Adjuvant cyclophosphamide, doxorubicin, and cisplatin chemotherapy for bladder cancer: an update

The impact of squamous cell transformation on the prognosis of patients treated with radical nephroureterectomy

BACKGROUND

Limited information is available for guiding the management of upper urinary tract (UUT) urothelial carcinoma with squamous differentiation (UC-SqD). We did not even know about the difference between pure urothelial carcinoma (UC) and UC-SqD in the UUT regardless of treatment policy and prognosis. Instead of direct comparisons against each other, we included the third UUT malignancy, squamous cell carcinoma (SCC). This three-way-race model allows us to more clearly demonstrate the impact of squamous cell transformation on patient outcomes in UUT malignancy.

METHODS

We retrospectively analysed 327 patients with UC, UC-SqD, or SCC who underwent radical nephroureterectomy with bladder cuff excision (RNU) at Taichung Veterans General Hospital, Taichung, Taiwan, between January 2006 and December 2013. A Kaplan-Meier survival analysis was used to evaluate the relationship between patient outcomes and histology. Multivariate Cox proportional hazards modelling was also used to predict patient prognoses.

RESULTS

The five-year postoperative cancer-specific survival (CSS) rates were 83.6% (UC), 74.4% (UC-SqD), and 55.6% (SCC), and the 5-year recurrence-free survival (RFS) rates were 87.7% (UC), 61.5% (UC-SqD), and 51.9% (SCC). UC patients had significantly better 5-year RFS than UC-SqD and SCC patients (P = 0.001 and P < 0.0001, respectively). Patients with pure UC had significantly better 5-year CSS than SCC patients (P = 0.0045). SCC or UC-SqD did not independently predict disease-specific mortality (HR 0.999, p = 0.999; HR 0.775, p = 0.632, respectively) or disease recurrence compared to pure UC (HR 2.934, p = 0.239; HR 1.422, p = 0.525, respectively). Age, lymphovascular invasion (LVI), and lymph node (LN) status independently predicted CSS, while pathological tumour stage, LN status, and LVI predicted RFS.

CONCLUSIONS

SCC and UC-SqD are not independent predictors of survival outcomes in patients with UUT tumours. However, they are associated with other worse prognostic factors. Hence, different treatments are needed for these two conditions, especially for SCC.

Clinical Outcomes of Patients With Histologic Variants of Urothelial Carcinoma Treated With Selective Tetramodal Bladder-preservation Therapy Incorporating Consolidative Partial Cystectomy

BACKGROUND

Tetramodal bladder-preservation therapy includes maximal transurethral resection (TUR), induction chemoradiotherapy (CRT), and consolidative partial cystectomy with pelvic lymph node dissection. Tetramodal bladder-preservation therapy theoretically provides surgical consolidation of chemotherapy- and radioresistant cells. However, its efficacy in providing optimal cancer control for patients with histologic variants of urothelial carcinoma (VUCs) is currently unknown. We compared the oncologic outcomes between patients with muscle-invasive bladder cancer (MIBC) and pure urothelial carcinoma (PUC) and those with MIBC and VUCs after selective tetramodal bladder-preservation therapy.

PATIENTS AND METHODS

We prospectively enrolled 154 patients. After maximal TUR and induction CRT, patients with a clinical complete response were offered consolidative partial cystectomy to achieve bladder preservation, with radical cystectomy recommended for the others. The VUCs identified in the maximal TUR samples were categorized according to the 2004 World Health Organization classification. The primary endpoint was cancer-specific survival. The secondary endpoints included the clinical and pathologic response rates to induction CRT and MIBC recurrence-free survival.

RESULTS

A VUC was identified in 37 patients (24%). The most frequent variants involved glandular differentiation (n = 13), squamous differentiation (n = 11), and micropapillary (n = 8). No difference was found in the clinical complete response rate to CRT between PUC and VUCs (P = .81). On an intention-to-treat basis, the 5-year cancer-specific survival rates for those with PUC (n = 116) and VUC (n = 37) were 82% and 81% (P = .86), respectively.

CONCLUSION

Tetramodal bladder-preservation therapy incorporating partial cystectomy could provide favorable locoregional control and survival for patients with VUC. Thus, patients with MIBC need not be excluded from the bladder-preservation approach because of the presence of a variant histologic type.

Peri-operative chemotherapy for muscle-invasive bladder cancer: status-quo in 2017

The role of perioperative chemotherapy associated with radical cystectomy (RC) for muscle-invasive bladder cancer has been analyzed in several landmark randomized controlled trials (RCTs) over the past decades. With regard to neoadjuvant chemotherapy (NAC), a meta-analysis of level 1 evidence and long-term results from the largest RCTs support its use, which is currently advocated as the standard of care by most of the clinical guidelines worldwide. However, with regard to the delivery of adjuvant chemotherapy (AC), evidence is more contentious. Specifically, several meta-analyses demonstrated a survival benefit associated with the use of cisplatin-based regimen but investigators identified multiple methodological limitations in most of included RCTs. Nonetheless, AC is currently considered for fit patients with adverse pathological features at RC. It is noteworthy that the delivery of such cytotoxic treatment after surgery may maintain significant anti-tumor activity even in those patients who previously received NAC. Finally, given its greater response rate, the methotrexate, vinblastine, adriamycin plus cisplatin combination remains preferentially considered in the neoadjuvant setting, while the gemcitabine plus cisplatin combination is more commonly delivered in the adjuvant setting because of its better toxicity profile. However, no prospective evidence comparing efficacy of both regimens for NAC or AC is currently available.

Systemic chemotherapy in muscle invasive and metastatic bladder cancer: present and future

Bladder cancer is the most frequent among the urothelial tumors, and it is responsible for about 2% of all cancer mortality worldwide. The mainstay of chemotherapy treatment, both for muscle-invasive and metastatic disease, is cisplatin-based regimens. In recent years, ground-breaking results have been achieved with immunotherapy, which have led to important breakthroughs in the bladder cancer treatment scenario, with the approval of several new agents. New insights derive from a greater characterization of the tumor genome, which could lead to developing new therapies, more personalized, in the near future.

Chemotherapy for Muscle-Invasive Bladder Cancer

OPINION STATEMENT

In the last 25 years, there has been an improved understanding of the pathogenesis of muscle-invasive bladder cancer (BC). Development of new treatment strategies has followed. We have progressed from the awareness of the efficacy of platinum compounds, especially cisplatin, as single agents to the development of effective drug combinations with greater attention in improving safety profiles while impacting on survival. Peri-operative chemotherapy (CHT) is the standard of care for non-metastatic disease. The most evidence in terms of a survival advantage is derived from neoadjuvant chemotherapy (NC) trials, but adjuvant medical treatment should be strongly considered when NC has not been utilized. Patient selection and a multidisciplinary approach are essential. Platinum-based CHT is still the standard of care for both early and advanced disease. A deeper knowledge of the pathogenesis of BC will derive from gene expression profiling (GEP), and this will give us new prognostic and predictive tools to develop more targeted treatments. A high mutational rate has been observed in BC, which can generate neoantigens that initiate cancer immunity. Immunotherapy will become a pivotal treatment for BC, in the very near future. Emerging data are encouraging, and these treatments may well revolutionize the medical approach to this disease while CHT will play a less important role.

Management of muscle-invasive bladder cancer in the elderly

PURPOSE OF REVIEW

The number of cases of muscle-invasive bladder cancer is increasing along with the age of the population. Management of muscle-invasive bladder cancer in the elderly is complex, requiring a multidisciplinary team approach and a comprehensive assessment of each individual patient.

RECENT FINDINGS

A geriatric assessment should be used to inform treatment decisions in elderly patients with bladder cancer. There is increasing evidence to support aggressive therapy in appropriate elderly patients, including radical cystectomy and neoadjuvant chemotherapy. Adjuvant chemotherapy also has a role in patients with high-risk disease after cystectomy. A bladder preservation approach with trimodality therapy is a well tolerated and effective alternative to cystectomy in appropriately selected patients.

SUMMARY

Treatment decisions should not be based on chronologic age alone and advanced age should not preclude aggressive or curative therapy. The recent molecular characterization of bladder cancer and several recent immunotherapy trials provide hope of a more targeted approach to treatment of bladder, potentially improving both effectiveness and tolerability of treatment regimens in the elderly.

Urothelial carcinoma with squamous differentiation: response to chemotherapy and radiation

PURPOSE

This review will summarize the literature relating urothelial carcinoma with squamous differentiation and its response to chemotherapy or radiation therapy.

METHODS

The English literature in PubMED was extensively search for articles pertaining to urothelial carcinoma with squamous differentiation and its response to chemotherapy or radiation. Articles reference lists were then further scrutinized to ensure all relevant literature had been identified.

RESULTS

Urothelial carcinoma with squamous differentiation is generally treated as if it were pure urothelial carcinoma. However, it remains unclear if such mixed histology portends a different prognosis for patients with bladder cancer, particularly regarding the response to chemotherapy and radiation. Initial studies suggested a worse response to such therapy in mixed histology but more recent data has challenged that observation. Unfortunately the literature is limited by the type and quality of the existent studies and mixed results among the data that is available.

CONCLUSION

The final word on whether urothelial carcinoma with squamous differentiation responds differently to chemotherapy or radiation therapy remains uncertain. This important question warrants careful study in the future.

Molecular mechanisms of squamous differentiation in urothelial cell carcinoma: a paradigm for molecular subtyping of urothelial cell carcinoma of the bladder

BACKGROUND

Recent molecular characterization studies focusing on bladder cancer have provided a wealth of information, including the identification of specific molecular subtypes of this disease. Interestingly, a particular molecular subtype identified by several different groups is characterized, at least in part, by the presence of squamous differentiation (SqD) in a significant fraction of primary tumors. Tumors that exhibit SqD are extremely aggressive. Moreover, conflicting reports exist relative to the sensitivity of bladder tumors exhibiting SqD to multimodal treatment. Bladder cancers that exhibit SqD appear to be distinct clinical entities and are often associated with a specific molecular subtype; therefore, it is important to understand the molecular drivers of this process.

PURPOSE

Because presence of SqD is closely associated with a basal molecular phenotype, we review the evidence for specific pathways in SqD. In addition, we pose key areas for future exploration.

Significance of lymphovascular invasion in organ-confined, node-negative urothelial cancer of the bladder: data from the prospective p53-MVAC trial

OBJECTIVES

To investigate the association between lymphovascular invasion (LVI) and clinical outcome in organ-confined, node-negative urothelial cancer of the bladder (UCB) in a post hoc analysis of a prospective clinical trial. To explore the effect of adjuvant chemotherapy with methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC) on outcome in the subset of patients whose tumours exhibited LVI.

PATIENTS AND METHODS

Surgical and tumour factors were extracted from the operative and pathology reports of 499 patients who had undergone radical cystectomy (RC) for pT1-T2 N0 UCB in the p53-MVAC trial (Southwest Oncology Group 4B951/NCT00005047). The presence or absence of LVI was determined by pathological examination of transurethral resection or RC specimens. Variables were examined in univariate and multivariate Cox proportional hazards models for associations with time to recurrence (TTR) and overall survival (OS).

RESULTS

Among 499 patients with a median follow-up of 4.9 years, a subset of 102 (20%) had LVI-positive tumours. Of these, 34 patients had pT1 and 68 had pT2 disease. LVI was significantly associated with TTR with a hazard ratio (HR) of 1.78 [95% confidence interval (CI) 1.15-2.77; number of events (EV) 95; P = 0.01) and with OS with a HR of 2.02 (95% CI 1.31-3.11; EV 98; P = 0.001) after adjustment for pathological stage. Among 27 patients with LVI-positive tumours who were randomised to receive adjuvant chemotherapy, receiving MVAC was not significantly associated with TTR (HR 0.70, 95% CI 0.16-3.17; EV 7; P = 0.65) or with OS (HR 0.45, 95% CI 0.11-1.83; EV 9; P = 0.26).

CONCLUSIONS

Our post hoc analysis of the p53-MVAC trial revealed an association between LVI and shorter TTR and OS in patients with pT1-T2N0 disease. The analysis did not show a statistically significant benefit of adjuvant MVAC chemotherapy in patients with LVI, although a possible benefit was not excluded.

Neoadjuvant therapy in muscle-invasive bladder cancer: a model for rational accelerated drug development

Since the advent of cisplatin-based combination therapy in the management of muscle-invasive and advanced bladder cancer, there has been little progress in improving outcomes for patients. Novel therapies beyond cytotoxic chemotherapy are needed. The neoadjuvant paradigm lends to acquiring ample pretreatment and posttreatment tumor tissue as a standard of care, which enables comprehensive biomarker analyses to better understand mechanisms of both response and resistance, which will aid drug development. This article discusses the evolution of neoadjuvant therapy as standard treatment and the role it may serve toward the development of novel therapies.

Discovery and validation of novel expression signature for postcystectomy recurrence in high-risk bladder cancer

Background

Nearly half of muscle-invasive bladder cancer patients succumb to their disease following cystectomy. Selecting candidates for adjuvant therapy is currently based on clinical parameters with limited predictive power. This study aimed to develop and validate genomic-based signatures that can better identify patients at risk for recurrence than clinical models alone.

Methods

Transcriptome-wide expression profiles were generated using 1.4 million feature-arrays on archival tumors from 225 patients who underwent radical cystectomy and had muscle-invasive and/or node-positive bladder cancer. Genomic (GC) and clinical (CC) classifiers for predicting recurrence were developed on a discovery set (n = 133). Performances of GC, CC, an independent clinical nomogram (IBCNC), and genomic-clinicopathologic classifiers (G-CC, G-IBCNC) were assessed in the discovery and independent validation (n = 66) sets. GC was further validated on four external datasets (n = 341). Discrimination and prognostic abilities of classifiers were compared using area under receiver-operating characteristic curves (AUCs). All statistical tests were two-sided.

Results

A 15-feature GC was developed on the discovery set with area under curve (AUC) of 0.77 in the validation set. This was higher than individual clinical variables, IBCNC (AUC = 0.73), and comparable to CC (AUC = 0.78). Performance was improved upon combining GC with clinical nomograms (G-IBCNC, AUC = 0.82; G-CC, AUC = 0.86). G-CC high-risk patients had elevated recurrence probabilities (P < .001), with GC being the best predictor by multivariable analysis (P = .005). Genomic-clinicopathologic classifiers outperformed clinical nomograms by decision curve and reclassification analyses. GC performed the best in validation compared with seven prior signatures. GC markers remained prognostic across four independent datasets.

Conclusions

The validated genomic-based classifiers outperform clinical models for predicting postcystectomy bladder cancer recurrence. This may be used to better identify patients who need more aggressive management.

Impact of squamous and glandular differentiation on oncologic outcomes in upper and lower tract urothelial carcinoma

Purpose

To investigate the prognostic significance of squamous and/or glandular differentiation in urothelial carcinoma (UC).

Materials and Methods

Among 800 consecutive patients who underwent radical cystectomy or nephroureterectomy at our institution from January 1990 to December 2010, 696 patients were included for the analysis. Clinicopathologic variables were compared according to the presence of squamous and/or glandular differentiation and the tumor location.

Results

A total of 51 (7.3%) patients had squamous and/or glandular differentiation. Patients with squamous and/or glandular differentiation had higher pathological T stage (p<0.001) and grade (p<0.001) than those with pure form of UC. After the median follow-up of 55.2 months, 84 (24.6%) and 82 (23.1%) died of upper urinary tract UC and UC of bladder, respectively. Patients with squamous and/or glandular differentiation in upper urinary tract UC showed poorer cancer-specific survival (CSS) (p<0.001) and overall survival (OS) (p<0.001) than those with pure form in upper urinary tract UC (p<0.001), but not in UC of bladder (p = 0.178 for CSS and p = 0.172 for OS). On multivariate Cox regression analysis, squamous and/or glandular differentiation was an independent predictor of CSS (hazard ratio [HR] 1.76; 95% confidence interval [CI] 1.08–2.85, p = 0.023), but it was not associated with OS (HR 1.52; 95% CI 1.00–2.32, p = 0.051).

Conclusions

The presence of variant histology could be associated with poorer survival outcome in patients with UC. Squamous and/or glandular differentiation is associated with features of biologically aggressive disease and an independent predictor of CSS.

Nestin is an independent predictor of cancer-specific survival after radical cystectomy in patients with urothelial carcinoma of the bladder

OBJECTIVES

To investigate the association between the expression of nestin, a class VI intermediate filament protein, and pathologic features or survival in patients with urothelial carcinoma of the bladder (UCB).

METHODS

Nestin expression in tumor cells was immunohistochemically studied in 93 patients with UCB who underwent radical cystectomy with pelvic lymphadenectomy. The associations with clinicopathologic parameters were evaluated. Kaplan-Meier survival analysis and Cox proportional hazards models were used to estimate the effect of nestin expression on survival.

RESULTS

Nestin expression in cystectomy specimens was observed in 13 of 93 patients (14.0%). Nestin expression was associated with pathologic tumor stage (p = 0.006). Nestin-negative patients had better overall survival compared with nestin-positive patients (log-rank p = 0.0148). Univariable analysis indicated that nestin expression, lymphovascular invasion, and lymph node status were significantly associated with cancer-specific survival (hazard ratios, 2.78, 2.15, and 2.80, respectively). On multivariable analysis, nestin expression and lymph node status were independent prognostic factors in cancer-specific survival (hazard ratios, 2.45 and 2.65, respectively).

CONCLUSIONS

The results suggest that nestin expression is a novel independent prognostic indicator for patients with UCB and a potentially useful marker to select patients who may be candidates for adjuvant chemotherapy.

Refining patient selection for neoadjuvant chemotherapy before radical cystectomy

PURPOSE

We evaluated the survival of patients with muscle invasive bladder cancer undergoing radical cystectomy without neoadjuvant chemotherapy to confirm the utility of existing clinical tools to identify low risk patients who could be treated with radical cystectomy alone and a high risk group most likely to benefit from neoadjuvant chemotherapy.

MATERIALS AND METHODS

We identified patients with muscle invasive bladder cancer who underwent radical cystectomy without neoadjuvant chemotherapy at our institution between 2000 and 2010. Patients were considered high risk based on the clinical presence of hydroureteronephrosis, cT3b-T4a disease, and/or histological evidence of lymphovascular invasion, micropapillary or neuroendocrine features on transurethral resection. We evaluated survival (disease specific, progression-free and overall) and rate of pathological up staging. An independent cohort of patients from another institution was used to confirm our findings.

RESULTS

We identified 98 high risk and 199 low risk patients eligible for analysis. High risk patients exhibited decreased 5-year overall survival (47.0% vs 64.8%) and decreased disease specific (64.3% vs 83.5%) and progression-free (62.0% vs 84.1%) survival probabilities compared to low risk patients (p <0.001). Survival outcomes were confirmed in the validation subset. On final pathology 49.2% of low risk patients had disease up staged.

CONCLUSIONS

The 5-year disease specific survival of low risk patients was greater than 80%, supporting the distinction of high risk and low risk muscle invasive bladder cancer. The presence of high risk features identifies patients with a poor prognosis who are most likely to benefit from neoadjuvant chemotherapy, while many of those with low risk disease can undergo surgery up front with good expectations and avoid chemotherapy associated toxicity.

[Non-invasive and invasive urothelial tumours: special challenges in uropathological diagnostics]

The current 2004 WHO classification of bladder tumors categorizes non-invasive and invasive urothelial neoplasms into prognostically relevant groups according to the histopathological cell morphology and underlying genetic changes. Although many parts of the classification have not been changed dramatically, even small changes have caused uncertainty and scepticism among urologists and pathologists in recent years. The following review article is structured into various challenges for urologists and pathologists and provides an overview of rare but clinically relevant subgroups and diagnostics, interpretation of diagnoses and pathological findings with respect to consequences for the daily clinical routine (extended diagnosis, therapy and prognosis).

Comparison between neoadjuvant and adjuvant gemcitabine plus cisplatin chemotherapy for muscle-invasive bladder cancer

Aim: Radical cystectomy plus platinum-based perioperative chemotherapy is a standard treatment for patients with clinically localized muscle-invasive bladder cancer. The standard perioperative chemotherapy is methotrexate, vinblastine, doxorubicin and cisplatin (MVAC). However, no prospective randomized trial has been published that compares neoadjuvant and adjuvant chemotherapy for bladder cancer. Moreover, the efficacy of perioperative chemotherapy with gemcitabine plus cisplatin (GC) has not been clarified. In this study we have compared the clinical outcomes between neoadjuvant and adjuvant chemotherapy in patients receiving GC.

Methods: We retrospectively reviewed the records of patients who were scheduled to be treated with a radical cystectomy plus perioperative chemotherapy with GC from 2005 to 2010 at our institution. The primary outcome measure was recurrence-free survival (RFS).

Results: A total of 42 patients received perioperative chemotherapy with GC (25 neoadjuvant, 17 adjuvant). The median number of cycles of GC administered to the two groups was not significantly different. The median duration of follow up was 28.6 months. During the follow-up period, recurrence was observed in nine and three patients in the neoadjuvant and adjuvant groups, respectively. The RFS rate at median follow up was 67 and 76% in the neoadjuvant and adjuvant groups, respectively. No significant difference in RFS at median follow up was observed between the two groups (P = 0.124).

Conclusion: Our results showed no statistically significant difference in RFS between neoadjuvant and adjuvant GC chemotherapy for muscle-invasive bladder cancer. We expect to validate these findings in a prospective randomized trial.

Treatment of locally advanced and metastatic bladder cancer

Background:

There is a significant variation in the treatment strategies adopted for the treatment of locally advanced T3b, T4a, N1-3 and metastatic bladder cancer. There is increasing evidence that we would be able to offer them some benefit in terms of disease-free survival and improving the quality of life. This article is aimed at reviewing the current literature on the treatment strategies in locally advanced and metastatic bladder cancer.

Materials and Methods:

Extensive literature search was done on Medline/Pubmed from 1980-2007 using the key words - treatment of locally advanced, metastatic bladder cancer. Standard textbooks on urology, urologic oncology and monograms were reviewed. Guidelines such as National Comprehensive Cancer Network guidelines, European Urology Association guidelines and American Urology Association guidelines were also studied.

Results and Conclusions:

There is a place for radical cystectomy in locally advanced T3b-T4 and N1-3 bladder cancer. Radical cystectomy alone rarely cures this subgroup of patients. There is increasing evidence that meticulous surgical clearance and extended lymphadenectomy has significant impact on disease-free survival. Adjuvant chemotherapy has been found to be effective in terms of recurrence-free survival and better than cystectomy alone. Neoadjuvant chemotherapy followed by radical cystectomy also has beneficial effects in terms of downstaging the disease and improving recurrence-free survival. This perioperative chemotherapy (adjuvant/neoadjuvant) has 5-7% survival benefit and 10% reduction in the death due to cancer disease. Excellent five-year survival rates have been achieved in patients achieving pT0 stage at surgery following chemotherapy (around 80%) and overall 40% five-year survival in node positive patients, which is promising. Though practiced widely, perioperative chemotherapy is not considered as a standard of care as yet. Current ongoing trials are likely to help us in reaching a consensus over this. There is no role of preoperative or postoperative radiotherapy in locally advanced/metastatic bladder cancer except in non TCC bilharzial/squamous cell carcinoma of bladder. Use of nomograms and prognostic factor evaluation may help us in the future in predicting the disease relapse and may help us in tailoring the treatment accordingly. Newer and more effective chemotherapeutic drugs and ongoing trials will have a significant impact on the treatment strategies and outcome of these patients in the future.

Histologic variants of urothelial bladder cancer and nonurothelial histology in bladder cancer

Bladder cancer can be classified histologically as urothelial or non-urothelial. Urothelial cancer has a propensity for divergent differentiation, which has increasingly been recognized in recent years due to heightened awareness and improved immunohistochemistry techniques. Furthermore, the recent World Health Organization classification of urothelial cancers improved clarity on this issue, with its listing of 13 histologic variants of urothelial cancer. The divergent differentiation patterns include, amongst others, squamous, glandular, micropapillary, nested, lymphepithelioma-like, plasmacytoid and sarcomatoid variants of urothelial cancer. Attempts to quantify the amount of divergent differentiation present, such as using the nonconventional differentiation number, have been made recently, which will improve the ability to compare publications from different centres. Genetic-based studies have indicated that the histologic variants of urothelial cancer arise from a common clonal precursor. Mostly, the current evidence suggests that urothelial cancer with divergent differentiation has a worse prognosis when compared with pure urothelial cancer. This article will review the current literature on variant histologies of urothelial cancer, and well as new developments in pure squamous cell carcinoma, small cell carcinoma and adenocarcinoma of the bladder.

The effectiveness of off-protocol adjuvant chemotherapy for patients with urothelial carcinoma of the urinary bladder

PURPOSE

The role of adjuvant chemotherapy for patients with high-risk urothelial carcinoma of the bladder (UCB) is not well defined. Here we address the value of adjuvant chemotherapy in patients undergoing radical cystectomy for UCB in an off-protocol routine clinical setting.

EXPERIMENTAL DESIGN

We collected and analyzed data from 11 centers contributing retrospective cohorts of patients with UCB treated with radical cystectomy without neoadjuvant chemotherapy. Patients were grouped into quintiles based on their risk of disease progression using estimates from a fitted multivariable Cox proportional hazards model. The association of adjuvant chemotherapy with survival was explored across separate quintiles.

RESULTS

The cohort consisted of 3,947 patients, 932 (23.6%) of whom received adjuvant chemotherapy. Adjuvant chemotherapy was independently associated with improved survival (hazard ratio, 0.83; 95% confidence interval, 0.72-0.97%, P = 0.017). However, the effect of adjuvant chemotherapy was significantly modified by the individual's risk of disease progression such that an increasing benefit from adjuvant chemotherapy was seen across higher-risk subgroups (P < 0.001). There was a significant improvement in survival between the treated and nontreated patients in the highest-risk quintile (hazard ratio, 0.75; 95% confidence interval, 0.62-0.90; P = 0.002). This group was characterized by an estimated 32.8% 5-year probability of cancer-specific survival, with 86.6% of patients having both advanced pathologic stage (> or =T(3)) and nodal involvement.

CONCLUSION

Adjuvant chemotherapy is associated with a significant improvement in survival for patients treated in an off-protocol clinical setting. Selective administration in patients at the highest risk for disease progression, such as those with advanced pathologic stage and nodal involvement, may optimize the therapeutic benefit of adjuvant chemotherapy.

Adjuvant and neoadjuvant radiotherapy for bladder cancer: revisited

To date, radical cystectomy has continued to be the treatment of choice for muscle-invasive bladder cancer. It is associated with a 5-year disease-free survival rate ranging from 27–55%. This outcome is significantly worse when reporting upon locally advanced cases. The independent prognostic factors include: tumor stage, grade, pelvic nodal involvement and some other additional factors. Beside the higher reported incidence of distant metastasis, local recurrence either alone or combined with systemic relapse has been shown to be experienced by 23–50% of locally advanced patients – a rate that was much more frequent than previously believed. Nonrandomized trials of preoperative radiotherapy have suggested improved survival rates. However, only one out of the six randomized preoperative trials in the literature published in English has proved to be significant. On the other hand, the only randomized trial and most retrospective studies dealing with postoperative radiotherapy revealed a significant increase in disease-free survival. Late complications of post operative radiotherapy, contrary to former belief, were acceptable and generally depended upon the volume of the irradiated normal tissues and the radiotherapy techniques used. Most of these adjuvant or neoadjuvant reports were performed in the 1970s and 1980s using conventional radiation techniques. Modern radiotherapy, delivering higher doses to the tumor while saving a significant amount of the surrounding normal structure, has not been rigorously tested. However, these techniques have already succeeded in improving treatment end results in other pelvic tumors.

The role of adjuvant chemotherapy in patients with locally advanced (pT3, pT4a) and/or lymph node-positive bladder cancer

OBJECTIVE

To report the long-term follow up of patients with locally advanced bladder cancer treated with either adjuvant chemotherapy with gemcitabine/cisplatin (GC) or methotrexate, vinblastine, epirubicin, and cisplatin (MVEC) or no additional treatment after radical cystectomy, to examine various survival endpoints and factors associated with long-term survival.

PATIENTS AND METHODS

Seventy-eight patients undergoing radical cystectomy for pathologic stage T3, T4 or lymph node-positive (N+) bladder cancer were divided to observation group (46 patients) and adjuvant chemotherapy group (32 patients). Data were obtained for recurrence free (RFS) and overall survival (OS).

RESULTS

One-, 2- and 5-year RFS rates were 74, 56.8 and 51.1% for chemotherapy arm, whereas these ratios were 50.6, 31 and 27.6% for control arm, respectively (P = 0.032). RFS rates were significantly better in patients with lymph node-negative disease than in those with positive lymph nodes for control arm (P = 0.007), but for the chemotherapy arm there was no statistical difference between patients with lymph node-negative and -positive disease (P = 0.28). Mean OS and RFS times were 31.03 and 28.4 months for chemotherapy arm, while they were 22.17 and 18.09 months for control arm, respectively (P = 0.142, P = 0.196). On multivariate analysis, lymph node metastasis and adjuvant chemotherapy remained significant independent prognostic factors for cancer-specific survival.

CONCLUSIONS

Bladder cancer is chemosensitive, and using adjuvant chemotherapy is likely to improve the outcome of local treatment and to decrease the rates of distant metastases.

Comprehensive surgical and chemotherapy treatment for invasive bladder cancer

INTRODUCTION

The treatment of transitional cell bladder cancer with muscular invasion remains difficult, due to the numerous patterns of biological behaviour of the disease. There is controversy regarding the application of systemic therapy in invasive bladder carcinoma and the ideal time for the indication of perioperative chemotherapy. This is an overview of systemic therapy in invasive bladder cancer.

MATERIALS AND METHODS

Using MEDLINE, we reviewed relevant English and Spanish literature published during the last five years, with "chemotherapy in bladder cancer" as keywords. We selected randomised trials, meta-analyses and clinical trials.

RESULTS

We obtained 241 articles, 31 of which referred to neoadjuvant and adjuvant chemotherapy in invasive bladder cancer. We classified the articles into three different groups: neoadjuvant, adjuvant and neoadjuvant plus chemotherapy. This information is shown in the tables within the text.

CONCLUSIONS

A multidisciplinary approach to the treatment of invasive bladder cancer is essential to guarantee adequate oncological control. Detailed evaluation and proper selection of each patient is fundamental in determining the best moment to start chemotherapy.

Lymphovascular invasion in radical cystectomy specimen: is it an independent prognostic factor in patients without lymph node metastases?

PURPOSE

To determine the prognostic significance of lymphovascular invasion (LVI) in patients with urothelial carcinoma of the bladder undergoing radical cystectomy (RC) and bilateral pelvic lymph node dissection.

METHODS

From 1992 to 2008, 526 patients underwent RC and pelvic lymphadenectomy at our institution by a single surgical team. All relevant data were entered into a database and analyzed. LVI was defined as "the presence of tumor cells within an endothelial lined space." The exclusion criteria were non-TCC histology, salvage cystectomy, neoadjuvant chemotherapy, and unknown LVI status.

RESULTS

A total of 357 patients met the inclusion criteria. Overall prevalence of LVI was 29%. LVI was significantly associated with higher T stage, lymph node (LN) metastases, and higher grade. Patients with LVI had significantly higher recurrence rate (P < 0.001) and decreased long-term survival (P < 0.001). In patients without LN metastases, LVI in the primary led to a significantly decreased recurrence-free (P = 0.003) and disease-specific survival (P = 0.001). In the presence of LN metastases, LVI did not significantly alter the recurrence-free or disease-specific survival. On multivariate analysis, T stage (P < 0.0001) and LN metastases (P = 0.01) were significant independent prognostic factors influencing disease-specific survival. LVI did not have independent prognostic value. T stage was the only significant prognostic factor in the lymph node negative group.

CONCLUSIONS

Although, the presence of LVI in node-negative patients is an adverse prognostic factor on univariate analysis of disease-specific survival, it is not an independent prognostic factor on multivariate analysis. Pathological stage is the only independent prognostic factor for survival.

Micropapillary bladder cancer: a review of Léon Bérard Cancer Center experience

Background

Micropapillary bladder cancer is a rare and aggressive variant of urothelial carcinoma. A retrospective review of our experience in management of patients with muscle-invasive or metastatic micropapillary bladder cancer was performed to better define the behavior of this disease.

Methods

We reviewed the records of the 11 patients with micropapillary bladder cancer who were evaluated and treated at Léon Bérard Cancer Center between 1994 and 2007, accounting for 1,2% of all urothelial tumors treated in this institution.

Results

Mean patients age was 60 years. The majority of patients (72%) were diagnosed after 2004. After a median follow-up of 31.7 months, median overall survival was 19 months. Two patients presented with stage II, one with stage III and eight with stage IV disease All 5 patients who had node positive metastases and treated with radical surgery and adjuvant chemotherapy relapsed and had a disease free survival of 9.6 months.

Conclusion

Micropapillary bladder cancer is probably an underreported variant of urothelial carcinoma associated with poor prognosis. Adjuvant chemotherapy might have a questionable efficacy and the optimal treatment strategy is yet to be defined.

Neoadjuvant and adjuvant chemotherapy in muscle-invasive bladder cancer

CONTEXT

The use of neoadjuvant and adjuvant chemotherapy in the treatment of muscle-invasive bladder cancer is still controversial.

OBJECTIVE

To determine the optimal use of chemotherapy in the neoadjuvant and adjuvant settings in patients with advanced urothelial cell carcinoma. Bladder preservation is also discussed.

EVIDENCE ACQUISITION

A critical review of the published literature on chemotherapy for patients with locally advanced bladder cancer was performed.

EVIDENCE SYNTHESIS

The presence of occult micrometastases at the time of radical cystectomy leads to both distant and local failure in patients with locally advanced transitional cell carcinoma of the bladder. Both neoadjuvant and adjuvant therapies have been evaluated in patients with locally advanced bladder cancer. Studies evaluating adjuvant chemotherapy have been limited by inadequate statistical power to detect meaningful clinical answers as well as by experimental arms utilizing inadequate chemotherapy.

CONCLUSIONS

The aggregate of available evidence suggests that neoadjuvant cisplatin-based combination chemotherapy should be considered as a standard of care for patients with muscle-invasive or locally advanced operable bladder cancer. In patients who are either unfit for or refuse radical cystectomy, neoadjuvant chemotherapy with or without radiation can render bladder preservation possible for patients who attain an excellent clinical response. With the introduction of new cytotoxic drugs, there is a need for well-designed studies to address the optimal utility of perioperative therapy in high-risk patients with bladder cancer.

Adjuvant chemotherapy of bladder cancer

BACKGROUND

Bladder cancer is one of the most common genitourinary cancer. 1/3 of patients presents with invasive disease. Radical cystectomy is the standard treatment for patients with muscle invasive disease: although local treatment can be curative, about 50% of patients will develop distant metastases. Optimal treatment for high risk patients includes local and perioperative systemic therapy (adjuvant or neoadjuvant chemotherapy).

PATIENTS AND METHODS

We performed a review of clinical trials and metanalysis of adjuvant treatment for muscle-invasive bladder cancer.

RESULTS

Data from single published trials of adjuvant chemotherapy (CT) are not univocal, and several methodological problems were found. A recent meta-analysis of individual patient data (IPD) from all eligible published and unpublished trials, found that adjuvant chemotherapy administration provides a significant survival and disease free survival advantage. Two large, multi-center, randomized trials are on-going to clarify the role of post-operative CT.

CONCLUSIONS

A trend in favour of adjuvant chemotherapy comes out from some of the trials reviewed by us and by the metanalysis performed by the ABC collaborative group. However it is not clear yet which patients might derive the maximum benefit from such an approach and which ones might be safety candidate to deferred treatment, on relapse. The incoming results of the EORTC trial and of the Italian trial which are currently comparing the value of early vs. deferred treatment of patients at higher risk of relapse will probably provide an adequate answer to this question. Outside clinical trials, the potential benefit of adjuvant chemotherapy should be appropriately weighted versus the putative hazards and decision making appropriately tailored in the individual patients according to the aggressiveness of his/her disease and the presence of comorbidities.

Muscle-Invasive Bladder Cancer: Predictive Factors and Prognostic Difference Between Primary and Progressive Tumors

OBJECTIVES

To establish whether a difference in the clinical outcomes of patients with progressive and primary muscle-invasive bladder cancer exists.

METHODS

The records of patients who had undergone radical cystectomy for bladder urothelial carcinoma from 1990 to 2005 were reviewed. According to our inclusion criteria, 109 patients with primary muscle-invasive tumor (group 1) and 45 patients with progressive tumors were selected (group 2). The correlation of clinical and pathologic variables with survival was investigated using the Cox proportional hazards test. The Kaplan-Meier method was used to estimate progression rates. Multivariate analysis was performed using the Cox regression survival method to investigate possible predictive factors.

RESULTS

The 2, 3, and 5-year cancer-specific survival rate was 72%, 61%, and 43% for patients with progressive tumor and 75%, 62%, and 54% for patients with primary tumor, respectively (P >0.05). For lymph node-negative tumors (pN0), the corresponding rates were 77%, 64%, and 56% in group 1 and 73%, 60%, and 39% in group 2 (P >0.05). On multivariate analysis, lymphovascular invasion and pT stage of the primary tumor remained significant independent prognostic factors for cancer-specific survival. The detection of local and/or distant metastasis during follow-up significantly shortened the cancer-specific survival of patients with muscle-invasive bladder cancer.

CONCLUSIONS

The results of our study have shown that patients with progressive muscle-invasive urothelial tumors do not have a worse prognosis than do those with primary tumors. During the early postoperative years, even patients with progressive tumors had better disease-specific survival rates. For both groups, pT stage and lymphovascular invasion seemed to be independent predictors of decreased cancer-specific survival.

Clinical and therapeutic significance of aberrant differentiation patterns in bladder cancer

Pure urothelial carcinoma makes up 90-95% of all bladder cancer. The remaining 5-10% represent urothelial carcinoma with aberrant differentiation patterns and nonurothelial carcinoma. Reviews on this topic often focus on the pathological features of these histologic subtypes. In this review we have summarized the clinical significance of each major histologic pattern and analyzed the response of each to standard treatment modalities. The main limitation to optimizing management is the inability to perform clinical trials owing to the rarity of these tumors. This can be circumvented to some degree by extrapolating knowledge acquired from more common similar tumors in other organ sites. Ultimately, however, multicenter clinical trials will need to be organized to address some key management issues.

Effectiveness of Adjuvant Chemotherapy in Transitional Cell Carcinoma of the Urinary Bladder with Lymph Node Involvement and/or Lymphovascular Invasion Treated by Radical Cystectomy

OBJECTIVES

To assess the effect of adjuvant chemotherapy on the postoperative survival of patients with transitional cell carcinoma of the bladder and lymph node involvement and/or lymphovascular invasion (LVI).

METHODS

We retrospectively analyzed the data from 260 patients who had undergone radical cystectomy for transitional cell carcinoma of the bladder. Of these 260 patients, 85 (33%) had nodal involvement and 125 (48%) had LVI. Chemotherapy, consisting of three to six cycles of either methotrexate, vinblastine, cisplatin, and doxorubicin or gemcitabine and cisplatin, was administered to 17 (26.6%) of 64 patients with pT3-4N0 disease and 43 (50.6%) of 85 patients with node-positive disease. We determined the factors influencing cancer-specific survival and the effect of chemotherapy according to pathologic stage, LVI, and nodal status. The mean follow-up was 43.8 months (range, 3 to 180; median 33.6).

RESULTS

The overall 5-year cancer-specific survival rate was 65.6%. When we considered nodal involvement and LVI simultaneously, the 5-year survival rate was 92.2% for the node and LVI-negative patients, 60.7% for the node-negative but LVI-positive patients, and 32.5% for the node-positive patients. Chemotherapy was beneficial in the node-positive patients (5-year survival rate of 37.4% versus 26.9%; P = 0.0035) but not beneficial in the node-negative patients, regardless of LVI status. When subclassifying node-positive patients with regard to N stage or LVI status, the effect of chemotherapy was limited to those with Stage N2 (P = 0.002) or LVI-positive status (P = 0.001).

CONCLUSIONS

Adjuvant chemotherapy would be beneficial in patients with node-positive transitional cell carcinoma, especially those with a high nodal disease burden (Stage N2) or LVI, after radical cystectomy.

Chemotherapy for bladder cancer: treatment guidelines for neoadjuvant chemotherapy, bladder preservation, adjuvant chemotherapy, and metastatic cancer

To determine the optimal use of chemotherapy in the neoadjuvant, adjuvant, and metastatic setting in patients with advanced urothelial cell carcinoma, a consensus conference was convened by the World Health Organization (WHO) and the Société Internationale d'Urologie (SIU) to critically review the published literature on chemotherapy for patients with locally advanced bladder cancer. This article reports the development of international guidelines for the treatment of patients with locally advanced bladder cancer with neoadjuvant and adjuvant chemotherapy. Bladder preservation is also discussed, as is chemotherapy for patients with metastatic urothelial cancer. The conference panel consisted of 10 medical oncologists and urologists from 3 continents who are experts in this field and who reviewed the English-language literature through October 2004. Relevant English-language literature was identified with the use of Medline; additional cited works not detected on the initial search regarding neoadjuvant chemotherapy, bladder preservation, adjuvant chemotherapy, and chemotherapy for patients with metastatic urothelial cancer were reviewed. Evidence-based recommendations for diagnosis and management of the disease were made with reference to a 4-point scale. Results of the authors' deliberations are presented as a consensus document. Meta-analysis of randomized trials on cisplatin-containing combination neoadjuvant chemotherapy revealed a 5% difference in favor of neoadjuvant chemotherapy. No randomized trials have yet compared survival with transurethral resection of bladder tumor alone versus cystectomy for the management of patients with muscle-invasive disease. Collaborative international adjuvant chemotherapy trials are needed to assist researchers in assessing the true value of adjuvant chemotherapy. Systemic cisplatin-based combination chemotherapy is the only current modality that has been shown in phase 3 trials to improve survival in responsive patients with advanced urothelial cancer. A panel of international experts has formulated grade A through D recommendations for the management of patients with locally advanced and metastatic urothelial cancer on the basis of level 1 to 3 evidence and the findings of phase 2 trials, prospective randomized clinical trials, and meta-analyses.