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Ditonno F, Veccia A, Montanaro F, Pettenuzzo G, Franco A, Manfredi C, Triggiani L, De Nunzio C, De Sio M, Cerruto M, Crivellaro S, Kutikov A, Autorino R, Antonelli A. Trimodal therapy vs radical cystectomy in patients with muscle-invasive bladder cancer: a systematic review and meta-analysis of comparative studies. BJU Int 2024. [PMID: 38622957 DOI: 10.1111/bju.16366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
OBJECTIVE To perform a systematic review and meta-analysis of trials comparing trimodal therapy (TMT) and radical cystectomy (RC), evaluating differences in terms of oncological outcomes, quality of life, and costs. MATERIALS AND METHODS In July 2023, a literature search of multiple databases was conducted to identify studies analysing patients with cT2-4 N any M0 muscle-invasive bladder cancer (MIBC; Patients) receiving TMT (Intervention) compared to RC (Comparison), to evaluate survival outcomes, recurrence rates, costs, and quality of life (Outcomes). The primary outcome was overall survival (OS). Secondary outcomes were cancer-specific survival (CSS) and metastasis-free survival (MFS). Hazard ratios (HRs) were used to analyse survival outcomes according to different treatment modalities and odds ratios were used to evaluate the likelihood of receiving each type of treatment according to T stage. RESULTS No significant difference in terms of OS was observed between RC and TMT (HR 1.07, 95% confidence interval [CI] 0.81-1.4; P = 0.6), even when analysing radiation therapy regimens ≥60 Gy (HR 1.02, 95% CI 0.69-1.52; P = 0.9). No significant difference was observed in CSS (HR 1.12, 95% CI 0.79-1.57, P = 0.5) or MFS (HR 0.88, 95% CI 0.66-1.16; P = 0.3). The mean cost of TMT was significantly higher than that of RC ($289 142 vs $148 757; P < 0.001), with greater effectiveness in terms of cost per quality-adjusted life-year. TMT ensured significantly higher general quality-of-life scores. CONCLUSION Trimodal therapy appeared to yield comparable oncological outcomes to RC concerning OS, CSS and MFS, while providing superior patient quality of life and cost effectiveness.
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Affiliation(s)
- Francesco Ditonno
- Department of Urology, Rush University Medical Center, Chicago, IL, USA
- Department of Urology, University of Verona, Verona, Italy
| | | | | | | | - Antonio Franco
- Department of Urology, Rush University Medical Center, Chicago, IL, USA
- Department of Urology, Sant'Andrea Hospital, La Sapienza University, Rome, Italy
| | - Celeste Manfredi
- Department of Urology, Rush University Medical Center, Chicago, IL, USA
- Urology Unit, Department of Woman, Child and General and Specialized Surgery, "Luigi Vanvitelli" University, Naples, Italy
| | - Luca Triggiani
- Department of Radiation Oncology, University and Spedali Civili Hospital, Brescia, Italy
| | - Cosimo De Nunzio
- Department of Urology, Sant'Andrea Hospital, La Sapienza University, Rome, Italy
| | - Marco De Sio
- Urology Unit, Department of Woman, Child and General and Specialized Surgery, "Luigi Vanvitelli" University, Naples, Italy
| | | | - Simone Crivellaro
- Department of Urology, University of Illinois at Chicago, Chicago, IL, USA
| | - Alexander Kutikov
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Riccardo Autorino
- Department of Urology, Rush University Medical Center, Chicago, IL, USA
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Saeedian A, Safaei AM, Azimi A, Kolahdouzan K, Tabatabaei FS, Esmati E. Implications for pelvic lymph node irradiation in definitive chemoradiotherapy of node negative muscle invasive bladder cancer based on predictive factors of clinicopathologic discrepancy. J Cancer Res Clin Oncol 2022; 149:2537-2542. [PMID: 35764702 DOI: 10.1007/s00432-022-04153-4] [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: 05/03/2022] [Accepted: 06/13/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE To identify pre-surgical imaging predictive value and factors associated with the clinicopathologic discrepancy for implication of definitive pelvic radiotherapy in clinically node-negative bladder cancer. METHOD The documented data of bladder cancer patients who underwent radical cystectomy plus pelvic lymphadenectomy were collected retrospectively. Patients' characteristics, last imaging, pathology reports, disease-specific survival and overall survival were retrieved. RESULTS From 142 patients, pre-surgical imaging had a sensitivity of 76.4%, specificity of 73.7%, positive predictive value (PPV) of 94.9%, and negative predictive value (NPV) of 32.6% (p value < 0.0001) for detection of muscle invasion. Also, for detection of positive lymph nodes, imaging had a sensitivity of 31.8%, specificity of 85.7%, PPV of 50%, and NPV of 73.7% (p value: 0.022). 44.4% of study population were upstaged after surgery (24.6% associated with N-upstaging) and 18.3% were downstaged (12% associated with N-downstaging). Receipt of neoadjuvant chemotherapy and T-stage were not correlated with N-upstaging. On multivariate analysis, lymphovascular invasion (LVI) maintained its significance for independent prediction of upstaging (OR 3.3, 95% CI 1.5-7.5, p value: 0.004) and inversely with downstaging (OR 0.34, 95% CI 0.12-0.96, p value: 0.04). Older age (OR 1.03, 95% CI 1.0-1.05, p value 0.047), positive margins (OR 2.1, 95% CI 1.2-3.8, p value 0.011), presence of LVI (OR 2.5, 95% CI 1.4-4.7, p value 0.003), perineural invasion (OR 2.0, 95% CI 1.2-3.4, p value 0.013), and lymph node ratio (OR 1.011, 95% CI 1.001-1.021, p value 0.03) were associated with worse survival. Also, N-upstaging independently predicted a worse survival after controlling for surgical pathology stage (OR 2.3, 95% CI 1.2-4.5, p value 0.011). CONCLUSIONS The optimal target volume in definitive chemoradiotherapy of node-negative bladder cancer patients remains to be established. Since then, customizing the treatment is considered especially for positive LVI in TURBT specimen.
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Affiliation(s)
- Arefeh Saeedian
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran.,Department of Radiation Oncology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Qarib Street, Keshavarz Blvd., Tehran, Iran
| | - Afsaneh Maddah Safaei
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran. .,Department of Radiation Oncology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Qarib Street, Keshavarz Blvd., Tehran, Iran.
| | - Amirali Azimi
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran.,School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Kasra Kolahdouzan
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran.,Department of Radiation Oncology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Qarib Street, Keshavarz Blvd., Tehran, Iran
| | - Fatemeh-Sadat Tabatabaei
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran.,School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Ebrahim Esmati
- Radiation Oncology Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran.,Department of Radiation Oncology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Qarib Street, Keshavarz Blvd., Tehran, Iran
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Alati A, Fabiano E, Geiss R, Mareau A, Charles-Nelson A, Bibault JE, Giraud P, Kreps S, Méjean A, Housset M, Durdux C. Bladder preservation in older adults with muscle-invasive bladder cancer: A retrospective study with concurrent chemotherapy and twice-daily hypofractionated radiotherapy schedule. J Geriatr Oncol 2022; 13:978-986. [PMID: 35717533 DOI: 10.1016/j.jgo.2022.05.014] [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: 12/29/2021] [Revised: 05/24/2022] [Accepted: 05/31/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Bladder cancer occurs mainly in older adults and surgery is not always possible when there are geriatric conditions and comorbidities. Trimodal treatment (TMT) combining trans-urethral resection of bladder tumour (TURBT) followed by concurrent chemoradiation (CRT) would be a curative alternative in such patients. METHODS All consecutive patients 75 years of age and older with non-metastatic muscle-invasive bladder cancer (MIBC) treated with TMT by Georges Pompidou European Hospital team were retrospectively analysed. Induction CRT combined hypofractionated twice-daily radiotherapy targeting bladder and pelvis to a total dose of 24 Gy (Gy) with concurrent platinum salt and 5-fluorouracil. Consolidation CRT to a total dose of 44 Gy was proposed to patients with biopsy-proven complete response after induction phase and those with persistent tumour underwent salvage cystectomy. We assessed using Kaplan-Meier method overall survival (OS), cancer specific survival (CSS), invasive recurrence-free survival (IRFS), metastasis-free survival (MFS), survival with bladder preserved (SBP), and toxicities. With a Cox model for OS and the Fine Gray method of competing risk for secondary endpoints, we analysed in univariate (u) and multivariate (m) analysis the impact of tumour characteristics and patient profiles: gender, age, age-adjusted Charlson comorbidity index, polypharmacy, and malnutrition. RESULTS From 1988 to 2017, 85 patients were included. After induction, complete response rate was 83.5%. With a median follow-up of 63 months, 5 year-OS, CSS, IRFS, MFS and SBP were 61.0%, 77.6%, 71%, 82.9%, and 70.2% respectively. A persistent tumour after induction impacted SBP (SHRm 3.61; p = 0.004), CSS (SHRm 3.27; p = 0.023), and MFS (SHRm 3.68; p = 0.018). Late grade 3 urinary and gastrointestinal toxicities were 3.5% and 1.2%. CONCLUSION We report here the largest series of bladder preservation over 75 years in a curative intent. Outcomes and tolerance in selected older adults compared favourably with surgical series and with CRT studies using classical fractionation.
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Affiliation(s)
- Aurélia Alati
- Department of Radiation Oncology, Georges Pompidou European Hospital, University of Paris Descartes, Paris, France.
| | - Emmanuelle Fabiano
- Department of Radiation Oncology, Georges Pompidou European Hospital, University of Paris Descartes, Paris, France
| | - Romain Geiss
- Geriatric Department, Georges Pompidou European Hospital, University of Paris Descartes, Paris, France
| | - Alexis Mareau
- Clinical Research Unit, Georges Pompidou European Hospital, University of Paris Descartes, Paris, France
| | - Anais Charles-Nelson
- Clinical Research Unit, Georges Pompidou European Hospital, University of Paris Descartes, Paris, France
| | - Jean-Emmanuel Bibault
- Department of Radiation Oncology, Georges Pompidou European Hospital, University of Paris Descartes, Paris, France
| | - Philippe Giraud
- Department of Radiation Oncology, Georges Pompidou European Hospital, University of Paris Descartes, Paris, France
| | - Sarah Kreps
- Department of Radiation Oncology, Georges Pompidou European Hospital, University of Paris Descartes, Paris, France
| | - Arnaud Méjean
- Department of Urology, Georges Pompidou European Hospital, University of Paris Descartes, Paris, France
| | - Martin Housset
- Department of Radiation Oncology, Georges Pompidou European Hospital, University of Paris Descartes, Paris, France
| | - Catherine Durdux
- Department of Radiation Oncology, Georges Pompidou European Hospital, University of Paris Descartes, Paris, France
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Huddart RA. Bladder Radiotherapy: Is Cinderella Ready for the Ball? Clin Oncol (R Coll Radiol) 2021; 33:343-345. [PMID: 33895059 DOI: 10.1016/j.clon.2021.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/01/2021] [Indexed: 11/22/2022]
Affiliation(s)
- R A Huddart
- Institute of Cancer Research, Sutton, Surrey, UK.
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