Downstaging to non-invasive urothelial carcinoma is associated with improved outcome following radical cystectomy for patients with cT2 disease

Oncological outcomes of visibly complete transurethral resection prior to neoadjuvant chemotherapy for bladder cancer

PURPOSE

To evaluate the potential oncologic benefit of a visibly complete transurethral resection of a bladder tumor (TURBT) prior to neoadjuvant chemotherapy (NAC) and radical cystectomy (RC).

MATERIALS AND METHODS

We identified patients who received NAC and RC between 2011-2021. Records were reviewed to assess TURBT completeness. The primary outcome was pathologic downstaging (

RESULTS

We identified 153 patients, including 116 (76%) with a complete TURBT. Sixty-four (42%) achieved

CONCLUSIONS

A visibly complete TURBT was not associated with pathologic downstaging, cancer-specific or recurrence-free survival following NAC and RC. These data do not support the need for repeat TURBT to achieve a visibly complete resection if NAC and RC are planned.

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Key Words

• Cystectomy
• Neoadjuvant Therapy
• Transurethral Resection of Bladder

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MESH Headings

• Humans
• Treatment Outcome
• Neoadjuvant Therapy
• Urinary Bladder Neoplasms/drug therapy
• Urinary Bladder Neoplasms/surgery
• Urinary Bladder Neoplasms/pathology
• Urologic Surgical Procedures
• Cystectomy
• Retrospective Studies
• Neoplasm Invasiveness

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Affiliation(s)

Bryce Baird Mayo ClinicDepartment of UrologyJacksonvilleFLUSADepartment of Urology Mayo Clinic, Jacksonville, FL, USA
Ahmet Bilgili Mayo ClinicDepartment of UrologyJacksonvilleFLUSADepartment of Urology Mayo Clinic, Jacksonville, FL, USA
Augustus Anderson Tulane UniversitySchool of MedicineNew OrleansLAUSATulane University School of Medicine, New Orleans, LA, USA
Gianpiero Carames University of AlabamaDepartment of PathologyBirminghamALUSADepartment of Pathology, University of Alabama at Birmingham, Birmingham, AL, USA
Ram A. Pathak Mayo ClinicDepartment of UrologyJacksonvilleFLUSADepartment of Urology Mayo Clinic, Jacksonville, FL, USA
Colleen T. Ball Mayo ClinicDepartment of Quantitative Health SciencesJacksonvilleFLUSADepartment of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL, USA
Raymond Pak Mayo ClinicDepartment of UrologyJacksonvilleFLUSADepartment of Urology Mayo Clinic, Jacksonville, FL, USA
Andrew Zganjar Mayo ClinicDepartment of UrologyJacksonvilleFLUSADepartment of Urology Mayo Clinic, Jacksonville, FL, USA
Paul R. Young Mayo ClinicDepartment of UrologyJacksonvilleFLUSADepartment of Urology Mayo Clinic, Jacksonville, FL, USA
Timothy D. Lyon Mayo ClinicDepartment of UrologyJacksonvilleFLUSADepartment of Urology Mayo Clinic, Jacksonville, FL, USA

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Radiologic Diagnosis and Staging of Bladder Cancer: An Update

Although cystoscopic biopsy is the standard of care for initial diagnosis and local staging of bladder cancer, radiologic imaging plays a major role in identifying local invasion, nodal status, distant metastasis, and posttreatment surveillance. Recent development of the Vesical Imaging-Reporting and Data System for interpretation of multiparametric magnetic resonance imaging of the bladder has expanded the role diagnostic imaging in the management of bladder cancer. This article reviews multimodality imaging appearances, staging, and differential diagnosis of bladder cancer.

Combined chemotherapy with cyclooxygenase-2 (COX-2) inhibitors in treating human cancers: Recent advancement

Chemotherapy with a single chemotherapeutic agent or a combined chemotherapeutic regimen is the clinically standardized treatment for almost all human cancers. Upregulated expression of cyclooxygenase (COX)-2, also known as prostaglandin-endoperoxide synthase (PTGS), is associated with human carcinogenesis and cancer progression and COX-2 inhibitors show antitumor activity in different human cancers. Thus, a combination of chemotherapeutic agents with COX-2 inhibitors has been shown to improve therapeutic effects on human cancers. This review discusses and summarizes recent advances in cancer control and treatment using various antineoplastic drugs combined with COX-2 inhibitors. These combinations showed synergistic antitumor effects. At the gene level, COX-2 inhibitors can reduce inflammatory factors thereby regulating macrophage recruitment for activating the antitumor immune microenvironment; downregulating vascular endothelial growth factor (VEGF) to inhibit tumor angiogenesis; and inhibiting the PI3K/Akt signaling pathway to induce tumor cell apoptosis. In addition, such a combination can reduce toxicity and chemoresistance and enhance radiosensitivity, although COX-2 inhibitors-related cardiotoxicity may potentially affect its use. Further in-depth investigation of these drug combinations is needed to maximize antitumor efficacy and minimize the side effects.

The Prognostic Value of Tumor Regression Grades Combined With TNM Classification in Patients With Muscle-Invasive Bladder Cancer Who Underwent Neoadjuvant Chemotherapy Followed by Radical Cystectomy

INTRODUCTION

Tumor regression grades (TRGs) quantify the pathologic response to neoadjuvant chemotherapy (NAC). The aim of the study was to investigate the prognostic value of TRGs in combination with the TNM classification in an independent cohort of patients with muscle-invasive bladder cancer (MIBC) treated with NAC followed by radical cystectomy (RC) in a retrospective setting.

PATIENTS AND METHODS

Patients treated with a complete course of NAC followed by RC for MIBC between December 2012 and December 2017 were enrolled in the study. TRGs were determined in RC specimens. Data were collected preoperatively, and the follow-up was continued up to August 2018. Kaplan-Meier curves and the Cox proportional hazards model were used to compare survival probabilities between major responders (no MIBC, < ypT2 and ypN0), partial responders (≥ ypT2 or ypN+ and TRG2), and non-responders (≥ ypT2 or ypN+ and TRG3).

RESULTS

A group of 70 patients with a median age of 64 years (interquartile range, 58-67 years) was analyzed. There were 36 major responders, 21 partial responders, and 13 non-responders. In comparison with a major response, a partial response was associated with a hazard ratio of 9.44 (95% confidence interval, 1.10-80.89; P = .04) and non- responders showed a hazard ratio of 17.85 (95% confidence interval, 2.18-145.85; P = .007) for death.

CONCLUSIONS

The study confirms the prognostic value of the pathologic response to NAC. Determination of TRGs is straightforward, provides valuable information, and could be easily included in the standard pathologic examination of RC surgical specimen. Prospective studies are needed to establish the role of TRG in routine clinical practice.

Preoperative chemotherapy for prostatic stromal invasive urothelial bladder cancer: comparison of oncological outcomes of male patients with cT4a disease undergoing radical cystectomy with or without preoperative chemotherapy

Background: The value of preoperative chemotherapy to prostatic stromal invasive urothelial bladder cancer remains uncertain. This study presented the pathological response and oncological outcomes of male patients with cT4a urothelial bladder cancer managed with preoperative chemotherapy followed by radical cystectomy. Materials and methods: Data were collected retrospectively from male patients with cT4a urothelial bladder cancer, who underwent radical cystectomy with or without preoperative chemotherapy. Patient characteristics and pathological response were compared. The Kaplan-Meier method and multivariable Cox regression were used to analyze recurrence-free survival and overall survival. Results: From 1989 to 2016, 90 male patients with primary cT4a urothelial bladder cancer underwent radical cystectomy at the institution, 55 (61%) did not have preoperative chemotherapy and 35 (39%) had preoperative chemotherapy. The preoperative chemotherapy group had more lymphovascular invasion on primary transurethral resection of bladder tumor (31.4% vs 18.2%, p = .2) and more clinically positive nodal disease (31.4% vs 10.9%, p = .09). At radical cystectomy, the preoperative chemotherapy group had more tumor down staging (60% vs 29.1%, p = .005), less lymphovascular invasion (40% vs 54.5%, p = .05) and less positive nodal disease (25.7% vs 45.5%, p = .006). Hydronephrosis, lymphovascular invasion and age >70 were associated with worse recurrence-free survival and overall survival (p < .05). Tumor down-staging was associated with improved recurrence-free survival and overall survival (p = .003, p = .03, respectively). Preoperative chemotherapy alone was not associated with improved oncologic outcomes. Conclusions: Preoperative chemotherapy is associated with cT4a bladder cancer down-staging, decreased lymphovascular invasion and decreased positive nodal disease. Preoperative chemotherapy provides survival benefit to those who achieved pathological response.

Persistent muscle-invasive bladder cancer after neoadjuvant chemotherapy: an analysis of Surveillance, Epidemiology and End Results-Medicare data

OBJECTIVES

To evaluate whether patients with persistent muscle-invasive bladder cancer (MIBC) after undergoing neoadjuvant chemotherapy (NAC) and radical cystectomy (RC) have worse overall survival (OS) and cancer-specific survival (CSS) than patients with similar pathology who undergo RC alone.

MATERIALS AND METHODS

Using the Surveillance, Epidemiology and End Results (SEER)-Medicare database, we identified the records of patients with pT2-4N0M0 disease who underwent RC, with and without NAC, for MIBC between 2004 and 2011. To evaluate survival outcomes in those with MIBC after NAC vs patients with MIBC who underwent RC alone, we used Kaplan-Meier time-to-event analysis and Cox proportional hazard regression modelling. Landmark analysis was conducted to mitigate immortal time bias. Propensity scoring was used to decrease the risk of selection bias.

RESULTS

Of the 1 886 patients with persistent pT2-4 disease at the time of RC, 1505 underwent RC alone and 381 received NAC + RC. After adjusting for confounders, the propensity-weighted risk of death from bladder cancer after diagnosis did not differ between the groups (hazard ratio [HR] 0.72, 95% confidence interval [CI] 0.72-1.08; P = 0.23); however, the risk of death from all causes was worse in the RC-alone group (HR 0.79, 95% CI0.67-0.94; P = 0.006).

CONCLUSIONS

Patients who had persistent MIBC after platinum-based NAC + RC vs RC alone derived an OS benefit but not a CSS benefit from NAC. This may represent a selection bias favouring patients who were selected for NAC; however, the OS benefit was not evident in patients with persistent pT3-T4N0M0 disease. This study underscores the importance of future research investigating methods to identify patients who will respond to NAC for bladder cancer. It also highlights the need to consider adjuvant therapy in patients who have persistent MIBC after NAC.

A systematic review and meta-analysis on the oncological long-term outcomes after trimodality therapy and radical cystectomy with or without neoadjuvant chemotherapy for muscle-invasive bladder cancer

OBJECTIVE

This study aimed to comprehensively analyze the oncological long-term outcomes of trimodal therapy (TMT) and radical cystectomy (RC) for the treatment of muscle-invasive bladder cancer (BC) with or without neoadjuvant chemotherapy (NAC).

PATIENTS AND METHODS

A systematic search was conducted according to the PRISMA guidelines for studies reporting on outcomes after TMT and RC. A total of 57 studies including 30,293 patients were included. The 10-year overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) rates for TMT and RC were assessed.

RESULTS

The mean 10-year OS was 30.9% for TMT and 35.1% for RC (P = 0.32). The mean 10-year DSS was 50.9% for TMT and 57.8% for RC (P = 0.26). NAC was administered before therapy to 453 (13.3%) of 3,402 patients treated with TMT and 812 (3.0%) of 27,867 patients treated with RC (P<0.001). Complete response (CR) was achieved in 1,545 (75.3%) of 2,051 evaluable patients treated with TMT. A 5-year OS, DSS, and RFS after CR were 66.9%, 78.3%, and 52.5%, respectively. Downstaging after transurethral bladder tumor resection or NAC to stage ≤pT1 at RC was reported in 2,416 (29.1%) of 8,311 patients. NAC significantly increased the rate of pT0 from 20.2% to 34.3% (P = 0.007) in cT2 and from 3.8% to 23.9% (P<0.001) in cT3-4. A 5-year OS, DSS, and RFS in downstaged patients (≤pT1) at RC were 75.7%, 88.3%, and 75.8%, respectively.

CONCLUSION

In this analysis, the survival outcomes of patients after TMT and RC for MIBC were comparable. Patients who experienced downstaging after NAC and RC exhibited improved survival compared to patients treated with RC only. Best survival outcomes after TMT are associated with CR to this approach.

Adjuvant treatment following radical cystectomy for muscle-invasive urothelial carcinoma and variant histologies: Is there a role for radiotherapy?

Comprehensive molecular characterisation of muscle-invasive urothelial carcinoma and variant histological subtypes has led to the identification of recurrent driver mutations that are distinct in these aggressive subgroups of bladder cancer. While distant metastasis dominates as a pattern of relapse following radical cystectomy or chemoradiotherapy, loco-regional control rates are also suboptimal with single modality local treatment, and likewise, harbour equivocal implications on the long-term prognosis of patients. The role of adjuvant radiotherapy for optimising disease control within the pelvis is controversial, with limited evidence to support its efficacy. Herein, we present a stepwise review on adjuvant radiotherapy post-cystectomy; first, discussing the evidence to date supporting the concept that adjuvant radiotherapy is effective in targeting occult metastases within the pelvis, and adds to the benefits of adjuvant chemotherapy. Next, we outlined the principles underlying the definition of radiotherapy target volumes. To conclude, we addressed the need for appropriate patient stratification for treatment intensification, based on existing clinical models and novel molecular indices of aggression in muscle-invasive urothelial cancers and variant histological subtypes.

Perioperative therapy for muscle invasive bladder cancer

Muscle invasive bladder cancer (MIBC) is an aggressive disease associated with poor survival rates. High rates of relapse, despite radical cystectomy, suggest that administration of systemic therapy in the perioperative period may improve clinical outcomes. Neoadjuvant treatment with cisplatin-based combination regimens is an established standard of care and has improved long-term survival in MIBC. As the use of neoadjuvant chemotherapy steadily increases, clinicians still need to decide about administering adjuvant chemotherapy to patients with high-risk disease. This review examines in detail the latest evidence available for both neoadjuvant and adjuvant chemotherapy, and highlights pertinent studies.

Accurate determination of the pathological stage with gross dissection protocol for radical cystectomy

The current protocol for reporting urinary bladder cancer in radical cystectomies may exhibit limitations in the diagnostic accuracy, such as a risk of understaging, especially in cases with prostatic involvement. Difficulty can arise in the verification of stage pT0, and the assessment of surgical margins is suboptimal. We have developed a daily gross dissection protocol practice where radical cystectomies are totally embedded and evaluated histologically in whole-mount sections. We report here on the first 138 consecutive specimens from 2008 to the first quarter of 2012 inclusive. The incidence of the cancer stages was compared with data on 15,586 radical cystectomies from the literature. The differences were analyzed with the one-sample z-test (p < 0.05). The following emerged from and our series and the literature data: pT0 8.7 % and 6.1 %; pTa 0.7 % and 2.9 %; pTis 2.9 % and 6 %; pT1 15.2 % and 15.5 %; pT2 21 % and 23.3 %; pT3 34.8 % and 34.3 %; and pT4 16.7 % and 11 %, respectively. Our findings closely reflected the means of the published statistical data based on a large number of cases. The differences were due to the more detailed processing: the case numbers in groups from pTis to pT2 were comparatively low, while those in groups pT3 and pT4 were higher. The difference in group pT4 was significant (p = 0.0494). With this method, only those samples were regarded as pT0 in which the granulomatous area and the hemosiderin deposition indicative of the earlier intervention were observable and the entire preparation was tumor-free.