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Bruins HM, Stein JP. Risk factors and clinical outcomes of patients with node-positive muscle-invasive bladder cancer. Expert Rev Anticancer Ther 2014; 8:1091-101. [DOI: 10.1586/14737140.8.7.1091] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Liew MS, Azad A, Tafreshi A, Eapen R, Bolton D, Davis ID, Sengupta S. USANZ: Time-trends in use and impact on outcomes of perioperative chemotherapy in patients treated with radical cystectomy for urothelial bladder cancer. BJU Int 2013; 112 Suppl 2:74-82. [DOI: 10.1111/bju.12384] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Mun Sem Liew
- Joint Austin-Ludwig Oncology Unit; Austin Health
- Ludwig Institute for Cancer Research; Austin Health
- University of Melbourne
| | - Arun Azad
- Joint Austin-Ludwig Oncology Unit; Austin Health
- Ludwig Institute for Cancer Research; Austin Health
| | - Ali Tafreshi
- Joint Austin-Ludwig Oncology Unit; Austin Health
| | | | - Damien Bolton
- Department of Urology; Austin Health
- University of Melbourne
| | - Ian D. Davis
- Joint Austin-Ludwig Oncology Unit; Austin Health
- Ludwig Institute for Cancer Research; Austin Health
- Department of Oncology; Eastern Health
- University of Melbourne
- Eastern Health Clinical School; Monash University
| | - Shomik Sengupta
- Ludwig Institute for Cancer Research; Austin Health
- Department of Urology; Austin Health
- University of Melbourne
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53
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Leow JJ, Martin-Doyle W, Rajagopal PS, Patel CG, Anderson EM, Rothman AT, Cote RJ, Urun Y, Chang SL, Choueiri TK, Bellmunt J. Adjuvant chemotherapy for invasive bladder cancer: a 2013 updated systematic review and meta-analysis of randomized trials. Eur Urol 2013; 66:42-54. [PMID: 24018020 DOI: 10.1016/j.eururo.2013.08.033] [Citation(s) in RCA: 295] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 08/13/2013] [Indexed: 12/21/2022]
Abstract
CONTEXT The role of adjuvant chemotherapy remains poorly defined for the management of muscle-invasive bladder cancer (MIBC). The last meta-analysis evaluating adjuvant chemotherapy, conducted in 2005, had limited power to fully support its use. OBJECTIVE To update the current evidence of the benefit of postoperative adjuvant cisplatin-based chemotherapy compared with control (ie, surgery alone) in patients with MIBC. EVIDENCE ACQUISITION A comprehensive literature review was performed to identify all randomized controlled trials (RCTs) comparing adjuvant cisplatin-based chemotherapy with control for patients with MIBC. The search included the Medline, Embase, Cochrane Central Register of Controlled Trials databases, and abstracts from the American Society of Clinical Oncology meetings up to May 2013. An updated systematic review and meta-analysis was performed. EVIDENCE SYNTHESIS A total of 945 patients included in nine RCTs (five previously analyzed, one updated, and three new) were examined. For overall survival, the pooled hazard ratio (HR) across all nine trials was 0.77 (95% confidence interval [CI], 0.59-0.99; p=0.049). For disease-free survival, the pooled HR across seven trials reporting this outcome was 0.66 (95% CI, 0.45-0.91; p=0.014). This disease-free survival benefit was more apparent among those with positive nodal involvement (p=0.010). CONCLUSIONS This updated and improved meta-analysis of randomized trials provides further evidence of an overall survival and disease-free survival benefit in patients with MIBC receiving adjuvant cisplatin-based chemotherapy after radical cystectomy.
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Affiliation(s)
- Jeffrey J Leow
- Harvard School of Public Health, Harvard University, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA; Division of Urology, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Padma S Rajagopal
- Harvard School of Public Health, Harvard University, Boston, MA, USA
| | - Chirayu G Patel
- Harvard School of Public Health, Harvard University, Boston, MA, USA
| | - Erin M Anderson
- Harvard School of Public Health, Harvard University, Boston, MA, USA
| | - Andrew T Rothman
- Harvard School of Public Health, Harvard University, Boston, MA, USA
| | - Richard J Cote
- Department of Pathology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Yuksel Urun
- Bladder Cancer Center, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Steven L Chang
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA; Division of Urology, Brigham and Women's Hospital, Boston, MA, USA
| | - Toni K Choueiri
- Bladder Cancer Center, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Joaquim Bellmunt
- Bladder Cancer Center, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA; University Hospital del Mar-IMIM, Barcelona, Spain.
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Gupta S, Mahipal A. Role of Systemic Chemotherapy in Urothelial Urinary Bladder Cancer. Cancer Control 2013; 20:200-10. [DOI: 10.1177/107327481302000308] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Shilpa Gupta
- Department of Genitourinary Oncology H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Amit Mahipal
- Clinical Research Unit H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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Yafi FA, Tanguay S, Rendon R, Jacobsen N, Fairey A, Izawa J, Kapoor A, Black P, Lacombe L, Chin J, So A, Lattouf JB, Bell D, Fradet Y, Saad F, Matsumoto E, Drachenberg D, Cagiannos I, Kassouf W. Adjuvant chemotherapy for upper-tract urothelial carcinoma treated with nephroureterectomy: assessment of adequate renal function and influence on outcome. Urol Oncol 2013; 32:31.e17-24. [PMID: 23428535 DOI: 10.1016/j.urolonc.2012.11.014] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 11/13/2012] [Accepted: 11/19/2012] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Upper-tract urothelial carcinoma (UTUC) is associated with poor outcomes. Our aim was to assess adequacy of renal function and evaluate the role of adjuvant chemotherapy (AC) in patients with UTUC treated by radical nephroureterectomy (RNU) in a universal health care system. MATERIALS AND METHODS Retrospective data from 1,029 patients treated with RNU across 10 Canadian academic centers were collected. Tested variables included various clinico-pathological parameters, the use of perioperative chemotherapy, preoperative and postoperative creatinine values, and estimated glomerular filtration rates (eGFR). Univariable and multivariable Cox regression models addressed overall survival and disease-specific survival after surgery. Kaplan-Meier survival curves were used to compare outcomes in patients who received or did not receive AC. RESULTS Median age of patients was 70 years with a median follow-up of patients who were alive of 26 months. The median preoperative and postoperative eGFR rates were 59 mL/min/1.73 m(2) and 47 mL/min/1.73 m(2), respectively. Using a cutoff eGFR of 60, 49% of all the patients and 48% of the patients with ≥ pT3 or pTxN+ or both diseases would have been eligible for cisplatin-based chemotherapy preoperatively and only 18% and 21% of the patients, respectively remained eligible postoperatively. Of the patients who received AC, 75% had an eGFR<60. On multivariate analysis, AC was not prognostic for improved overall survival or disease-specific survival. CONCLUSIONS Chronic kidney disease is common in patients with UTUC. Following RNU, 57% of the high-risk patients with good preoperative renal function became ineligible for cisplatin-based chemotherapy. Use of AC did not translate into improved survival. Whether this is due to inherent biases of retrospective analysis, limited efficacy of AC in patients with UTUC, or use of suboptimal regimen or dose because of poor postoperative renal function requires further evaluation.
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Affiliation(s)
- Faysal A Yafi
- Department of Surgery (Urology), McGill University, Montreal, Quebec, Canada
| | - Simon Tanguay
- Department of Surgery (Urology), McGill University, Montreal, Quebec, Canada
| | - Ricardo Rendon
- Department of Urology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Niels Jacobsen
- Department of Surgery (Urology), University of Alberta, Edmonton, Alberta, Canada
| | - Adrian Fairey
- Department of Surgery (Urology), University of Alberta, Edmonton, Alberta, Canada
| | - Jonathan Izawa
- Department of Surgery (Urology), University of Western Ontario, London, Ontario, Canada
| | - Anil Kapoor
- Department of Surgery (Urology), McMaster University, Hamilton, Ontario, Canada
| | - Peter Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Louis Lacombe
- Department of Surgery (Urology), Laval University, Quebec, Quebec, Canada
| | - Joe Chin
- Department of Surgery (Urology), University of Western Ontario, London, Ontario, Canada
| | - Alan So
- Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - David Bell
- Department of Urology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Yves Fradet
- Department of Surgery (Urology), Laval University, Quebec, Quebec, Canada
| | - Fred Saad
- Department of Surgery (Urology), University of Montreal, Montreal, Quebec, Canada
| | - Edward Matsumoto
- Department of Surgery (Urology), McMaster University, Hamilton, Ontario, Canada
| | - Darrel Drachenberg
- Department of Surgery (Urology), University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ilias Cagiannos
- Department of Surgery (Urology), University of Ottawa, Ottawa, Ontario, Canada
| | - Wassim Kassouf
- Department of Surgery (Urology), McGill University, Montreal, Quebec, Canada.
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Dall'Era MA, Cheng L, Pan CX. Contemporary management of muscle-invasive bladder cancer. Expert Rev Anticancer Ther 2013; 12:941-50. [PMID: 22845409 DOI: 10.1586/era.12.60] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The current standard treatment for muscle-invasive nonmetastatic bladder cancer is neoadjuvant platinum-based chemotherapy followed by radical cystectomy. However, neoadjuvant chemotherapy is not widely accepted even with level 1 evidence. Adjuvant chemotherapy should be discussed if patients have not received neoadjuvant chemotherapy before surgery and have high-risk pathologic features. Although not considered standard of care, bladder-sparing therapy can be considered for highly selected patients and for those medically unfit for surgery. Even though there are no level 1 data, the treatment outcomes for highly select patients given bladder-sparing therapy appear promising, with many patients retaining a functional bladder. Personalized chemotherapy is currently being actively pursued to target the underlying molecular changes and tailor to individual needs.
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Affiliation(s)
- Marc A Dall'Era
- Department of Urology, University of California Davis, 4860 Y Street, Suite 3500, Sacramento, CA 95817, USA.
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Neoadjuvant chemotherapy improves survival rate in advanced urothelial carcinoma. Kaohsiung J Med Sci 2012; 29:200-5. [PMID: 23541265 DOI: 10.1016/j.kjms.2012.08.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Accepted: 12/01/2011] [Indexed: 01/08/2023] Open
Abstract
Radical surgery (RS) with adjuvant chemotherapy (AC) or radiotherapy has been conventionally used for patients with advanced urothelial carcinoma (AUC). Recent research has indicated that systemic neoadjuvant chemotherapy (NC) with RS yields better outcomes than RS alone for patients with locally advanced bladder cancer. However, there are no reports indicating whether NC or AC would be beneficial for patients with AUC. The present study compared the survival rate for AUC patients receiving NC or AC. A retrospective analysis was conducted using data for 64 patients with AUC who underwent RS and systemic chemotherapy at our institution between March 2002 and March 2011. Of the 64 patients, 30 received NC before RS and 34 received RS followed by systemic AC. Pathologic stages (p=0.002), grades (p=0.018) and lymphovascular invasion (p=0.047) were significantly lower in the patients who received NC first than in those who received RC first. Furthermore, analysis of the surgical specimens revealed that 26.7% of patients who received NC before RS had complete remission. There were no significant differences in demographic data, surgical complications, and chemotoxicity between the two patient groups. The progression-free survival (PFS) and overall survival (OS) of patients who received initial NC were significantly better than those of patients who received initial RC (p=0.002 and 0.018, respectively). Our results indicate that NC administration before RS significantly improved the PFS and OS of AUC patients, without increasing surgical complications and chemotoxicity. Further prospectively controlled trials need to be conducted to confirm the effectiveness of NC for AUC patients.
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58
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Raghavan D, Burgess E, Gaston KE, Haake MR, Riggs SB. Neoadjuvant and adjuvant chemotherapy approaches for invasive bladder cancer. Semin Oncol 2012; 39:588-97. [PMID: 23040255 DOI: 10.1053/j.seminoncol.2012.08.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Deeply invasive bladder cancer, representing approximately 20% of incident cases, is cured by radical cystectomy or radiotherapy in less than 50% of cases. In an effort to improve cure rates, based on objective response rates in metastatic disease of 40%-70% from combination chemotherapy regimens, systemic chemotherapy has been incorporated into programs of definitive treatment for this disease. Several randomized trials and a meta-analysis have confirmed a survival benefit from neoadjuvant chemotherapy followed by definitive local treatment, reflecting both median survival figures and cure rates. Despite several promising phase II trials, no randomized trial of classical adjuvant chemotherapy for bladder cancer has demonstrated an overall survival benefit, despite increments in disease-free survival. Molecular prognostication has been studied in an effort to improve the utility of systemic therapy for invasive non-metastatic bladder cancer, but randomized trials have not shown associated survival benefit. Despite level 1 evidence of a survival benefit from neoadjuvant MVAC (methotrexate, vinblastine, doxorubicin [Adriamycin], cisplatin) or cisplatin, methotrexate, and vinblastine (CMV) chemotherapy, more than 50% of incident cases do not receive such treatment.
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Affiliation(s)
- Derek Raghavan
- Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC, USA.
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59
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Lee EK, Herr HW, Dickstein RJ, Kassouf W, Munsell MF, Grossman HB, Dinney CPN, Kamat AM. Lymph node density for patient counselling about prognosis and for designing clinical trials of adjuvant therapies after radical cystectomy. BJU Int 2012; 110:E590-5. [PMID: 22758775 DOI: 10.1111/j.1464-410x.2012.11325.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED What's known on the subject? and What does the study add? Patients with positive lymph nodes at radical cystectomy have a poor prognosis. The actual outcome of patients varies based on many factors, among which lymph node density has emerged as being more informative than nodal status of TNM staging. We combined clinical data from two major cancer centres in the USA and identified patients with an adequate lymphadenectomy and no perioperative chemotherapy to understand the natural history of the disease. Using this information, we created prognostic tools incorporating lymph node density that can be used for risk stratification, patient counselling and clinical trial design. OBJECTIVE • To develop a clinical tool based on lymph node density (LND) for patient counselling after radical cystectomy and for design of clinical trials of adjuvant therapies after radical cystectomy. PATIENTS AND METHODS • Using pooled data from two comprehensive cancer centres, we identified patients with lymph node metastases after radical cystectomy who received an adequate lymph node dissection according to existing literature (resection of eight or more nodes). • Only patients who had not received neoadjuvant or adjuvant chemotherapy were included to ensure that prediction models were based on the natural course of the disease. • Thresholds for LND ranging from 5% to 35%, in 5% increments, were used to dichotomize the study population. Within each set of two groups, the Kaplan-Meier product-limit estimator was used to estimate disease-specific survival (DSS) for each group, and Cox proportional hazards regression was used to test the significance of differences in DSS between the group with higher LND and the group with lower LND. • Tables and graphs showing the relationship between LND categories and 2-year and 5-year estimated DSS were created to aid in clinical decision-making. RESULTS • LND was valuable as a tool for stratifying node-positive patients into different risk groups based on expected survival. • At each LND threshold from 10% to 35%, patients with higher LND had significantly worse DSS than patients with lower LND (P ≤ 0.001). • As expected, DSS in the higher-LND group worsened with each 5% increase in LND threshold: patients with LND > 35% had a 5-year DSS rate of 4%. • Using our data as a tool, multiple cut-offs can be employed to categorize patients into various risk groups with different risk. For example, patients with LND ≤ 10% have an estimated 5-year DSS rate of 61.9%, whereas patients with LND > 15% have an estimated 5-year DSS rate of 19.2%. CONCLUSIONS • Patients with node-positive bladder cancer have poor outcomes, and survival varies widely according to LND. • Categorical LND should be used to risk-stratify patients for counselling regarding prognosis. • Furthermore, categorical LND should be used as a tool for designing and reporting on clinical trials of adjuvant therapies.
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Affiliation(s)
- Eugene K Lee
- Department of Urology Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Apolo AB, Grossman HB, Bajorin D, Steinberg G, Kamat AM. Practical use of perioperative chemotherapy for muscle-invasive bladder cancer: summary of session at the Society of Urologic Oncology annual meeting. Urol Oncol 2012; 30:772-80. [PMID: 23218068 PMCID: PMC3524835 DOI: 10.1016/j.urolonc.2012.01.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 01/26/2012] [Accepted: 01/27/2012] [Indexed: 11/29/2022]
Abstract
At the 11th annual meeting of the Society of Urologic Oncology, an expert panel was convened to discuss the practical use of perioperative chemotherapy for muscle-invasive bladder cancer. The discussion was structured as a case-based debate among the panelists. The topics included: neoadjuvant chemotherapy with a focus on T2 disease, pros and cons, survival data, tolerability of cisplatin-based therapy, can we avoid radical cystectomy in complete responders, limitations and alternatives to cisplatin-based therapy, management of 'suboptimal' chemotherapy, residual disease after neoadjuvant chemotherapy, adjuvant chemotherapy, and key aspects of radical cystectomy and lymph-node dissection in multimodal therapy. The presentations were derived from published literature. The panelists agreed that patients with muscle-invasive bladder cancer should be managed with a multidisciplinary team, including urologist and medical oncologist. Cisplatin-based neoadjuvant chemotherapy has demonstrated improved survival and should be incorporated into the management of all eligible patients with muscle-invasive bladder cancer. However, in some centers, neoadjuvant chemotherapy is reserved for patients with >T2 disease or high-risk features. There are no data for the administration of non-cisplatin-based neoadjuvant chemotherapy, such as carboplatin-combinations. Cisplatin-ineligible patients should proceed directly to surgical extirpation with adjuvant cisplatin-based chemotherapy considered based on pathologic findings. However, the data for adjuvant chemotherapy is less compelling. As our refinement of the selection process continues, we may be able to better identify subsets of patients who may be spared chemotherapy, but much work remains to be done in this arena. The current standard for muscle-invasive bladder cancer patients is cisplatin-based neoadjuvant chemotherapy followed by radical cystectomy and pelvic lymph-node dissection.
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Affiliation(s)
- Andrea B. Apolo
- Medical Oncology Branch, National Cancer Institute, Bethesda, Maryland
| | - H. Barton Grossman
- Department of Urology, University of Texas MD Anderson Cancer, Houston, TX
| | - Dean Bajorin
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center
| | - Gary Steinberg
- Section of Urology, University of Chicago Medical Center, Chicago, IL
| | - Ashish M. Kamat
- Department of Urology, University of Texas MD Anderson Cancer, Houston, TX
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Cordier J, Sonpavde G, Stief CG, Tilki D. Oncologic outcomes obtained after neoadjuvant and adjuvant chemotherapy for the treatment of urothelial carcinomas of the upper urinary tract: a review. World J Urol 2012; 31:77-82. [PMID: 23053212 DOI: 10.1007/s00345-012-0960-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Accepted: 09/18/2012] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Nephroureterectomy with excision of a bladder cuff is the gold standard in the treatment of upper urinary tract carcinomas (UTUC). But especially for patients suffering from advanced tumor stages, life expectancy has not improved over the years with local recurrence or distant metastases being the main reasons for treatment failure. Chemotherapy in an adjuvant or neoadjuvant setting seems therefore to be a promising approach. METHODS The literature of the last 20 years was searched using Medline. Articles were chosen by using the given abstracts. Only articles written in English and not older than 20 years were considered. RESULTS Most information concerning chemotherapy of urothelial carcinomas is gained from studies comprising patients suffering from lower urinary tract carcinomas. The combination of methotrexate, adriamycin, vinblastine and cisplatin as well as the combination of gemcitabine and cisplatin are the most used chemotherapy regimens in advanced UCC and have shown beneficial results. The summarized data of studies for UTUC contained no level one information. Down staging effects as well as prolongation of survival have been shown for some patients treated with neoadjuvant chemotherapy, but because of the small study groups and the retrospective design, no definite conclusions can be drawn from these results. In addition, there exists an uncertainty for preoperative staging. Results for adjuvant chemotherapy are lacking. CONCLUSION No definite recommendations for peri-operative chemotherapy in UTUC can be derived from the current literature. Current therapy is largely based on extrapolation from the bladder cancer literature. Prospective studies dedicated to UTUC are needed.
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Affiliation(s)
- Jan Cordier
- Department of Urology, University Hospital Grosshadern, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany
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Fichtenbaum EJ, Marsh WL, Zynger DL. CK5, CK5/6, and double-stains CK7/CK5 and p53/CK5 discriminate in situ vs invasive urothelial cancer in the prostate. Am J Clin Pathol 2012; 138:190-7. [PMID: 22904129 DOI: 10.1309/ajcp5zc4gqvnwtyr] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
For primary bladder tumors, distinguishing urothelial carcinoma (UC) invading the fibromuscular stroma of the prostate (pT4a) from in situ UC involving prostatic ducts can be difficult. Immunohistochemical markers (cytokeratin [CK]5/6, CK5, CK7, CK20, p53, p63, high-molecular-weight keratin [HMWK], androgen receptor, prostate-specific antigen [PSA], prostate specific acid phosphatase [PSAP], laminin, CD44s, CD141) were assessed for their usefulness in determining depth of UC invasion in the prostate. In cystoprostatectomy specimens containing in situ UC in prostatic ducts, both CK5/6 and CK5 clearly differentiated prostatic basal cells from in situ UC. The remaining markers were not effective in determining depth of tumor invasion. Double-stain combinations CK7/CK5 and p53/CK5 were performed and robustly color contrasted in situ tumor from surrounding basal cells. The use of CK5/6, CK5, CK7/CK5, or p53/CK5 is recommended to assist in determining the depth of UC invasion in the prostate when histologic findings are equivocal.
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Affiliation(s)
| | - William L. Marsh
- Department of Pathology, The Ohio State University Medical Center, Columbus
| | - Debra L. Zynger
- Department of Pathology, The Ohio State University Medical Center, Columbus
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Castellano D, Carles J, Esteban E, Trigo JM, Climent MÁ, Maroto JP, García del Muro X, Font A, Paz-Ares L, Arranz JÁ, Bellmunt J. Recommendations for the optimal management of early and advanced urothelial carcinoma. Cancer Treat Rev 2012; 38:431-41. [DOI: 10.1016/j.ctrv.2011.10.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 10/18/2011] [Accepted: 10/22/2011] [Indexed: 10/15/2022]
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A systematic review of neoadjuvant and adjuvant chemotherapy for muscle-invasive bladder cancer. Eur Urol 2012; 62:523-33. [PMID: 22677572 DOI: 10.1016/j.eururo.2012.05.048] [Citation(s) in RCA: 170] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Accepted: 05/22/2012] [Indexed: 01/05/2023]
Abstract
CONTEXT Muscle-invasive bladder cancer (MIBC) is a disease with a pattern of predominantly distant and early recurrences. Neoadjuvant cisplatin-based combination chemotherapy has demonstrated improved outcomes for MIBC. OBJECTIVE To review the data supporting perioperative chemotherapy and emerging regimens for MIBC. EVIDENCE ACQUISITION Medline databases were searched for original articles published before April 1, 2012, with the search terms bladder cancer, urothelial cancer, radical cystectomy, neoadjuvant chemotherapy, and adjuvant chemotherapy. Proceedings from the last 5 yr of major conferences were also searched. Novel and promising drugs that have reached clinical trial evaluation were included. EVIDENCE SYNTHESIS The major findings are addressed in an evidence-based fashion. Prospective trials and important preclinical data were analyzed. CONCLUSIONS Cisplatin-based neoadjuvant combination chemotherapy is an established standard, improving overall survival in MIBC. Pathologic complete response appears to be an intermediate surrogate for survival, but this finding requires further validation. Definitive data to support adjuvant chemotherapy do not exist, and there are no data to support perioperative therapy in cisplatin-ineligible patients. Utilization of neoadjuvant cisplatin is low, attributable in part to patient/physician choice and the advanced age of patients, who often have multiple comorbidities including renal and/or cardiac dysfunction. Trials are using the neoadjuvant paradigm to detect incremental pathologic response to chemobiologic regimens and brief neoadjuvant single-agent therapy to screen for the biologic activity of agents.
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Cognetti F, Ruggeri EM, Felici A, Gallucci M, Muto G, Pollera CF, Massidda B, Rubagotti A, Giannarelli D, Boccardo F. Adjuvant chemotherapy with cisplatin and gemcitabine versus chemotherapy at relapse in patients with muscle-invasive bladder cancer submitted to radical cystectomy: an Italian, multicenter, randomized phase III trial. Ann Oncol 2012; 23:695-700. [PMID: 21859900 DOI: 10.1093/annonc/mdr354] [Citation(s) in RCA: 158] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The purpose of the study was to evaluate the benefit of adjuvant chemotherapy (AC) versus surgery alone in patients with muscle-invasive bladder cancer (MIBC). PATIENTS AND METHODS One hundred and ninety-four patients with pT2G3, pT3-4, N0-2 transitional cell bladder carcinoma were randomly allocated to control (92 patients) or to four courses of AC (102 patients). These latter patients were further randomly assigned to receive gemcitabine 1000 mg/m(2) days 1, 8 and 15 and cisplatin 70 mg/m(2) day 2 or gemcitabine as above plus cisplatin 70 mg/m(2) day 15, every 28 days. RESULTS At a median follow-up of 35 months, the 5-year overall survival (OS) was 48.5%, with no difference between the two arms [P = 0.24, hazard ratio (HR) 1.29, 95% confidence interval (CI) 0.84-1.99]. Mortality hazard was significantly correlated with Nodes (N) and Tumor (T) stage. The control and AC arms had comparable disease-free survival (42.3% and 37.2%, respectively; P = 0.70, HR 1.08, 95% CI 0.73-1.59). Only 62% of patients received the planned cycles. A significant higher incidence of thrombocytopenia was observed in patients receiving cisplatin on day 2 (P = 0.006). A similar global quality of life was observed in the two arms. CONCLUSION The study was underpowered to demonstrate that AC with cisplatin and gemcitabine improves OS and disease-free survival in patients with MIBC.
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Affiliation(s)
- F Cognetti
- Department of Medical Oncology, Regina Elena Cancer Institute, Rome.
| | - E M Ruggeri
- Division of Medical Oncology, Belcolle Hospital, Viterbo
| | - A Felici
- Department of Medical Oncology, Regina Elena Cancer Institute, Rome
| | - M Gallucci
- Department of Urology, Regina Elena Cancer Institute, Rome
| | - G Muto
- Department of Urology, San Giovanni Bosco Hospital, Torino
| | - C F Pollera
- Division of Medical Oncology, Belcolle Hospital, Viterbo
| | - B Massidda
- Department of Medical Oncology, Policlinico Universitario, Cagliari
| | - A Rubagotti
- Departments of Medical Oncology and of Oncology, Biology and Genetics (Biostatistics Unit), National Cancer Research Institute and University, Genova; Departments of Medical Oncology and of Oncology, Biology and Genetics, National Cancer Research Institute and University, Genova
| | - D Giannarelli
- Department of Biostatistics, Regina Elena Cancer Institute, Rome, Italy
| | - F Boccardo
- Departments of Medical Oncology and of Oncology, Biology and Genetics, National Cancer Research Institute and University, Genova
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Azuma H, Inamoto T, Takahara K, Ibuki N, Nomi H, Yamamoto K, Narumi Y, Ubai T. Neoadjuvant and adjuvant chemotherapy for locally advanced bladder carcinoma: development of novel bladder preservation approach, Osaka Medical College regimen. Int J Urol 2011; 19:26-38. [PMID: 22077821 DOI: 10.1111/j.1442-2042.2011.02856.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Haruhito Azuma
- Departments of Urology, Osaka Medical College, Takatsuki, Osaka, Japan.
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Kwan A, Mazhar D. Role of chemotherapy in upper urinary tract urothelial cell cancers. Future Oncol 2011; 7:1067-75. [PMID: 21919694 DOI: 10.2217/fon.11.83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Urothelial cancers of the upper urinary tract are uncommon and often treated in a similar fashion to lower urinary tract urothelial malignancies. Currently, there are no clear guidelines on the use of systemic chemotherapy for upper urinary tract urothelial cancers either in the perioperative setting or in cases of advanced disease. The aim of this article is to review the key studies in upper urinary tract cancers to help develop an understanding about the optimal management and suggest areas for future research.
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Affiliation(s)
- Amy Kwan
- Addenbrooke's Hospital, Hill's Road, Cambridge CB2 0QQ, UK
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69
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Neoadjuvant or adjuvant chemotherapy: what is the best treatment of muscle invasive bladder cancer? Oncol Rev 2011. [DOI: 10.1007/s12156-011-0085-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Mitsui Y, Yasumoto H, Arichi N, Honda S, Shiina H, Igawa M. Current chemotherapeutic strategies against bladder cancer. Int Urol Nephrol 2011; 44:431-41. [PMID: 21667254 DOI: 10.1007/s11255-011-0009-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Accepted: 05/24/2011] [Indexed: 10/18/2022]
Abstract
Urothelial cancer is a chemotherapy-sensitive malignancy, with the regimen of methotrexate, vinblastine, doxorubicin, and cisplatin (M-VAC) until recently considered to be the first choice for chemotherapy. Poor survival and substantial toxicity associated with M-VAC have led to investigations into alternative chemotherapy strategies, and the combination of gemcitabine and cisplatin (GC) may be promising. In addition, combination chemotherapy of taxanes along with gemcitabine and/or platinum-based agents is also considered to provide clinical benefits as second-line chemotherapy following M-VAC or GC therapy. In the near future, results of trials using molecular target therapies may bring improved outcomes for patients with bladder cancer.
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Affiliation(s)
- Yozo Mitsui
- Department of Urology, Shimane University School of Medicine, Shimane 89-1, Enya-cho, Izumo 693-8501, Japan.
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Rôle de la chimiothérapie dans la prise en charge du cancer de la vessie. Prog Urol 2011; 21:369-82. [DOI: 10.1016/j.purol.2011.02.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2010] [Revised: 11/08/2010] [Accepted: 02/08/2011] [Indexed: 11/19/2022]
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Shah JB, McConkey DJ, Dinney CP. New Strategies in Muscle-Invasive Bladder Cancer: On the Road to Personalized Medicine: Figure 1. Clin Cancer Res 2011; 17:2608-12. [DOI: 10.1158/1078-0432.ccr-10-2770] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Booth CM, Ohorodnyk P, Zhu L, Tu D, Meyer RM. Randomised controlled trials in oncology closed early for benefit: trends in methodology, results, and interpretation. Eur J Cancer 2011; 47:854-63. [PMID: 21296570 DOI: 10.1016/j.ejca.2010.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Revised: 12/02/2010] [Accepted: 12/07/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE To assess methodology, results and interpretation of oncology randomised controlled trials closed early for benefit (RCTCEB). METHODS Structured literature search (1950-2008) to identify all published oncology RCTCEB. We then searched for related follow-up articles and conference abstracts to evaluate whether study results and conclusions changed with longer follow-up. A standardised data abstraction process captured information related to statistical methodology, details of interim analyses, results and conclusions. Original articles and follow-up reports were compared for results of primary end-point and author conclusions. RESULTS We identified 71 RCTCEB. In 16 articles (23%) the study primary end-point was not explicitly stated. Most trials were open to accrual (47/71, 66%) at the time of closure. Formal interim analysis was performed in 65 (92%) trials of which 72% (47/65) was reported as planned; 82% (53/65) reported stopping rules. Trials on average accrued 75% of the planned sample size. Amongst the 23 (32%) RCTCEB with follow-up reports, in only one case did the study results or conclusions change substantially. CONCLUSIONS While the majority of oncology RCTCEB follows rigourous methodological principles, an important percentage includes limitations in design and/or analysis. Amongst the 23 studies with subsequent follow-up reports, initial results were confirmed in 22 (96%).
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Affiliation(s)
- Christopher M Booth
- NCIC Clinical Trials Group and Queen's University Cancer Research Institute, Kingston, Canada.
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Yafi FA, Aprikian AG, Chin JL, Fradet Y, Izawa J, Estey E, Fairey A, Rendon R, Cagiannos I, Lacombe L, Lattouf JB, Bell D, Drachenberg D, Kassouf W. Contemporary outcomes of 2287 patients with bladder cancer who were treated with radical cystectomy: a Canadian multicentre experience. BJU Int 2010; 108:539-45. [PMID: 21166753 DOI: 10.1111/j.1464-410x.2010.09912.x] [Citation(s) in RCA: 145] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED Study Type -Therapy (case series). LEVEL OF EVIDENCE 4. OBJECTIVE To evaluate data obtained from a large, multi-institutional, contemporary series of patients who underwent radical cystectomy (RC) in a universal healthcare system aiming to assess outcome and identify novel prognostic variables. MATERIALS AND METHODS Data were collected and pooled from 2287 patients treated with RC between 1998 and 2008 by urological oncologists from eight Canadian academic centres. Collected variables included various clinicopathological parameters, recurrence and death. Survival and prognostic variables were analyzed using the Kaplan-Meier method and Cox regression analysis. RESULTS The median age of patients was 68 years with a mean (median) follow-up time of 35 (29) months. The 30, 60 and 90-day postoperative mortality rates were 1.3%, 2.6% and 3.2%, respectively. The 5-year overall, recurrence-free and cancer-specific survival was 57%, 48% and 67%, respectively, with a local recurrence rate of 6%. Pathological stage distribution was <pT2N0, n = 498 (23%); pT2N0, n = 365 (17%); pT3N0, n = 463 (21%); pT4N0, n = 170 (8%); and pTxN+, n = 507 (23%). Only 3.1% of patients received neoadjuvant chemotherapy and 19.4% received adjuvant chemotherapy. On multivariate analysis, lower pathological stage, negative surgical margins, receipt of adjuvant chemotherapy, performance of pelvic lymphadenectomy and an absence of smoking were associated with prolonged disease-specific and overall survival. CONCLUSIONS RC performed at academic centres provides excellent local control of disease and an acceptable clinical outcome with low perioperative mortality in patients who are treated within a universal healthcare system. Smoking, pelvic lymphadenectomy and receipt of adjuvant chemotherapy are independent prognostic factors for survival. Neoadjuvant chemotherapy continues to be under-utilized in Canada.
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Affiliation(s)
- Faysal A Yafi
- Department of Surgery (Urology), McGill University, Montreal, Canada
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MDR1 and ERCC1 expression predict outcome of patients with locally advanced bladder cancer receiving adjuvant chemotherapy. Neoplasia 2010; 12:628-36. [PMID: 20689757 DOI: 10.1593/neo.10402] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Revised: 05/22/2010] [Accepted: 05/27/2010] [Indexed: 01/29/2023] Open
Abstract
PURPOSE The role of adjuvant chemotherapy in patients with locally advanced bladder cancer still remains to be defined. We hypothesized that assessing the gene expression of the chemotherapy response modifiers multidrug resistance gene 1 (MDR1) and excision repair cross-complementing 1 (ERCC1) may help identify the group of patients benefiting from cisplatin-based adjuvant chemotherapy. EXPERIMENTAL DESIGN Formalin-fixed paraffin-embedded tumor samples from 108 patients with locally advanced bladder cancer, who had been enrolled in AUO-AB05/95, a phase 3 trial randomizing a maximum of three courses of adjuvant cisplatin and methotrexate (CM) versus methotrexate, vinblastine, epirubicin, and cisplatin (M-VEC), were included in the study. Tumor cells were retrieved by laser-captured microdissection and analyzed for MDR1 and ERCC1 expression using a quantitative real-time reverse transcription-polymerase chain reaction assay. Gene expression levels were correlated with clinical outcomes by multivariate Cox proportional hazards regression analysis. RESULTS Expressions of MDR1 and ERCC1 were independently associated with overall progression-free survival (P = .001, relative risk = 2.9 and P = .01, relative risk = 2.24, respectively). The correlation of high MDR1 expression with inferior outcome was stronger in patients receiving M-VEC, whereas ERCC1 analysis performed equally in the CM and M-VEC groups. CONCLUSIONS High MDR1 and ERCC1 gene expressions are associated with inferior outcome after cisplatin-based adjuvant chemotherapy for locally advanced bladder cancer. Prospective studies are warranted to define a role for MDR1 and ERCC1 analysis in individualizing multimodality treatment in locally advanced bladder cancer.
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Tilki D, Svatek RS, Karakiewicz PI, Novara G, Seitz M, Sonpavde G, Gupta A, Kassouf W, Fradet Y, Ficarra V, Skinner E, Lotan Y, Sagalowsky AI, Stief CG, Reich O, Shariat SF. pT3 Substaging is a Prognostic Indicator for Lymph Node Negative Urothelial Carcinoma of the Bladder. J Urol 2010; 184:470-4. [DOI: 10.1016/j.juro.2010.04.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2009] [Indexed: 11/30/2022]
Affiliation(s)
- Derya Tilki
- Department of Urology, Ludwig-Maximilians-University, Klinikum Grosshadern, Munich, Germany
| | | | | | | | - Michael Seitz
- Department of Urology, Ludwig-Maximilians-University, Klinikum Grosshadern, Munich, Germany
| | | | - Amit Gupta
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Wassim Kassouf
- McGill University Health Centre, Montréal, Québec, Canada
| | - Yves Fradet
- Laval University, Québec City, Québec, Canada
| | | | - Eila Skinner
- University of Southern California, Los Angeles, California
| | - Yair Lotan
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Christian G. Stief
- Department of Urology, Ludwig-Maximilians-University, Klinikum Grosshadern, Munich, Germany
| | - Oliver Reich
- Department of Urology, Ludwig-Maximilians-University, Klinikum Grosshadern, Munich, Germany
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Svatek RS, Shariat SF, Lasky RE, Skinner EC, Novara G, Lerner SP, Fradet Y, Bastian PJ, Kassouf W, Karakiewicz PI, Fritsche HM, Müller SC, Izawa JI, Ficarra V, Sagalowsky AI, Schoenberg MP, Siefker-Radtke AO, Millikan RE, Dinney CPN. The effectiveness of off-protocol adjuvant chemotherapy for patients with urothelial carcinoma of the urinary bladder. Clin Cancer Res 2010; 16:4461-7. [PMID: 20651056 DOI: 10.1158/1078-0432.ccr-10-0457] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Robert S Svatek
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Lane BR, Smith AK, Larson BT, Gong MC, Campbell SC, Raghavan D, Dreicer R, Hansel DE, Stephenson AJ. Chronic kidney disease after nephroureterectomy for upper tract urothelial carcinoma and implications for the administration of perioperative chemotherapy. Cancer 2010; 116:2967-73. [PMID: 20564402 DOI: 10.1002/cncr.25043] [Citation(s) in RCA: 149] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The prevalence of chronic kidney disease (CKD) in patients with upper tract urothelial carcinoma (UTUC) is poorly defined, both before and after nephrouretectomy. Although multimodal treatment paradigms for UTUC are under-developed, this has important implications on patients' ability to receive cisplatin-based combination chemotherapy (CBCC). METHODS Estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease formula in 336 patients with UTUC, who were treated at the Cleveland Clinic by nephroureterectomy since 1992. An eGFR cutoff of 60 mL/min/1.73 m(2) was used to determine the presence of CKD and eligibility for CBCC. RESULTS Median age was 72 years and median preoperative eGFR was 59 mL/min/1.73m(2). Before nephroureterectomy, only 48% of patients were eligible to receive CBCC and this decreased to 22% postoperatively (P < .001). In the 144 patients with pT2-pT4 and/or pN1-pN3 disease who are suitable to receive CBCC, these proportions were 40% and 24%, respectively (P = .009). Although 50 patients overall received some form of perioperative chemotherapy, only 3 and 11 patients received neoadjuvant and adjuvant CBCC, respectively. CONCLUSIONS CKD is prevalent in the UTUC population and a minority of patients has an optimal eGFR to receive neoadjuvant CBCC. Nephrouretectomy may eliminate CBCC as a therapeutic option in 49% of high-risk patients if it is deferred to the adjuvant setting. Multimodal treatment strategies for UTUC should focus on neoadjuvant chemotherapy, as few patients are eligible for adjuvant CBCC because of the substantial decline in eGFR caused by nephroureterectomy.
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Affiliation(s)
- Brian R Lane
- Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
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Reşorlu B, Türkölmez K, Ergün G, Baltacı S, Göğüş C, Bedük Y. The role of adjuvant chemotherapy in patients with locally advanced (pT3, pT4a) and/or lymph node-positive bladder cancer. Int Urol Nephrol 2010; 42:959-64. [PMID: 20405206 DOI: 10.1007/s11255-010-9736-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2009] [Accepted: 03/30/2010] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Berkan Reşorlu
- Department of Urology, Kecioren Training and Research Hospital, Ankara, Turkey.
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80
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Bolenz C, Herrmann E, Bastian PJ, Michel MS, Wülfing C, Tiemann A, Buchner A, Stief CG, Fritsche HM, Burger M, Wieland WF, Höfner T, Haferkamp A, Hohenfellner M, Müller SC, Ströbel P, Trojan L. Lymphovascular invasion is an independent predictor of oncological outcomes in patients with lymph node-negative urothelial bladder cancer treated by radical cystectomy: a multicentre validation trial. BJU Int 2010; 106:493-9. [DOI: 10.1111/j.1464-410x.2009.09166.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Stenzl A, Cowan N, De Santis M, Jakse G, Kuczyk M, Merseburger A, Ribal M, Sherif A, Witjes J. Actualización de las Guías Clínicas de la Asociación Europea de Urología sobre el carcinoma vesical músculo-invasivo y metastásico. Actas Urol Esp 2010. [DOI: 10.1016/s0210-4806(10)70010-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Gallagher DJ, Milowsky MI, Iasonos A, Maluf FC, Russo P, Dalbagni G, Donat MS, Boyle MG, Zheng J, Riches J, Bajorin DF. Sequential adjuvant chemotherapy after surgical resection of high-risk urothelial carcinoma. Cancer 2009; 115:5193-201. [PMID: 19670454 DOI: 10.1002/cncr.24570] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Despite definitive surgery, the survival of patients with high-risk urothelial carcinoma (UC) is poor. Adjuvant cisplatin-based chemotherapy may be beneficial, but it is restricted by the need for normal renal function (RF). Sequential administration of adjuvant chemotherapy facilitates drug delivery and improves survival in patients with breast cancer. The objective of this study was to evaluate the feasibility and survival impact of adjuvant, sequential chemotherapy in patients with high-risk UC. METHODS Fifty patients were treated on 2 simultaneous protocols between 1997 and 2004. The patients on Protocol A (normal RF) received doxorubicin and gemcitabine (AG) followed by paclitaxel and cisplatin. The patients on Protocol B (impaired RF) received AG followed by paclitaxel plus carboplatin. Overall survival (OS) and disease-specific survival (DSS) were compared with a group of 203 contemporary control patients who had similar pathology and RF and who underwent surgery alone. RESULTS The median follow-up of protocol patients was 6.5 years (range, 0.9-8.6 years), and 25 patients remained alive. The median follow-up of the control group was 4.7 years (0.0-9.2), and 68 patients remained alive. The median OS for patients on Protocol A was greater than that for controls who had good RF (4.6 years vs 2.5 years; P = .03). The median OS for patients on Protocol B was greater than that for controls who had impaired RF (3.4 years vs 2 years; P = .04). DSS for the protocol and matched control groups was similar (good RF: 4.6 years vs 3 years; P = .24; impaired RF: 3.4 years vs 3.3 years; P = .40). CONCLUSIONS In this nonrandomized study, adjuvant, sequential chemotherapy for patients with high-risk UC did not improve DSS over that observed with surgery alone.
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Affiliation(s)
- David J Gallagher
- Genitourinary Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
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83
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Shariat SF, Karakiewicz PI, Godoy G, Karam JA, Ashfaq R, Fradet Y, Isbarn H, Montorsi F, Jeldres C, Bastian PJ, Nielsen ME, Müller SC, Sagalowsky AI, Lotan Y. Survivin as a Prognostic Marker for Urothelial Carcinoma of the Bladder: A Multicenter External Validation Study. Clin Cancer Res 2009; 15:7012-9. [DOI: 10.1158/1078-0432.ccr-08-2554] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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85
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Sonpavde G, Goldman BH, Speights VO, Lerner SP, Wood DP, Vogelzang NJ, Trump DL, Natale RB, Grossman HB, Crawford ED. Quality of pathologic response and surgery correlate with survival for patients with completely resected bladder cancer after neoadjuvant chemotherapy. Cancer 2009; 115:4104-9. [PMID: 19517476 PMCID: PMC3079554 DOI: 10.1002/cncr.24466] [Citation(s) in RCA: 149] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND In a retrospective study of Southwestern Oncology Group (SWOG)-S8710/INT-0080 (radical cystectomy [RC] alone vs 3 cycles of neoadjuvant chemotherapy [NC] with methotrexate, vinblastine, doxorubicin, and cisplatin before RC for bladder cancer), factors found to be associated with improved overall survival (OS) included pathologic complete response, defined as P0; treatment with NC; completion of RC with negative surgical margins; and >or=10 pelvic lymph nodes (LNs) removed. METHODS The authors used stratified Cox regression to retrospectively study the association of quality of pathologic response after RC with OS in the subset of S8710 patients who received NC and RC with negative surgical margins. RESULTS Of 154 patients who received NC, 68 (44.2%) were CONCLUSIONS NC and RC with negative surgical margins for bladder cancer followed by pathologic P0 and LN- disease were found to correlate with improved OS. A combination of baseline clinical stage and post-RC pathologic stage may better predict OS.
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Affiliation(s)
- Guru Sonpavde
- Department of Medicine, Section of Medical Oncology, Baylor College of Medicine, Houston, Texas, USA.
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86
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Clark PE. Neoadjuvant versus adjuvant chemotherapy for muscle-invasive bladder cancer. Expert Rev Anticancer Ther 2009; 9:821-30. [PMID: 19496719 DOI: 10.1586/era.09.36] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Muscle-invasive bladder cancer is a deadly disease that often requires more than radical surgery for optimal management. The best level one evidence supports the use of neoadjuvant methotrexate, vinblastine, doxorubicin and cisplatin (MVAC) chemotherapy followed by surgery. There remains controversy, however, with some continuing to argue in favor of selective adjuvant chemotherapy only in the highest risk patients. Certain patients and situations argue in favor of a surgery-first approach, with selective chemotherapy in an adjuvant setting. There is a need for better markers for disease risk and progression in advanced bladder cancer to identify those who would benefit the most from aggressive, multimodal therapy. Further studies are needed to address the ongoing questions that remain in the management of this disease.
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Affiliation(s)
- Peter E Clark
- Vanderbilt University Medical Center, A-1302 Medical Center North, Nashville, TN 37232-2765, USA.
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[Prognostic factors for survival in patients with transitional bladder cancer treated with radical cystectomy]. Actas Urol Esp 2009; 33:249-57. [PMID: 19537062 DOI: 10.1016/s0210-4806(09)74138-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE To recognize clinical and pathological variables that influence in bladder cancer specific mortality in patients with transitional bladder cancer treated with radical cystectomy. MATERIAL AND METHOD Retrospective analysis of 333 patients with transitional bladder cancer treated with radical cystectomy. Variables included during pre-cystectomy, peri-cystectomy and post-cystectomy period were analyzed. Four groups were defined based on pathological state: a) Organ-confine bladder cancer without lymph node metastasis (pT0-2, pN0); b) Extravesical desease without lymph node metastasis (pT3-4, pN0); c) Bladder cancer with lymph node metastasis (pT0-4, pN+); d) No data of lymph node affection (pT0-4, pNx). Univariate analysis and two models of multivariate analysis were performed including the risk group as a variable in one the latest. RESULTS Mean follow up was 52.6 +/- 51 (2-221) months with a median of 31 months. Pathological state pT0 was observed in 7.2% of the patients, 12% were pT1, 26.7% pT2, 34.5% pT3 and 10.5% pT4. Lymph node metastasis was detected in 20.7% of the patients. Lymph node metastasis increased according to pathological state rises. Five and 10 years specific survival was 57% and 54% respectively. CONCLUSIONS Local pathological state, lymph node status and risk groups were independent predictive factors for bladder cancer specific survival. Risk group association is a reliable method to predict bladder cancer specific survival and to identify the suitable patient group to get benefit from adjuvant therapy.
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Abstract
Bladder cancer is a heterogeneous disease, with 70% of patients presenting with superficial tumours, which tend to recur but are generally not life threatening, and 30% presenting as muscle-invasive disease associated with a high risk of death from distant metastases. The main presenting symptom of all bladder cancers is painless haematuria, and the diagnosis is established by urinary cytology and transurethral tumour resection. Intravesical treatment is used for carcinoma in situ and other high grade non-muscle-invasive tumours. The standard of care for muscle-invasive disease is radical cystoprostatectomy, and several types of urinary diversions are offered to patients, with quality of life as an important consideration. Bladder preservation with transurethral tumour resection, radiation, and chemotherapy can in some cases be equally curative. Several chemotherapeutic agents have proven to be useful as neoadjuvant or adjuvant treatment and in patients with metastatic disease. We discuss bladder preserving approaches, combination chemotherapy including new agents, targeted therapies, and advances in molecular biology.
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Affiliation(s)
- Donald S Kaufman
- Department of Medicine, the Claire and John Bertucci Center for Genitourinary Cancers, Massachusetts General Hospital, Boston, MA 02114, USA.
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89
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Molecular biomarkers for urothelial carcinoma of the bladder: challenges in clinical use. ACTA ACUST UNITED AC 2009; 5:676-85. [PMID: 19050710 DOI: 10.1038/ncpuro1259] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2008] [Accepted: 10/29/2008] [Indexed: 12/28/2022]
Abstract
Conventional clinical and pathological parameters are limited in their capacity to detect patients with urothelial carcinoma of the bladder (UCB) who are at high risk for recurrence or mortality. The assessment of molecular biomarkers in surgical UCB specimens offers additional information on the biology of the disease, and might improve the prediction of oncologic end points. A wide range of candidate biomarkers, including key cell-cycle regulators, apoptotic markers and specific growth factors, have been reported to be of prognostic value. To date, however, no molecular biomarker for UCB has been introduced into clinical practice, mainly owing to insufficient validation and the absence of prospective studies. Knowledge about the value of molecular biomarkers in predicting the response to adjuvant or neoadjuvant therapies is also lacking. Prospective trials need to be initiated in high-risk patients selected on the basis of the expression patterns of molecular biomarkers that have already passed the initial steps towards clinical utility.
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Shimomura T, Ohtsuka N, Yamada H, Miki J, Hayashi N, Kimura T, Kuruma H, Egawa S. Patterns of failure and influence of potential prognostic factors after surgery in transitional cell carcinoma of the upper urinary tract. Int J Clin Oncol 2009; 14:213-8. [PMID: 19593612 DOI: 10.1007/s10147-008-0837-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2007] [Accepted: 09/07/2008] [Indexed: 10/20/2022]
Abstract
BACKGROUND We investigated the long-term outcome of upper urinary tract transitional cell carcinoma (TCC) after surgery. METHODS The study population comprised 114 surgically treated patients with upper urinary tract TCC treated at Jikei University Hospital between March 1990 and December 2004. All these patients underwent radical surgery without any type of neoadjuvant therapy. Patterns of failure and patient survival were compared with clinicopathological parameters. RESULTS The 5- and 10-year overall survival (OAS) rates for the patients were 85% (95% confidence interval [CI], 81%-89%) and 76% (95% CI, 69%-83%). To date, 19 patients (16.7%) have experienced distant or lymph node metastasis at a mean of 13.3 months following surgery (range, 1 to 50 months). The site of the primary tumor did not affect patient survival (P > 0.05). Both lymphovascular involvement (LVI) and positive lymph nodes were found to have poor prognosis in univariate analysis (P = 0.004 and P < 0.0001). Multivariate analysis indicated pathological stage and bladder recurrence (bladder recurrence being a better prognostic factor) to be independent predictors of metastasis-free survival, but not of OAS or cause-specific survival (CSS). CONCLUSION Pathological stage and bladder recurrence were found to be the predictors of metastasis-free survival in this study. Further searching for reliable biomarkers is needed to accurately predict the prognosis of this malignancy.
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Affiliation(s)
- Tatsuya Shimomura
- Department of Urology, Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
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91
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Heudel P, El Karak F, Ismaili N, Droz JP, Flechon A. Micropapillary bladder cancer: a review of Léon Bérard Cancer Center experience. BMC Urol 2009; 9:5. [PMID: 19534791 PMCID: PMC2713271 DOI: 10.1186/1471-2490-9-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2009] [Accepted: 06/17/2009] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Pierre Heudel
- Léon Bérard Cancer Center, 28 Rue Laennec, 69008 Lyon, France.
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92
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Management of muscle-invasive bladder cancer: an update. ACTA ACUST UNITED AC 2009; 5:501-8. [PMID: 18769377 DOI: 10.1038/ncpuro1202] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2007] [Accepted: 07/28/2008] [Indexed: 11/08/2022]
Abstract
The aim of this Review is to critically assess the currently used methods for the treatment of muscle-invasive bladder cancer. Radical cystectomy seems to be the gold standard for the treatment of bladder cancer, and the optimum extent of lymph-node dissection has now been identified. An early cystectomy should be carried out once a diagnosis of muscle invasion is established. Preoperative radiation is no longer popular, but could be due a reassessment in view of technical advances. Results of neoadjuvant and adjuvant chemotherapy trials are subject to criticism. Most trials are retrospective, used different chemotherapy protocols and did not have uniform end point assessment. Bladder-preservation strategies can offer cures for a selection of subpopulations, but these patient groups have yet to be clearly defined. Developments in molecular biology are exciting, and their potential application is pending translational research. To be meaningful and useful, future trials that involve additional or alternative modalities should be prospective, randomized and adequately powered.
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Gofrit ON, Stadler WM, Zorn KC, Lin S, Silvestre J, Shalhav AL, Zagaja GP, Steinberg GD. Adjuvant chemotherapy in lymph node positive bladder cancer. Urol Oncol 2009; 27:160-4. [DOI: 10.1016/j.urolonc.2007.12.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2007] [Revised: 12/15/2007] [Accepted: 12/17/2007] [Indexed: 11/29/2022]
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The role of chemotherapy in upper tract urothelial carcinoma. Adv Urol 2009:419028. [PMID: 19190766 PMCID: PMC2630419 DOI: 10.1155/2009/419028] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2008] [Accepted: 11/03/2008] [Indexed: 11/17/2022] Open
Abstract
Locally advanced upper tract urothelial carcinoma has a poor prognosis. While surgery represents the only potentially curable therapeutic intervention, recurrences are common and typically systemic in nature. It is thus reasonable to consider perioperative chemotherapy in an effort to decrease the risk of recurrence. There are very little direct data providing clinical guidance in this scenario. For urothelial cancer of the bladder, there are randomized phase III data demonstrating a survival advantage with neoadjuvant cisplatin-based combination chemotherapy. Although arguments favoring adjuvant chemotherapy could be made for upper tract urothelial cancer, the loss of renal function that occurs with nephrectomy can complicate administration of appropriate perioperative treatment. Therefore, by analogy to urothelial carcinoma of the lower tract, it is argued that cisplatin-based neoadjuvant chemotherapy should be the standard of care for patients with locally advanced upper tract urothelial cancer.
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Indications, Extent, and Benefits of Pelvic Lymph Node Dissection for Patients with Bladder and Prostate Cancer. Oncologist 2009; 14:40-51. [DOI: 10.1634/theoncologist.2008-0123] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Margulis V, Lotan Y, Karakiewicz PI, Fradet Y, Ashfaq R, Capitanio U, Montorsi F, Bastian PJ, Nielsen ME, Muller SC, Rigaud J, Heukamp LC, Netto G, Lerner SP, Sagalowsky AI, Shariat SF. Multi-Institutional Validation of the Predictive Value of Ki-67 Labeling Index in Patients With Urinary Bladder Cancer. J Natl Cancer Inst 2009; 101:114-9. [DOI: 10.1093/jnci/djn451] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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The updated EAU guidelines on muscle-invasive and metastatic bladder cancer. Eur Urol 2009; 55:815-25. [PMID: 19157687 DOI: 10.1016/j.eururo.2009.01.002] [Citation(s) in RCA: 282] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2008] [Accepted: 01/02/2009] [Indexed: 12/17/2022]
Abstract
CONTEXT New data regarding diagnosis and treatment of muscle-invasive and metastatic bladder cancer (MiM-BC) has emerged and led to an update of the European Association of Urology (EAU) guidelines for MiM-BC. OBJECTIVE To review the new EAU guidelines for MiM-BC. EVIDENCE ACQUISITION A comprehensive workup of the literature obtained from Medline, the Cochrane central register of systematic reviews, and reference lists in publications and review articles was developed and screened by a group of urologists, oncologists, and radiologist appointed by the EAU Guideline Committee. Previous recommendations based on the older literature on this subject were taken into account. Levels of evidence and grade of guideline recommendations were added, modified from the Oxford Centre for Evidence-based Medicine Levels of Evidence. EVIDENCE SYNTHESIS The diagnosis of muscle-invasive bladder cancer (BCa) is made by transurethral resection (TUR) and following histopathologic evaluation. Patients with confirmed muscle-invasive BCa should be staged by computed tomography (CT) scans of the chest, abdomen, and pelvis, if available. Adjuvant chemotherapy is currently only advised within clinical trials. Radical cystectomy (RC) is the treatment of choice for both sexes, and lymph node dissection should be an integral part of cystectomy. An orthotopic bladder substitute should be offered to both male and female patients lacking any contraindications, such as no tumour at the level of urethral dissection. Multimodality bladder-preserving treatment in localised disease is currently regarded only as an alternative in selected, well-informed, and compliant patients for whom cystectomy is not considered for clinical or personal reasons. An appropriate schedule for disease monitoring should be based on (1) natural timing of recurrence, (2) probability of disease recurrence, (3) functional deterioration at particular sites, and (4) consideration of treatment of a recurrence. In metastatic disease, the first-line treatment for patients fit enough to sustain cisplatin is cisplatin-containing combination chemotherapy. Presently, there is no standard second-line chemotherapy. CONCLUSIONS These EAU guidelines are a short, comprehensive overview of the updated guidelines of (MiM-BC) as recently published in the EAU guidelines and also available in the National Guideline Clearinghouse.
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98
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Adjuvant Chemotherapy in Bladder Cancer: A Good Concept But Where’s the Proof? Bladder Cancer 2009. [DOI: 10.1007/978-1-59745-417-9_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Neoadjuvant Chemotherapy: The New Standard. Bladder Cancer 2009. [DOI: 10.1007/978-1-59745-417-9_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Milowsky MI, Stadler WM, Bajorin DF. Integration of neoadjuvant and adjuvant chemotherapy and cystectomy in the treatment of muscle-invasive bladder cancer. BJU Int 2008; 102:1339-44. [PMID: 19035902 DOI: 10.1111/j.1464-410x.2008.07980.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Bladder cancer is a potentially curable malignancy but for those patients who present with or develop muscle-invasive disease, there is a high risk of metastases and cancer-related death. The treatment of patients with muscle-invasive bladder cancer uses a multimodal approach, including radical cystectomy with pelvic lymph node dissection and perioperative chemotherapy. Neoadjuvant cisplatin combination chemotherapy has a modest survival benefit, with those patients achieving a complete pathological response after chemotherapy having the best outcome. Adjuvant chemotherapy, although less well substantiated, is a reasonable option for patients with extravesical disease or lymph node involvement after cystectomy. Perioperative chemotherapy is substantially underused despite the level-1 evidence showing a survival benefit. Ongoing research will focus on individualized patient care, with biomarkers to predict a pathological complete response and the development of novel targeted therapies.
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Affiliation(s)
- Matthew I Milowsky
- Genitourinary Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
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