESULTS

One-hundred pelvic sides were analyzed. The amount of contrast medium in the bladder arteries using D-BOAI was more than twice that using S-BOAI (right, 3.03-fold; left, 2.81-fold).

CONCLUSION

The amount of contrast medium in the bladder arteries using D-BOAI was higher than that using conventional S-BOAI. This may increase the anticancer drug concentration in the affected bladder, leading to a good clinical response.

Neoadjuvant and adjuvant chemotherapy for locally advanced bladder carcinoma: development of novel bladder preservation approach, Osaka Medical College regimen

Cisplatin-based chemotherapy has been widely used in a neoadjuvant as well as adjuvant setting. Furthermore, trimodal approaches including complete transurethral resection of the bladder tumor followed by combined chemotherapy and radiation have generally been performed as bladder preservation therapy. However, none of the protocols have achieved a 5-year survival rate of more than 70%. Additionally, the toxicity of chemotherapy and/or a decreased quality of life due to urinary diversion cannot be ignored, as most patients with bladder cancer are elderly. We therefore newly developed the novel trimodal approach of "combined therapy using balloon-occluded arterial infusion of anticancer agent and hemodialysis with concurrent radiation, which delivers an extremely high concentration of anticancer agent to the site of a tumor without systemic adverse effects ("Osaka Medical College regimen" referred to as the OMC regimen). We initially applied the OMC regimen as neoadjuvant chemotherapy for locally advanced bladder cancer. However, since more than 85% of patients with histologically-proven urothelial cancer achieved complete response with no evidence of recurrence after a mean follow-up of 170 (range 21-814) weeks, we have been applying the OMC-regimen as a new approach for bladder sparing therapy. We summarize the advantage and/or disadvantage of chemotherapy in neoadjuvant as well as adjuvant settings, and show the details of our newly developed bladder sparing approach OMC regimen in this review.