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Subiela JD, Rodríguez Faba Ó, Aumatell J, Gonzalez-Padilla DA, Rosales Bordes A, Huguet J, Krajewski W, Algaba F, López Curtis D, Brasero Burgos J, Sánchez González Á, Jiménez Cidre MÁ, Burgos Revilla FJ, Breda A, Palou J. Long-term Recurrence and Progression Patterns in a Contemporary Series of Patients with Carcinoma In Situ of the Bladder With or Without Associated Ta/T1 Disease Treated with Bacillus Calmette-Guérin: Implications for Risk-adapted Follow-up. Eur Urol Focus 2022; 9:325-332. [PMID: 36163105 DOI: 10.1016/j.euf.2022.09.007] [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: 07/26/2022] [Revised: 08/23/2022] [Accepted: 09/12/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Limited data are available on patients with carcinoma in situ (CIS) of the bladder managed according to current clinical practice guidelines. OBJECTIVE To assess the patterns of recurrence, progression to muscle-invasive bladder cancer (MIBC), and upper tract urothelial carcinoma (UTUC) in patients with CIS, and to compare the effectiveness of adequate versus inadequate bacillus Calmette-Guérin (BCG) immunotherapy. DESIGN, SETTING, AND PARTICIPANTS A retrospective analysis of 386 patients with CIS of the bladder with or without associated pTa/pT1 disease treated with BCG between 2008 and 2015. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Kaplan-Meier estimations and an inverse probability of treatment weighting (IPTW)-Cox regression were performed to compare recurrence-free survival (RFS) and progression-free survival (PFS) and UTUC incidence over time for patients who received adequate versus inadequate BCG treatment. RESULTS AND LIMITATIONS The median follow-up was 70.5 mo. At 5 and 10 yr, RFS was 82% and 52%, PFS was 93.6% and 75.8%, and UTUC incidence was 1.7% and 2.9%, respectively. Most recurrence (73.6%) and progression (69.1%) events occurred in the first 3 yr of follow-up, while 38.7% of UTUC incident events were recorded after 5 yr of follow-up. IPTW-Cox regression revealed that patients who received BCG treatment had a lower risk of recurrence (hazard ratio [HR] 0.21, 95% confidence interval [CI] 0.13-0.34), progression (HR 0.46, 95% CI 0.25-0.87), and UTUC incidence (HR 0.24, 95% CI 0.09-0.64). Limitations include the retrospective design and potential selection bias. CONCLUSIONS Patients with CIS of the bladder show a high risk of recurrence, progression, and UTUC incidence. Most of these outcomes occur during the first 3 yr of follow-up, but a significant proportion of the events occur at long-term follow-up. Although receipt of adequate BCG treatment improves outcomes, intensive and long-term surveillance may be warranted. PATIENT SUMMARY We investigated the long-term cancer control outcomes for patients with carcinoma in situ (CIS; cancerous cells that have not spread from where they first formed) of the bladder. Patients with CIS have a high risk of cancer recurrence and progression. Treatment with bacillus Calmette-Guérin (BCG) improves outcomes.
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Affiliation(s)
- José Daniel Subiela
- Department of Urology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, IRYCIS, Madrid, Spain.
| | - Óscar Rodríguez Faba
- Urooncology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Spain
| | - Júlia Aumatell
- Urooncology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Spain
| | | | - Antonio Rosales Bordes
- Urooncology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Spain
| | - Jorge Huguet
- Urooncology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Spain
| | - Wojciech Krajewski
- Department of Urology and Oncological Urology, Department of Public Health, Wrocław Medical University, Wrocław, Poland
| | - Ferran Algaba
- Department of Pathology, Fundació Puigvert, Universitat Autònoma de Barcelona, Spain; Department of Morphological Sciences, Barcelona, Spain
| | - David López Curtis
- Department of Urology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | - Jennifer Brasero Burgos
- Department of Urology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | - Álvaro Sánchez González
- Department of Urology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | - Miguel Ángel Jiménez Cidre
- Department of Urology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | | | - Alberto Breda
- Urooncology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Spain
| | - Joan Palou
- Urooncology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Spain
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Subiela JD, Rodríguez Faba Ó, Aumatell J, Calderón J, Mercadé A, Balañà J, Esquinas C, Algaba F, Breda A, Palou J. Contemporary outcomes of bladder carcinoma in situ treated with an adequate bacille Calmette-Guérin immunotherapy. BJU Int 2021; 129:542-550. [PMID: 34375494 DOI: 10.1111/bju.15567] [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] [Received: 05/14/2021] [Revised: 07/10/2021] [Accepted: 08/03/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess whether bacillus Calmette-Guérin (BCG) responsiveness after initiation of an adequate BCG treatment (at least five of six instillations of induction and at least two of three instillations of maintenance) impacts oncological outcomes in patients with carcinoma in situ (CIS) of the bladder treated with BCG immunotherapy. PATIENTS AND METHODS Data were available for 193 patients with bladder CIS with or without associated cTa/cT1 disease who received an adequate BCG treatment between 2008 and 2015. Bladder biopsies were taken at 6 months and patients were then stratified as either BCG responsive (negative biopsies) or BCG unresponsive (positive biopsies). Inverse probability weighting (IPW)-adjusted Kaplan-Meier and IPW-adjusted Cox regression were performed to compare progression-free survival (PFS), radical cystectomy-free survival (RCFS), overall survival OS, and cancer-specific survival (CSS) in the two groups. RESULTS AND LIMITATIONS Comparing the BCG-responsive and BCG-unresponsive groups, IPW-adjusted Kaplan-Meier analysis revealed, respectively, a median (interquartile range) of PFS of 9 (5-15) vs 48.5 (28-77) months (P = 0.001), a RCFS of 11 (9-15) vs 49 (24-76) months (P < 0.001), and a CSS of 25 (13-60) vs 109 (78-307) months (P = 0.004). On IPW-adjusted Cox regression analysis, BCG-unresponsive patients had a worse PFS (hazard ratio [HR] 3.40, 95% confidence interval [CI] 1.59-7.27), RCFS (HR 3.52, 95% CI 1.77-7), and CSS (HR 4.42, 95% CI 1.95-10.01). We found no significant differences for OS. CONCLUSION Using an IPW method we found that lack of response after initiation of an adequate BCG treatment has prognostic implications beyond identification of complete response in patients with CIS. BCG-unresponsive patients, satisfying the novel definition of BCG unresponsive, showed a poor PFS, RCFS, and CSS. In this setting, the patients should be counselled regarding RC as a first option or enrolled in a clinical trial if they refuse RC or are unfit for surgery.
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Affiliation(s)
- José Daniel Subiela
- Urooncology Unit, Department of Urology, Fundació Puigvert, Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain.,Oncological and Functional Bladder Pathology Unit, Department of Urology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, Spain
| | - Óscar Rodríguez Faba
- Urooncology Unit, Department of Urology, Fundació Puigvert, Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Júlia Aumatell
- Urooncology Unit, Department of Urology, Fundació Puigvert, Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Julio Calderón
- Urooncology Unit, Department of Urology, Fundació Puigvert, Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Asier Mercadé
- Urooncology Unit, Department of Urology, Fundació Puigvert, Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Josep Balañà
- Urooncology Unit, Department of Urology, Fundació Puigvert, Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Cristina Esquinas
- Statistics Unit, Department of Urology, Fundació Puigvert, Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ferran Algaba
- Department of Pathology, Fundació Puigvert, Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alberto Breda
- Urooncology Unit, Department of Urology, Fundació Puigvert, Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joan Palou
- Urooncology Unit, Department of Urology, Fundació Puigvert, Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
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Subiela JD, Faba ÓR, Aumatell J, Krajewski W, Calderón J, Parada R, Huguet J, Algaba F, Breda A, Palou J. Impact of clinical and pathological subtypes of carcinoma in situ (CIS) of the bladder: Lessons learned from long-term follow-up of a series of CIS patients treated with BCG. Urol Oncol 2021; 40:9.e9-9.e17. [PMID: 34140244 DOI: 10.1016/j.urolonc.2021.05.006] [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: 02/11/2021] [Revised: 04/14/2021] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Some attempts have previously been made to stratify patients with CIS for the purpose of risk-adapted clinical management and clinical trial design. In particular, two classification systems have been proposed: clinical classification, comprising primary (P-CIS), concomitant (C-CIS), and secondary (S-CIS) disease, and pathological classification, comprising P-CIS, cTa-CIS, and cT1-CIS. The aim of the present study was to assess the impact of both classifications on BCG response, recurrence-free survival (RFS), progression-free survival (PFS), overall survival (OS), and cancer-specific survival (CSS). PATIENTS AND METHODS We performed a retrospective analysis of 386 patients with bladder CIS, with or without associated cTa/cT1 disease, treated with BCG instillations between 2008 and 2015. Patients were stratified according to the two classification systems. Cox multivariate regression models were used to assess the impact of these subtypes on BCG response, RFS, PFS, OS, and CSS. We also performed a cumulative meta-analysis according to PRISMA guidelines. RESULTS The median follow-up was 70.5 months. According to the clinical classification, 34 (8.8%) patients had P-CIS, 81 (21%) S-CIS, and 271 (70.2%) C-CIS. The pathological classification showed 34 (8.8%) patients to have P-CIS, 190 (49.2%) cTa-CIS, and 162 (42%) cT1-CIS. In the overall cohort, BCG response was reported in 296 (76.7%); 159 (41.2%) had recurrence, 55 (14.2%) had progression, and 67 (17.4%) underwent radical cystectomy. Death from any cause was recorded in 135 (35%) and death from urothelial carcinoma in 38 (9.9%). Cox multivariate regression analysis showed that neither clinical classification nor pathological classification is an independent predictive factor for BCG response, RFS, PFS, OS, or CSS after adjusting for confounders. In the pooled meta-analysis, two studies and the present series were included for evidence synthesis, recruiting a total of 941 patients. We found no statistically significant difference across the groups for both classifications with respect to BCG response, RFS, PFS, and CSS. CONCLUSIONS Currently, the supporting evidence for an impact of clinical classification and pathological classification on oncological outcomes of CIS of the bladder is insufficient to justify their use to guide clinical management or follow-up.
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Affiliation(s)
- José Daniel Subiela
- Urooncology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Department of Surgery, Barcelona, Spain.
| | - Óscar Rodríguez Faba
- Urooncology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Department of Surgery, Barcelona, Spain
| | - Julia Aumatell
- Urooncology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Department of Surgery, Barcelona, Spain
| | - Wojciech Krajewski
- Department of Pathology, Fundació Puigvert, Universitat Autònoma de Barcelona, Department of Morphological Sciences, Barcelona, Spain
| | - Julio Calderón
- Urooncology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Department of Surgery, Barcelona, Spain
| | - Rubén Parada
- Urooncology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Department of Surgery, Barcelona, Spain
| | - Jorge Huguet
- Urooncology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Department of Surgery, Barcelona, Spain
| | - Ferran Algaba
- Department of Urology and Oncological Urology, Department of Public Health, Wrocław Medical University, Wrocław, Poland
| | - Alberto Breda
- Urooncology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Department of Surgery, Barcelona, Spain
| | - Joan Palou
- Urooncology Unit, Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Department of Surgery, Barcelona, Spain
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Abstract
PURPOSE OF REVIEW The standard diagnosis of carcinoma in situ (CIS) of the bladder, based on white light cystoscopy and urine cytology, is limited because CIS can vary from normal-appearing mucosa to a lesion indistinguishable from an inflammatory process. Intravesical instillation of Bacillus Calmette-Guerin (BCG) remains first-line therapy; however, a significant proportion of cases persist or recur after BCG treatment. This review summarizes recent improvements in the detection and treatment of CIS. RECENT FINDINGS The new optical technologies improve CIS detection, with a potential positive impact on oncological outcomes. The usefulness of MRI-photodynamic diagnosis fusion transurethral resection in CIS detection is unclear and further studies are needed. BCG instillation remains the first-line therapy in CIS patients and seems to improve recurrence and progression rates, especially with the use of maintenance. Intravesical device-assisted therapies could be effective in both BCG-naïve and BCG-unresponsive CIS patients, but further studies are ongoing to clarify their clinical benefit. A phase II clinical trial with pembrolizumab has shown the potential effectiveness of immune checkpoint inhibitors in BCG-unresponsive CIS patients and further trials are ongoing. SUMMARY New optical techniques increase the CIS detection rate. BCG instillation remains the first-line treatment. Immune checkpoint inhibitors could be a future alternative in BCG-naïve and BCG-unresponsive CIS patients.
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Piszczek R, Krajewski W, Małkiewicz B, Krajewski P, Tukiendorf A, Zdrojowy R, Kołodziej A. Clinical outcomes and survival differences between primary, secondary and concomitants carcinoma in situ of urinary bladder treated with BCG immunotherapy. Transl Androl Urol 2020; 9:1338-1344. [PMID: 32676418 PMCID: PMC7354324 DOI: 10.21037/tau.2020.03.40] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background The carcinoma in situ (CIS) of urinary bladder is a flat, high-grade and aggressive manifestation of urothelial cancer which carries a great risk for progression to muscle invasive disease and metastatic spread. The aim of the study was to analyse the clinical history and survival differences between primary, secondary and concomitants CIS of the bladder. Methods We analysed a database of 301 patients who were treated between 1998 and 2017 in university BCG outpatient department. Primary, secondary and concomitants CIS cases were included in the study with minimum follow-up of 12 months. Recurrence-free survival (RSF), progression-free survival (PFS) and cancer specific survival (CSS) were analysed by Kaplan–Meier curves and log-rank test. Additionally, Cox regression models were performed. Results Seventy-two patients with primary, 58 with secondary and 171 with CIS concomitants were analysed. The patients were followed from mean 61,9 months. RFS rates at 5-years follow-up were 54.9%, 55.3% and 60.4% for primary, concomitants and secondary CIS (P>0.05). PFS rates at 5-years follow-up were 65.8%, 72.1% and 77% for primary, concomitants and secondary CIS (P>0.05). CSS rates at 5-years follow-up were 83.1%, 81.9% and 90.1% for primary, concomitants and secondary CIS (P>0.05). There were no statistically significant differences between any CIS subtype in any of analysed endpoints in multivariate analysis. Female gender was associated with worse RFS and the instillation number was positively associated with all analysed survival rates. On contrary, age was not statistically related to RFS, PFS nor CSS. Conclusions In this study it was shown that when compared with secondary and concomitants CIS, primary CIS presented the worst RFS and PFS, however, the differences between subgroups were not statistically significant.
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Affiliation(s)
- Radosław Piszczek
- Department of Urology and Oncologic Urology, Lowersilesian Specialistic Hospital, Wroclaw, Poland
| | - Wojciech Krajewski
- Department of Urology and Oncological Urology, Wrocław Medical University, Wrocław, Poland
| | - Bartosz Małkiewicz
- Department of Urology and Oncological Urology, Wrocław Medical University, Wrocław, Poland
| | - Piotr Krajewski
- Department of Urology and Oncological Urology, Wrocław Medical University, Wrocław, Poland
| | - Andrzej Tukiendorf
- Department of Public Health, Wrocław Medical University, Wrocław, Poland
| | - Romuald Zdrojowy
- Department of Urology and Oncological Urology, Wrocław Medical University, Wrocław, Poland
| | - Anna Kołodziej
- Department of Urology and Oncological Urology, Wrocław Medical University, Wrocław, Poland
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