Neoadjuvant Chemotherapy in Transitional-cell Carcinoma of the Bladder

Neoadjuvant cisplatin chemotherapy before chemoradiation: a flawed paradigm?

Effective chemotherapy (CT) treatment of solid tumors emerged with the introduction of anthracyclines and platinum CT in the late 1970s, at first with palliative intent, and later extended into the adjuvant setting. High response rates led to the belief that systemic CT might improve locoregional control and also decrease the risk of distant metastases. A new strategy advocated cisplatin-based neoadjuvant CT (NACT) before definitive local treatment-either surgery or radiotherapy (RT). Response to NACT was viewed as a favorable prognostic sign, which allows the selection of patients most likely to benefit from RT or chemoradiotherapy (CRT). The aim of this discussion is to raise the debate regarding NACT in reducing metastases, improving local control and selecting out good responders for nonsurgical treatment in the following sites: head and neck, esophagus, cervix, anus, nasopharynx, and bladder; as well as non-small-cell lung cancer. NACT has almost invariably failed to deliver an improved outcome in terms of disease-free survival (DFS) or overall survival (OS) when delivered before RT or CRT in all solid tumor sites. The evidence that NACT may improve outcome in terms of DFS or OS is strongest when it is administered before surgical resection, but remains scant before RT or CRT. Taxane-containing regimens look more promising than does cisplatin NACT, but have not been shown to improve on concurrent CRT. Future meta-analyses should compare induction CT followed by RT and induction followed by CRT versus RT or CRT alone.

Long-term follow up of patients with invasive bladder carcinoma receiving combined cisplatin-based intra-arterial chemotherapy and radiotherapy

OBJECTIVES

Combined cisplatin-based intra-arterial chemotherapy and radiotherapy is an effective treatment for patients with locally invasive bladder carcinoma. We report long-term follow-up data regarding definitive treatment of locally invasive bladder carcinoma, regardless of whether bladder preservation was possible.

METHODS

The follow-up data from 24 patients (18 males and six females; aged, 31-85 years; median, 73 years) with invasive bladder carcinoma, between 1993 and 2003, was examined. The clinical stages of the patients ranged T2-T4, all N0M0, and involved 13 patients at T2 (T2a, T2b), seven patients at T3 and four patients at T4. Combined cisplatin-based intra-arterial chemotherapy and radiotherapy was performed.

RESULTS

The 5-year overall survival rate and cancer-specific survival rate for all patients were 81.6% and 85.6%, respectively. When the patients were divided into complete response (CR) of 10 patients and non-CR groups of 14 patients, the 5-year overall survival rate for the CR group was 87.5%, while that of the non-CR group was 78.6% (P = 0.58). The tumor grade of the CR group was significantly lower than that of the non-CR group (P = 0.01). When the non-CR group was divided into radical cystectomy and non-radical cystectomy groups, the 5-year overall survival rate for the radical cystectomy group (100%) was higher than that of the non-radical cystectomy group (70%).

CONCLUSION

This combined chemo-radiotherapy was effective for local invasive bladder carcinoma, leading to the possibility of bladder preservation using this therapy.

Urothelial Carcinoma with Divergent Histologic Differentiation (Mixed Histologic Features) Predicts the Presence of Locally Advanced Bladder Cancer When Detected at Transurethral Resection

OBJECTIVES

The histologic classification of bladder tumors remains an important predictor of treatment response and patient outcome, with pure nonurothelial tumors associated with poorer outcome compared with pure urothelial carcinoma (UC). Little, however, is known about the significance of UC with divergent (mixed) histologic features at transurethral resection of bladder tumor (TURBT). This study examined the incidence, pathologic spectrum, and clinical significance of this phenomenon.

METHODS

The histologic patterns of 448 consecutive TURBT and 295 subsequent cystectomy specimens from this subgroup were analyzed. The type of divergent tumor differentiation observed in the mixed histologic type cases was categorized and quantified. Pure non-UC cases were excluded. Various clinicopathologic parameters were compared between the mixed histologic type and pure UC cohorts.

RESULTS

UC with mixed histologic features was identified in 25% of all TURBT specimens and was uniformly (100%) high grade and invasive (99%). The most common mixed histologic components were squamous (40%) and glandular (18%). Eleven percent of cases had multiple mixed histologic types. Compared with the pure high-grade UC, UCs with mixed histologic features were associated with muscle invasion at TURBT (chi-square test, P <0.001) and with extravesical disease at cystectomy (chi-square test, P = 0.0001). The presence of mixed histologic features at TURBT was an independent predictor of extravesical disease in a multivariate logistic model (P = 0.007). However, it was not significant for disease-specific survival in the univariate (P = 0.17) or multivariate (P = 0.68) models.

CONCLUSIONS

The results of our study have shown that the presence of mixed histologic features at TURBT indicates locally aggressive disease. Patients with mixed histologic features might benefit from an aggressive multimodality treatment strategy.