Oncologic outcome and urinary function after radical cystectomy for rhabdomyosarcoma in children: role of the orthotopic ileal neobladder based on 15-year experience at a single center

Long-term Follow-up of Detaenial Sigmoid Neobladder Reconstruction for Paediatric Patients with Bladder and Prostate Rhabdomyosarcoma: Technique and Results from a Single High-volume Centre

BACKGROUND

Rhabdomyosarcoma (RMS) is the most common paediatric soft-tissue sarcoma. Approximately 15-20% of RMS cases arise from the bladder and prostate (B/P). The optimal treatment strategy for B/P RMS remains unclear.

OBJECTIVE

To retrospectively evaluate the applicability of our procedure performed to treat paediatric patients with B/P RMS.

DESIGN, SETTING, AND PARTICIPANTS

This is a retrospective analysis from a single tertiary referral hospital. From August 2003 to March 2021, 62 children pathologically diagnosed with B/P RMS underwent radical cystectomy and orthotopic detaenial sigmoid neobladder reconstruction in our centre.

SURGICAL PROCEDURE

Surgical procedures included laparoscopic radical cystectomy and detaenial sigmoid neobladder reconstruction, which is demonstrated in the accompanying video.

MEASUREMENTS

Demographic, clinical, and follow-up data were collected. Perioperative and long-term oncological and functional outcomes were reported. A logistic regression analysis was also performed.

RESULTS AND LIMITATIONS

All surgeries, including three intracorporeal laparoscopic surgeries, were completed successfully. Of the 62 patients, 54 were alive without evidence of disease recurrence or metastasis at the last follow-up. Five of the 14 >12-yr-old boys reported that they experienced erections. Two female patients >12 yr old reported that they menstruated. However, this was a retrospective study conducted at a single centre with limited surgeon experience.

CONCLUSIONS

Our results confirmed the safety and feasibility of primary orthotopic sigmoid neobladder reconstruction after radical cystectomy for paediatric patients with B/P RMS. Good outcomes in terms of oncological control and functional recovery were achieved. The high histocompatibility and tissue adaptability of children are inspiring.

PATIENT SUMMARY

We describe our stepwise technique of radical cystectomy and detaenial sigmoid neobladder reconstruction for paediatric patients with bladder and prostate rhabdomyosarcoma. With this technique, we were able to achieve good functional recovery without compromising cancer control and significantly increasing complications.

Intravesical alprostadil as a promising agent in BK virus-associated hemorrhagic cystitis: A report of a refractory case

Allogeneic stem cell transplant recipients are at risk of BK virus-associated hemorrhagic cystitis. This condition causes a significant morbidity and worsens clinical outcomes. The standard cares for BK virus-associated hemorrhagic cystitis are saline irrigation and forced diuresis. Notably, several beneficial roles are proposed for antiviral and anti-inflammatory agents against BK virus-associated hemorrhagic cystitis. However, cases who are at risk of cystectomy remain refractory. Herein, we present a 13-year-old boy with severe hematuria by passing two months from his allogeneic stem cell transplantation. The laboratory work up showed high BK viremia >1.1 ×  10⁸ copies/ml in this case's urine sample. The patient was treated with antiviral agents in combination with supportive care. Moreover, intravesical alum was administered, but no clinical benefits were achieved. Finally, intravesical alprostadil was prepared under the supervision of a pediatric clinical pharmacist. In this regard, an alprostadil solution was prepared by constitution of 250 μg alprostadil in 50 mL saline. After administrating the first dose of intravesical alprostadil, an acceptable clinical response was observed, and hematuria stopped. Of note, alprostadil induces platelet aggregation and vasoconstriction. Thus, bleeding can be controlled after the administration of intravesical alprostadil. This strategy may be associated with several side effects including bladder spasm. This study is the first report describing the special role of intravesical alprostadil in refractory cases of BK virus-associated hemorrhagic cystitis. In such refractory cases, clinicians can use intravesical alprostadil rather than invasive therapies in the treatment of BK virus-hemorrhagic cystitis.

Robotic-assisted Laparoscopic Management of Bladder/Prostate Rhabdomyosarcoma in Children: Initial Series and 1-yr Outcomes

OBJECTIVE

To present our preliminary experiences of robotic-assisted laparoscopic radical or partial cystectomy for bladder/prostate rhabdomyosarcoma in children.

METHODS

A retrospective study was conducted with children who underwent robotic-assisted laparoscopic surgery for bladder/prostate rhabdomyosarcoma (B/P RMS) between July 2018 and March 2020. The patient characteristics, tumor position, perioperative information, short time oncologic survival outcomes, and urinary function were recorded and evaluated.

RESULTS

We identified eight children who underwent robotic-assisted laparoscopic surgery for B/P RMS. Partial cystectomy was performed on all but one patient, who underwent a radical cystectomy and sigmoid neobladder reconstruction. Preoperative chemotherapy was administered to all eight patients, while preoperative radiotherapy was conducted in three cases, including one patient with a history of pelvic rhabdomyosarcoma. Unilateral/bilateral ureter reimplantation was done in four cases in which the patients' ureter orifices were involved. The mean follow-up time was 13.3 months, and no local recurrence or metastasis was observed. No patient experienced urinary incontinence eventually.

CONCLUSION

Robotic-assisted laparoscopic resection for bladder rhabdomyosarcoma in children is safe and feasible. Preoperative radiotherapy could decrease the tumor volume so that the membranous urethra could be preserved for as long as possible. The oncological efficacy and overall survival rate require further investigation and longer follow-up.

Benefit of delayed primary excision in rhabdomyosarcoma: A report from the Children's Oncology Group

BACKGROUND

Most children with intermediate-risk rhabdomyosarcoma (RMS) have gross disease (group III) at the initiation of chemotherapy. Delayed primary excision (DPE) after induction chemotherapy allows for a reduction in adjuvant radiation dose, but with the risk of potential surgical morbidity. The objectives of this study were to compare outcomes in children with group III RMS who did and did not undergo DPE and to assess surgical morbidity.

METHODS

The study included 369 patients who had clinical group III RMS at sites amenable to DPE from intermediate-risk Children's Oncology Group studies D9803 (encouraged DPE) and ARST0531 (discouraged DPE).

RESULTS

The primary tumor site was bladder/prostate (136 patients; 37%), extremity (97 patients; 26%), trunk (24 patients; 7%), retroperitoneum (91 patients; 25%), or intrathoracic/perineum/perianal (21 patients; 6%). In total, 112 patients (53.9%) underwent DPE in D9803, and 26 patients (16.2%) underwent DPE in ARST0531 (P < .001), with loss of vital organ or function in 30 of 138 patients (22%). DPE allowed for a reduced radiation dose in 110 of 135 patients (81%; 51% were reduced to 36 Gy, and 30% were reduced to 42 Gy). Patients who underwent DPE had improved unadjusted overall survival (P = .013). In adjusted regression analysis, the risk of death (hazard ratio, 0.71; 95% CI 0.43-1.16) was similar for patients who did and did not undergo DPE and was improved for the subset of patients who had tumors of the trunk and retroperitoneum (hazard ratio, 0.44; 95% CI, 0.20-0.97).

CONCLUSIONS

Children with group III RMS have equivalent or improved outcomes with DPE and can receive a decreased radiation dose for definitive local control. The choice of local control modality should weigh the potential morbidity of surgery versus that of higher dose irradiation.

Appraisal of the role of radical prostatectomy for rhabdomyosarcoma in children: oncological and urological outcome

The latest multimodal protocols for treatment of bladder/prostate rhabdomyosarcoma (RMS) have shifted the goal of treatment from patient survival to bladder preservation. Consistently, partial resections, such as radical prostatectomy (RP), are favoured when surgery is deemed necessary. We sought to determine the oncological risks - that is, failure to achieve disease control - and the possible benefits in terms of urinary continence associated with RP in RMS patients based on a review of our experience and the data reported in the literature. We identified 18 children undergoing RP for RMS (3 at our institution, 15 in the literature). In five cases, a pubectomy/symphisiotomy was performed to improve surgical exposure. Two cases experienced local relapse, suggesting that this approach can be viable to achieve local control. No clear-cut indications could be extrapolated from the literature, however, to determine how to select the patients most suitable for this approach. We offered this treatment to patients with evidence of disease localized only within the prostate on radiological and endoscopic re-assessment after chemo-/radio-therapy. Eight of the 18 cases (44%) eventually required lower urinary tract reconstruction, suggesting that often this approach does not allow for the preservation of urinary continence with volitional voiding. Finally, data about additional interesting outcomes such as erectile function and fertility in RMS patients undergoing RP are extremely sparse.

Current Treatment of Pediatric Bladder and Prostate Rhabdomyosarcoma

PURPOSE OF REVIEW

Rhabdomyosarcoma (RMS) is the most common sarcoma diagnosed in the first 20 years of life; bladder/prostate (BP) RMS accounts for 5% of all cases. Through efforts from multiple cooperative study groups, survival has improved significantly. This article aims to review the complex RMS classification system and treatment of BP RMS, with a focus on developing aspects of treatment.

RECENT FINDINGS

Recent advancements in technology are responsible for most of the progress in RMS treatment. PET-CT scanning has been shown to be superior to conventional metastatic workup. The use of proton beam therapy and brachytherapy to reduce the side effects of radiation is also showing promise. All cooperative oncology groups agree on surgical biopsy for diagnosis and staging of BP RMS. Patients are then grouped and risk classified before receiving chemotherapy. Regardless of local control strategy, oncologic outcomes appear to be similar for BP RMS. Alternative treatment strategies, which remain unproven, include brachytherapy and proton therapy.

Bladder Fetal Rhabdomyoma Intermediate Type

INTRODUCTION

Rhabdomyomas are benign tumors of striated muscle, the bladder localization is very rare.

CLINICAL CASE

We present an 87-year-old male consulting for gross hematuria. Cystoscopy was done with evidence of bulged bladder mucosa in right side wall and dome. Post-transurethral resection of the bladder (TURB) pathological anatomy was negative for malignancy. As extension study abdominopelvic computed tomography was performed identifying a bladder thickening of right posterior sidewall and an increased density of the adjacent fat. Second TURB was performed and a fetal bladder rhabdomyoma intermediate type was obtained. We performed another biopsy to confirm this rare pathology, with the same diagnosis. Subsequently, the patient continues with hematuria deciding on hemostatic radiotherapy (not candidate for cystectomy or arterial embolization). Currently, the patient is asymptomatic.

DISCUSSION

Bladder rhabdomyomas are rare tumors, and, in fact, there have been only 5 papers published. Some cases are only isolation cited in the bladder mesenchymal tumors, and other polemic cases in which clinical and macroscopic characteristics remembered a rhabdomyosarcoma. The importance of this publication case is the macro- and microscopic images that can corroborate the final diagnosis, helping us to differentiate between rhabdomyoma, rhabdomyofibroma, or the malignant rhabdomyosarcoma, and shows the treatment possibilities of these tumors.

Adult genitourinary sarcoma: Clinical characteristics and survival in a series of patients treated at a high-volume institution

OBJECTIVES

To report our institutional experience in the management of adult genitourinary sarcoma.

METHODS

This was a retrospective analysis of data on adult genitourinary sarcoma treated at the West China Hospital, Sichuan University, Chengdu, Sichuan, China from 1985 to 2010. Clinicopathological parameters were analyzed to determine their impact on overall, recurrence-free and metastasis-free survivals.

RESULTS

A total of 46 women and 142 men were included, with a median age of 42 years. Of these, 152 cases were high-grade. The most common site was the paratesticular region. Surgical resection was carried out in 155 patients (82.4%), with negative margin in 106. After a minimum follow up of 5 years, 20 patients (11.6%) survived disease-free, 14 (8.1%) were alive with disease and 138 (80.2%) died of disease. Survival rates at 1, 3 and 5 years were 91.3%, 64.0% and 47.7%. In univariate analyses, liposarcoma, high grade, metastasis at diagnosis, a lack of surgical resection and positive margin were predictive of unfavorable survival. In multivariate analyses, high grade, a lack of surgical resection and chemotherapy were independent predictors of poor survival.

CONCLUSIONS

Adult genitourinary sarcoma is an aggressive malignancy, usually presenting at advanced stage, with a high incidence of recurrence and metastasis. Complete resection and selective combination of chemotherapy and radiotherapy might constitute the optimal treatment for this disease.

Prognostic factors in children undergoing salvage surgery for bladder/prostate rhabdomyosarcoma

BACKGROUND

Prognostic factors have been studied in patients with rhabdomyosarcoma in general, but little is known about prognostic factors in the subgroup of patients with bladder/prostate rhabdomyosarcoma (BP-RMS) requiring salvage surgery after failure of chemotherapy ± radiotherapy to achieve local control. We reviewed the 28-year Italian experience with BP-RMS requiring salvage surgery after failure of nonsurgical management indicated by evidence of disease persistence after chemotherapy ± radiotherapy. Our hypothesis was that the same variables identified as prognostic factors in the general population with RMS could have prognostic value in this subgroup.

METHOD

Between 1986 and 2014, 108 patients with a histological diagnosis of BP-RMS were registered into three consecutive protocols. Patients undergoing salvage surgery after failure of chemotherapy ± radiotherapy and follow-up >5 years were considered for study. Variables related to the patient, to treatment, and to the surgical specimen were compared using the log-rank test in patients who achieved and failed to achieve 5-year progression-free survival (5-yr PFS). Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated for significant variables.

RESULTS

Of the 108 patients enrolled in the protocols, 33 (30.6%) underwent salvage surgery and 26 matched study criteria. Seventeen patients were disease-free after a median follow-up of 125 months (range 65.5-311.7 months), 5-yr PFS 65.4%. Nine events were registered after a median follow-up of 5.4 months (range 1.9-27.5 months). Among the variables assessed (Table), only an undifferentiated histology proved to be significantly associated with a poorer 5-yr PFS, whereas a tumor size above 5 cm in the removed specimen approached significance. The OR (95% CI) for failure of 5-yr PFS was 28 (2.4-326.8) and 8.3 (1.03-67.1), respectively.

CONCLUSION

5-yr PFS proved unrelated to excision margins of the surgical specimen, that is on whether there was evidence of microscopic residues left behind during surgery. These data suggest that the outcome is more influenced by the biological properties of the tumor. If small foci of differentiated cells are left behind, these probably do not compromise final prognosis. In our patients requiring salvage bladder-prostate surgery after failure of chemotherapy ± radiotherapy, long-term progression-free survival seemed unrelated to patient/tumor characteristics at presentation and preoperative management. Regarding the characteristics of the removed specimen, instead, an undifferentiated tumor histology and a diameter of the removed tumor >5 cm negatively influenced prognosis, whereas the presence of positive excision margins did not.

Determinants of Survival for Adolescents and Young Adults with Urothelial Bladder Cancer: Results from the California Cancer Registry

PURPOSE

Bladder cancer is a common malignancy often diagnosed in older adults. Previous studies have reported racial/ethnic disparities in bladder cancer survival outcomes but have not focused on younger patients. We identified whether factors influencing cause specific survival in adolescents and young adults (ages 15 to 39) differed from older adults, and defined prognostic factors specifically in adolescents and young adults using the California Cancer Registry.

MATERIALS AND METHODS

Patients diagnosed with bladder cancer between 1988 through 2012 were included in the study. The primary outcome measure was cause specific survival. A multivariable Cox proportional hazards regression model was used to evaluate predictors of cause specific survival in patients of all ages and in adolescents/young adults. Interactions of age and other variables between younger and older adult patients were assessed.

RESULTS

Of 104,974 patients with bladder cancer we identified 1,688 adolescent and young adult patients (1.6%). Compared to older patients these patients had a 58% reduced risk of bladder cancer death (HR 0.42, p <0.001). Significant age interactions were identified involving race/ethnicity and histology. Among adolescents and young adults, nonHispanic African-American patients with low socioeconomic status had poor cause specific (HR 7.1, p <0.001) and overall (HR 5.02, p <0.001) survival.

CONCLUSIONS

Racial/ethnic and socioeconomic disparities exist in adolescent and young adult patients with bladder cancer in California. Further studies are warranted to identify the underlying causes in order to overcome these disparities.