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von Deimling M, Mertens LS, Furrer M, Li R, Tendijck GAH, Taylor J, Crocetto F, Maas M, Mari A, Pichler R, Moschini M, Tully KH, D'Andrea D, Laukhtina E, Del Giudice F, Marcq G, Velev M, Gallioli A, Albisinni S, Mori K, Khanna A, Rink M, Fisch M, Minervini A, Black PC, Lotan Y, Spiess PE, Kiss B, Shariat SF, Pradere B. The optimal number of induction chemotherapy cycles in clinically lymph node-positive bladder cancer. BJU Int 2024; 134:119-127. [PMID: 38470089 DOI: 10.1111/bju.16319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
OBJECTIVE To investigate the optimal number of induction chemotherapy cycles needed to achieve a pathological response in patients with clinically lymph node-positive (cN+) bladder cancer (BCa) who received three or four cycles of induction chemotherapy followed by consolidative radical cystectomy (RC) with pelvic lymph node dissection. PATIENTS AND METHODS We included 388 patients who received three or four cycles of cisplatin/gemcitabine or (dose-dense) methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC), followed by consolidative RC for cTanyN1-3M0 BCa. We compared pathological complete (pCR = ypT0N0) and objective response (pOR = yp ≤T1N0) between treatment groups. Predictors of pCR and/or pOR were assessed using uni- and multivariable logistic regression analysis. The secondary endpoints were overall (OS) and cancer-specific survival (CSS). We evaluated the association between the number of induction chemotherapy cycles administered and survival outcomes on multivariable Cox regression. RESULTS Overall, 101 and 287 patients received three or four cycles of induction chemotherapy, respectively. Of these, 72 (19%) and 128 (33%) achieved pCR and pOR response, respectively. The pCR (20%, 18%) and pOR (40%, 31%) rates did not differ significantly between patients receiving three or four cycles (P > 0.05). The number of cycles was not associated with pCR or pOR on multivariable logistic regression analyses. The 2-year OS estimates were 63% (95% confidence interval [CI] 0.53-0.74) and 63% (95% CI 0.58-0.7) for patients receiving three or four cycles, respectively. Receiving three vs four cycles was not associated with OS and CSS on uni- or multivariable Cox regression analyses. CONCLUSION Pathological response and survival outcomes did not differ between administering three or four induction chemotherapy cycles in patients with cN+ BCa. A fewer cycles (minimum three) may be oncologically sufficient in patients with cN+ BCa, while decreasing the wait for definitive local therapy in those patients who end up without a response to chemotherapy. This warrants further validation.
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Affiliation(s)
- Markus von Deimling
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laura S Mertens
- Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Marc Furrer
- Department of Urology, University Hospital of Bern, University of Bern, Bern, Switzerland
- Department of Urology, Solothurner Spitäler AG, Kantonsspital Olten and Bürgerspital Solothurn, Switzerland
| | - Roger Li
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Guus A H Tendijck
- Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jacob Taylor
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
| | - Felice Crocetto
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Naples, Italy
| | - Moritz Maas
- Department of Urology, Eberhard Karls University Tübingen, Tübingen, Germany
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Andrea Mari
- Unit of Oncologic Minimally-Invasive Urology and Andrology, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, Florence, Italy
| | - Renate Pichler
- Department of Urology, Comprehensive Cancer Center Innsbruck, Medical University of Innsbruck, Innsbruck, Austria
| | - Marco Moschini
- Department of Urology, Urological Research Institute, Vita-Salute San Raffaele, Milan, Italy
| | - Karl H Tully
- Department of Urology and Neurourology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - David D'Andrea
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Ekaterina Laukhtina
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Francesco Del Giudice
- Department of Maternal Infant and Urologic Sciences, Policlinico Umberto I Hospital, "Sapienza" University of Rome, Rome, Italy
| | - Gautier Marcq
- Department of Urology, CHU Lille, Claude Huriez Hospital, Lille, France
- CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity Plasticity and Resistance to Therapies, University of Lille, Lille, France
| | - Maud Velev
- Department of Cancer Medicine, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Andrea Gallioli
- Department of Urology, Fundació Puigvert, Autonomous University of Barcelona, Barcelona, Spain
| | - Simone Albisinni
- Urology Unit, Department of Surgical Sciences, Tor Vergata University Hospital, University of Rome Tor Vergata, Rome, Italy
- Service d'Urologie, Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Keiichiro Mori
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | | | - Michael Rink
- Department of Urology, Marienkrankenhaus, Hamburg, Germany
| | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andrea Minervini
- Unit of Oncologic Minimally-Invasive Urology and Andrology, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, Florence, Italy
| | - Peter C Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Yair Lotan
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
| | - Philippe E Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Bernhard Kiss
- Department of Urology, University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
- Department of Urology, Weill Cornell Medical College, New York, NY, USA
- Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan
- Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Benjamin Pradere
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Urology, Urosud, La Croix Du Sud Hospital, Quint-Fonsegrives, France
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Grobet-Jeandin E, Lenfant L, Pinar U, Parra J, Mozer P, Renard-Penna R, Thibault C, Rouprêt M, Seisen T. Management of patients with muscle-invasive bladder cancer with clinical evidence of pelvic lymph node metastases. Nat Rev Urol 2024; 21:339-356. [PMID: 38297079 DOI: 10.1038/s41585-023-00842-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2023] [Indexed: 02/02/2024]
Abstract
Identification of clinically positive pelvic lymph node metastases (cN+) in patients with muscle-invasive bladder cancer is currently challenging, as the diagnostic accuracy of available imaging modalities is limited. Conventional CT is still considered the gold-standard approach to diagnose lymph node metastases in these patients. The development of innovative diagnostic methods including radiomics, artificial intelligence-based models and molecular biomarkers might offer new perspectives for the diagnosis of cN+ disease. With regard to the treatment of these patients, multimodal strategies are likely to provide the best oncological outcomes, especially using induction chemotherapy followed by radical cystectomy and pelvic lymph node dissection in responders to chemotherapy. Additionally, the use of adjuvant nivolumab has been shown to decrease the risk of recurrence in patients who still harbour ypT2-T4a and/or ypN+ disease after surgery. Alternatively, the use of avelumab maintenance therapy can be offered to patients with unresectable cN+ tumours who have at least stable disease after induction chemotherapy alone. Lastly, patients with cN+ tumours who are not responding to induction chemotherapy are potential candidates for receiving second-line treatment with pembrolizumab.
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Affiliation(s)
- Elisabeth Grobet-Jeandin
- Sorbonne University, GRC 5, Predictive Onco-Urology, APHP, Pitié-Salpêtrière Hospital, Urology, 75013, Paris, France
- Division of Urology, Geneva University Hospitals, Geneva, Switzerland
| | - Louis Lenfant
- Sorbonne University, GRC 5, Predictive Onco-Urology, APHP, Pitié-Salpêtrière Hospital, Urology, 75013, Paris, France
| | - Ugo Pinar
- Sorbonne University, GRC 5, Predictive Onco-Urology, APHP, Pitié-Salpêtrière Hospital, Urology, 75013, Paris, France
| | - Jérôme Parra
- Sorbonne University, GRC 5, Predictive Onco-Urology, APHP, Pitié-Salpêtrière Hospital, Urology, 75013, Paris, France
| | - Pierre Mozer
- Sorbonne University, GRC 5, Predictive Onco-Urology, APHP, Pitié-Salpêtrière Hospital, Urology, 75013, Paris, France
| | - Raphaele Renard-Penna
- Sorbonne University, GRC 5, Predictive Onco-Urology, APHP, Pitié-Salpêtrière Hospital, Radiology, 75013, Paris, France
| | - Constance Thibault
- Department of medical oncology, Hôpital Européen Georges Pompidou, Institut du Cancer Paris CARPEM, AP-HP centre, Paris, France
| | - Morgan Rouprêt
- Sorbonne University, GRC 5, Predictive Onco-Urology, APHP, Pitié-Salpêtrière Hospital, Urology, 75013, Paris, France
| | - Thomas Seisen
- Sorbonne University, GRC 5, Predictive Onco-Urology, APHP, Pitié-Salpêtrière Hospital, Urology, 75013, Paris, France.
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von Deimling M, Furrer M, Mertens LS, Mari A, van Ginkel N, Bacchiani M, Maas M, Pichler R, Li R, Moschini M, Bianchi A, Vetterlein MW, Lonati C, Crocetto F, Taylor J, Tully KH, Afferi L, Soria F, Del Giudice F, Longoni M, Laukhtina E, Antonelli A, Rink M, Fisch M, Lotan Y, Spiess PE, Black PC, Kiss B, Pradere B, Shariat SF. Impact of the extent of lymph node dissection on survival outcomes in clinically lymph node-positive bladder cancer. BJU Int 2024; 133:341-350. [PMID: 37904652 DOI: 10.1111/bju.16210] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2023]
Abstract
OBJECTIVE To determine the oncological impact of extended pelvic lymph node dissection (ePLND) vs standard PLND (sPLND) during radical cystectomy (RC) in clinically lymph node-positive (cN+) bladder cancer (BCa). PATIENTS AND METHODS In this retrospective, multicentre study we included 969 patients who underwent RC with sPLND (internal/external iliac and obturator lymph nodes) or ePLND (sPLND plus common iliac and presacral nodes) with or without platin-based peri-operative chemotherapy for cTany N1-3 M0 BCa between 1991 and 2022. We assessed the impact of ePLND on recurrence-free survival (RFS) and the distribution of recurrences (locoregional and distant recurrences). The secondary endpoint was overall survival (OS). We performed propensity-score matching using covariates associated with the extent of PLND in univariable logistic regression analysis. The association of the extent of PLND with RFS and OS was investigated using Cox regression models. RESULTS Of 969 cN+ patients, 510 were 1:1 matched on propensity scores. The median (interquartile range [IQR]) time to recurrence was 8 (4-16) months, and median (IQR) follow-up of alive patients was 30 (13-51) months. Disease recurrence was observed in 104 patients in the ePLND and 107 in the sPLND group. Of these, 136 (27%), 47 (9.2%) and 19 patients (3.7%) experienced distant, locoregional, or both distant and locoregional disease recurrence, respectively. When stratified by the extent of PLND, we did not find a difference in recurrence patterns (P > 0.05). ePLND improved neither RFS (hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.70-1.19; P = 0.5) nor OS (HR 0.78, 95% CI 0.60-1.01; P = 0.06) compared to sPLND. Stratification by induction chemotherapy did not change outcomes. CONCLUSION Performing an ePLND at the time of RC in cN+ patients improved neither RFS nor OS compared to sPLND, regardless of induction chemotherapy status. Pretreatment risk stratification is paramount to identify ideal candidates for RC with ePLND as part of a multimodal treatment approach.
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Affiliation(s)
- Markus von Deimling
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marc Furrer
- Department of Urology, University Hospital of Bern, University of Bern, Bern, Switzerland
- Department of Urology, Solothurner Spitäler AG, Olten, Solothurn, Switzerland
| | - Laura S Mertens
- Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Andrea Mari
- Unit of Oncologic Minimally-Invasive Urology and Andrology, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, Florence, Italy
| | - Noor van Ginkel
- Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Mara Bacchiani
- Unit of Oncologic Minimally-Invasive Urology and Andrology, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, Florence, Italy
| | - Moritz Maas
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
- Department of Urology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Renate Pichler
- Department of Urology, Comprehensive Cancer Center Innsbruck, Medical University of Innsbruck, Innsbruck, Austria
| | - Roger Li
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Marco Moschini
- Department of Urology, Urological Research Institute, Milan, Italy
| | - Alberto Bianchi
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Malte W Vetterlein
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Chiara Lonati
- Department of Urology, Spedali Civili of Brescia, Brescia, Italy
| | - Felice Crocetto
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples 'Federico II', Naples, Italy
| | - Jacob Taylor
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
| | - Karl H Tully
- Department of Urology and Neurourology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Luca Afferi
- Department of Urology, Luzerner Kantonsspital, Luzern, Switzerland
| | - Francesco Soria
- Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Studies of Torino, Turin, Italy
| | - Francesco Del Giudice
- Department of Maternal Infant and Urologic Sciences, 'Sapienza' University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Mattia Longoni
- Department of Urology, Urological Research Institute, Milan, Italy
| | - Ekaterina Laukhtina
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Alessandro Antonelli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Michael Rink
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Yair Lotan
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
| | - Philippe E Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Peter C Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Bernhard Kiss
- Department of Urology, University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Benjamin Pradere
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Urology, Urosud, La Croix Du Sud Hospital, Quint-Fonsegrives, France
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
- Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan
- Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria
- Department of Urology, Weill Cornell Medical College, New York, NY, USA
- Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
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4
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Swinton M, Mariam NBG, Tan JL, Murphy K, Elumalai T, Soni M, Ferrera A, Richardson C, Walshaw R, Mistry H, Ramani V, Song Y, Birtle A, Henry A, Chan J, Hoskin P, Choudhury A. Bladder-Sparing Treatment With Radical Dose Radiotherapy Is an Effective Alternative to Radical Cystectomy in Patients With Clinically Node-Positive Nonmetastatic Bladder Cancer. J Clin Oncol 2023; 41:4406-4415. [PMID: 37478391 DOI: 10.1200/jco.23.00725] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/10/2023] [Accepted: 06/08/2023] [Indexed: 07/23/2023] Open
Abstract
PURPOSE Bladder-sparing trimodal therapy (TMT) is an alternative to radical cystectomy (RC) according to international guidelines. However, there are limited data to guide management of nonmetastatic clinically node-positive bladder cancer (cN+ M0 BCa). We performed a multicenter retrospective analysis of survival outcomes in node-positive patients to inform practice. METHODS Data from patients diagnosed with cN+ M0 BCa were collected from participating UK Oncology centers offering both TMT and RC. Overall survival (OS) and progression-free survival (PFS) outcomes were collected with details of treatment and clinical factors. RESULTS A total of 287 patients with cN+ M0 BCa were included in the survival analysis. Median OS across all patients was 1.55 years (95% CI, 1.35 to 1.82 years). Receiving radical treatments was associated with improved OS (hazard ratio [HR], 0.32; 95% CI, 0.23 to 0.44; P < .001) compared with receiving palliative treatment. Radically treated patients (n = 163) received RC (n = 76) or radical dose radiotherapy (RT, n = 87); choice of radical treatment showed no association with OS (HR, 0.94; 95% CI, 0.63 to 1.41; P = .76) or PFS (HR, 0.74; 95% CI, 0.50 to 1.08; P = .12) on multivariable analysis. CONCLUSION Patient cohorts with cN+ M0 BCa had equivalent survival outcomes whether treated with surgery or radical RT. Given the known morbidities of RC-in a patient group with poor survival-this study confirms that bladder-sparing TMT treatment should be a treatment option available to all patients with cN+ M0 BCa.
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Affiliation(s)
- Martin Swinton
- Christie Hospital NHS Foundation Trust, Manchester, United Kingdom
- Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, United Kingdom
| | | | - Jean Ling Tan
- Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, United Kingdom
| | - Katherine Murphy
- Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, United Kingdom
| | - Thiraviyam Elumalai
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Manjusha Soni
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | | | | | - Richard Walshaw
- Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, United Kingdom
| | - Hitesh Mistry
- Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, United Kingdom
| | - Vijay Ramani
- Christie Hospital NHS Foundation Trust, Manchester, United Kingdom
| | - Yeepei Song
- Christie Hospital NHS Foundation Trust, Manchester, United Kingdom
| | - Alison Birtle
- Rosemere Cancer Centre, Royal Preston Hospital, Preston, United Kingdom
| | - Ann Henry
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Joachim Chan
- Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, United Kingdom
| | - Peter Hoskin
- Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, United Kingdom
| | - Ananya Choudhury
- Christie Hospital NHS Foundation Trust, Manchester, United Kingdom
- Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, United Kingdom
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5
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Long-Term Outcome of Patients with Stage II and III Muscle-Invasive Urothelial Bladder Cancer after Multimodality Approach. Which Is the Best Option? Medicina (B Aires) 2022; 59:medicina59010050. [PMID: 36676675 PMCID: PMC9865683 DOI: 10.3390/medicina59010050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/18/2022] [Accepted: 12/22/2022] [Indexed: 12/29/2022] Open
Abstract
Background and Objectives: There is no consensus regarding the optimal therapy sequence in stage II and III bladder cancer. The study aimed to evaluate the long-term oncologic outcomes in patients with bladder cancer after a multimodality approach. Materials and methods: Medical files of 231 consecutive patients identified with stage II (46.8%), IIIA (30.3%), and IIIB (22.9%) transitional cell carcinoma of the bladder (BC) treated with a multimodality approach were retrospectively reviewed. The treatment consisted of transurethral resections or cystectomy, radiotherapy alone or concurrent chemoradiotherapy as definitive treatment, or neoadjuvant chemotherapy using platinum salt regimens. Results: Median age at diagnosis was 65 ± 10.98 years. Radical or partial cystectomy was performed in 88 patients (37.1%), and trans-urethral resection of bladder tumor (TURBT) alone was performed in 143 (61.9%) patients. Overall, 40 patients (17.3%) received neoadjuvant chemotherapy and 82 (35.5%) received definitive chemoradiotherapy. After a median follow-up of 30.6 months (range 3-146 months), the median disease-free survival (DFS) for an entire lot of patients was 32 months, and the percentage of patients without recurrence at 12, 24, and 36 months was 86%, 58%, and 45%, respectively. Patients receiving neoadjuvant chemotherapy had a better oncologic outcome compared to patients without neoadjuvant chemotherapy (median DFS not reached vs. 31 months, p = 0.038, HR = 0.55, 95% CI 0.310-0.951). There was a trend for better 3-year DFS with radical cystectomy vs. TURBT (60 months vs. 31 months, p = 0.064). Definitive chemoradiotherapy 3-year DFS was 58% compared to 44% in patients who received radiotherapy or chemotherapy alone. Conclusions: In patients with stages II and III, both neoadjuvant chemotherapy and concurrent radio-chemotherapy are valid options for treatment and must be part of a multidisciplinary approach.
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Abufaraj M, Li R, Meeks J, Shariat SF. Cytoreductive Surgery in Patients with Urothelial Bladder Cancer. Eur Urol Focus 2022; 9:278-279. [PMID: 36509654 DOI: 10.1016/j.euf.2022.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 11/26/2022] [Indexed: 12/13/2022]
Abstract
Cytoreductive cystectomy appears to have survival advantages as a part of multimodal approach for well-selected patients with bladder cancer. Patient with clinical lymph node metastases might benefit from surgical consolidation after achieving a measurable response to chemotherapy. The exact role of cytoreductive/consolidative cystectomy is yet to be determined in well-designed prospective trials.
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Affiliation(s)
- Mohammad Abufaraj
- Division of Urology, Department of Special Surgery, The University of Jordan, Amman, Jordan; Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Roger Li
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Joshua Meeks
- Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, University of Texas Southwestern, Dallas, TX, USA; Department of Urology, Weill Cornell Medical College, New York, NY, USA.
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7
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Selecting the Best Candidates for Cisplatin-based Adjuvant Chemotherapy After Radical Cystectomy Among Patients with pN+ Bladder Cancer. Eur Urol Oncol 2022; 5:722-725. [PMID: 35715319 DOI: 10.1016/j.euo.2022.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 03/07/2022] [Accepted: 04/11/2022] [Indexed: 01/26/2023]
Abstract
A trend towards greater benefit from adjuvant chemotherapy (ACT) in pN+ bladder cancer (BCa) has been observed in multiple randomized controlled trials. However, it is still unclear which patients might benefit the most from this approach. We retrospectively analyzed a multicenter cohort of 1381 patients with pTany pN1-3 cM0 R0 urothelial BCa treated with radical cystectomy (RC) with or without cisplatin-based ACT. The main endpoint was overall survival (OS) after RC. We performed 1:1 propensity score matching to adjust for baseline characteristics and conducted a classification and regression tree (CART) analysis to assess postoperative risk groups and Cox regression analyses to predict OS. Overall, 391 patients (28%) received cisplatin-based ACT. After matching, two cohorts of 281 patients with pN+ BCa were obtained. CART analysis stratified patients into three risk groups: favorable prognosis (≤pT2 and positive lymph node [PLN] count ≤2; odds ratio [OR] 0.43), intermediate prognosis (≥pT3 and PLN count ≤2; OR 0.92), and poor prognosis (pTany and PLN count ≥3; OR 1.36). Only patients with poor prognosis benefitted from ACT in terms of OS (HR 0.51; p < 0.001). We created the first algorithm that stratifies patients with pN+ BCa into prognostic classes and identified patients with pTany BCa with PLN ≥3 as the most suitable candidates for cisplatin-based ACT. PATIENT SUMMARY: We found that overall survival among patients with bladder cancer and evidence of lymph node involvement depends on cancer stage and the number of positive lymph nodes. Patients with more than three nodes affected by metastases seem to experience the greatest overall survival benefit from cisplatin-based chemotherapy after bladder removal. Our study suggests that patients with the highest risk should be prioritized for cisplatin-based chemotherapy after bladder removal.
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8
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Powles T, Bellmunt J, Comperat E, De Santis M, Huddart R, Loriot Y, Necchi A, Valderrama BP, Ravaud A, Shariat SF, Szabados B, van der Heijden MS, Gillessen S. Bladder cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol 2022; 33:244-258. [PMID: 34861372 DOI: 10.1016/j.annonc.2021.11.012] [Citation(s) in RCA: 202] [Impact Index Per Article: 101.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 12/24/2022] Open
Affiliation(s)
- T Powles
- Barts Cancer Centre, Barts Health NHS Trust, Queen Mary University of London, London, UK
| | - J Bellmunt
- Beth Israel Deaconess Medical Centre-IMIM Lab, Harvard Medical School, Boston, USA
| | - E Comperat
- L'Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Paris, France
| | - M De Santis
- Department of Urology, Charité Universitätsmedizin, Berlin, Germany
| | - R Huddart
- Royal Marsden Hospital, Institute of Cancer Research, London, UK
| | - Y Loriot
- Département de Médecine Oncologique, Université Paris-Saclay and Gustave Roussy, Villejuif, France
| | - A Necchi
- Vita-Salute San Raffaele University, Department of Medical Oncology, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - A Ravaud
- Hôpital Saint-André CHU, Bordeaux, France; Department of Medical Oncology, Bordeaux University Hospital, Bordeaux, France
| | - S F Shariat
- Department of Urology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - B Szabados
- Barts Cancer Centre, Barts Health NHS Trust, Queen Mary University of London, London, UK; Department of Urology, University College London Hospital, London, UK
| | - M S van der Heijden
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - S Gillessen
- Oncology Institute of Southern Switzerland (IOSI), EOC, Lugano, Switzerland
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9
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Carboplatin-based adjuvant chemotherapy versus observation after radical cystectomy in patients with pN1-3 urothelial bladder cancer. World J Urol 2022; 40:1489-1496. [PMID: 35142865 DOI: 10.1007/s00345-022-03948-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/24/2022] [Indexed: 10/19/2022] Open
Abstract
PURPOSE To test the impact of carboplatin-based ACT on overall survival (OS) in patients with pN1-3 cM0 BCa. METHODS A retrospective analysis was conducted on 1057 patients with pTany pN1-3 cM0 urothelial BCa treated with or without carboplatin-based ACT after radical cystectomy and bilateral lymph-node dissection between 2002 and 2018 at 12 European and North-American hospitals. No patient received neoadjuvant chemotherapy or radiation therapy. Only patients with negative surgical margins at surgery were included. A 3:1 propensity score matching (PSM) was performed using logistic regression to adjust for baseline characteristics. Univariable and multivariable Cox regression analyses were used to predict the effect of carboplatin-based ACT on OS. The Kaplan-Meier method was used to display OS in the matched cohort. RESULTS Of the 1057 patients included in the study, 69 (6.5%) received carboplatin-based ACT. After PSM, 244 total patients were identified in two cohorts that did not differ for baseline characteristics. Death was recorded in 114 (46.7%) patients over a median follow-up of 19 months. In the multivariable Cox regression analyses, increasing age at surgery (hazard ratio [HR] 1.02, 95% confidence interval [CI] 1.01-1.06, p < 0.001) and increasing number of positive lymph nodes (HR 1.06, 95% CI 1.01-1.07, p = 0.02) were independent predictors of worse OS. The delivery of carboplatin-based ACT was not predictive of improved OS (HR 0.67, 95% CI 0.43-1.04, p = 0.08). The main limitations of this study are its retrospective design and the relatively low number of patients involved. CONCLUSIONS Carboplatin-based might not improve OS in patients with pN1-3 cM0 BCa. Our results underline the need for alternative therapies for cisplatin-ineligible patients.
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Compérat E. Latest Developments and Current Problems in Bladder Cancer. World J Urol 2021; 39:4009-4010. [PMID: 34643773 DOI: 10.1007/s00345-021-03857-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Eva Compérat
- Department of Pathology, Hôpital Tenon, Sorbonne University, Paris VI, Paris, France.
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Surgical intervention in patients with urothelial carcinoma of the bladder and lymph node metastasis. Curr Opin Urol 2021; 31:220-225. [PMID: 33742983 DOI: 10.1097/mou.0000000000000866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To systematically review the most recent evidence on the role of surgery in patients with urothelial carcinoma of bladder and lymph node metastasis. RECENT FINDINGS Patients with urothelial carcinoma of bladder and lymph node metastasis have a poor prognosis. The mainstay treatment for these patients is systemic chemotherapy. However, slowly growing body of literature suggests that multimodal therapy comprised of radical cystectomy, lymph node dissection, and perioperative chemotherapy is more effective than either chemotherapy or surgery alone. The timing of chemotherapy, whether preoperative or adjuvant chemotherapy, is still controversial, but the current evidence indicates that patients who achieve a major or complete response after induction chemotherapy appear to benefit from the surgical intervention in the form of radical cystectomy and pelvic lymph node dissection. The limit of lymph node dissection has to be determined. SUMMARY Multimodal therapy is associated with better survival outcomes in bladder cancer patients with lymph node metastasis. The current guidelines recommend systemic chemotherapy as the mainstay of treatment for these patients, and there is no convincing evidence on the efficacy of surgical intervention in isolation. Nonetheless, studies comparing multiple treatment modalities demonstrated that surgical salvage therapy is beneficial only when combined with chemotherapy. The methodological limitations of the current literature preclude a robust conclusion of survival advantage. Further studies are needed to help improve imaging for detecting lymph node metastasis and novel strategies to enrich our multimodal therapeutic implementation.
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Management of Clinically Regional Node-Positive Urothelial Carcinoma of the Bladder. Curr Oncol Rep 2021; 23:24. [PMID: 33559760 DOI: 10.1007/s11912-021-01018-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2021] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Clinically regional node-positive (cN+) urothelial carcinoma of the bladder requires a multi-modal management approach amidst growing recognition that it represents a spectrum of disease. Herein, we review the contemporary evidence for the natural history, evaluation, and management of clinically regional node-positive urothelial carcinoma of the bladder, highlighting recent changes in lymph node staging. RECENT FINDINGS Despite advances in techniques, cross-sectional imaging remains relatively insensitive for the detection of lymph node metastases. Recent changes to nodal staging that distinguish between cN1, cN2-3, and non-regional lymph node metastases reflect an increasing understanding that node-positive disease is heterogeneous and its management must be individualized according to nodal staging. Systemic therapy remains the initial management strategy, either alone or in conjunction with radiotherapy, with choice and sequencing of agents extrapolated from studies of metastatic disease. Consolidative radical cystectomy is an option for patients with disease response to upfront systemic therapy, and several series demonstrate a subset of patients with favorable oncologic outcomes. The comparative effectiveness of radiotherapy and radical cystectomy as local therapy remains an important evidence gap. Future studies that identify predictive biomarkers will help inform optimal choice of systemic therapy. The management of clinically regional node-positive disease requires a multimodal approach comprising both systemic and local therapy, tailored to the patient and to disease response. While choice of systemic therapy will be informed by ongoing studies in patients with metastatic disease, including the elucidation of predictive biomarkers, the comparative effectiveness of local therapies remains an important evidence gap.
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