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Taylor JI, Kamat AM, O'Donnell MA, Annapureddy D, Howard J, Tan WS, McElree I, Davaro F, Yim K, Harrington S, Dyer E, Black AJ, Kanabur P, Roumiguié M, Lerner S, Black PC, Raman JD, Preston MA, Steinberg G, Huang W, Li R, Packiam VT, Woldu SL, Lotan Y. Long-term outcomes of bladder-sparing therapy vs radical cystectomy in BCG-unresponsive non-muscle-invasive bladder cancer. BJU Int 2024. [PMID: 39183466 DOI: 10.1111/bju.16509] [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: 08/27/2024]
Abstract
OBJECTIVE To quantify the oncological risks of bladder-sparing therapy (BST) in patients with Bacillus Calmette-Guérin (BCG)-unresponsive non-muscle-invasive bladder cancer (NMIBC) compared to upfront radical cystectomy (RC). PATIENTS AND METHODS Pre-specified data elements were collected from retrospective cohorts of patients with BCG-unresponsive NMIBC from 10 international sites. After Institutional Review Board approval, patients were included if they had BCG-unresponsive NMIBC meeting United States Food and Drug Administration criteria. Oncological outcomes were collected following upfront RC or BST. BST regimens included re-resection or surveillance only, repeat BCG, intravesical chemotherapy, systemic immunotherapy, and clinical trials. RESULTS Among 578 patients, 28% underwent upfront RC and 72% received BST. The median (interquartile range) follow-up was 50 (20-69) months. There were no statistically significant differences in metastasis-free survival, cancer-specific survival, or overall survival between treatment groups. In the BST group, high-grade recurrence rates were 37% and 52% at 12 and 24 months and progression to MIBC was observed in 7% and 13% at 12 and 24 months, respectively. RC was performed in 31.7% in the BST group and nodal disease was found in 13% compared with 4% in upfront RC (P = 0.030). CONCLUSION In a selected cohort of patients, initial BST offers comparable survival outcomes to upfront RC in the intermediate term. Rates of recurrence and progression increase over time especially in patients treated with additional lines of BST.
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Affiliation(s)
- Jacob I Taylor
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ashish M Kamat
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Jeffrey Howard
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Wei Shen Tan
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | | | | | | | - Anna J Black
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Seth Lerner
- Baylor College of Medicine, Houston, TX, USA
| | - Peter C Black
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | - William Huang
- New York University Langone Health, New York, NY, USA
| | - Roger Li
- Moffit Cancer Center, Tampa, FL, USA
| | | | - Solomon L Woldu
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Yair Lotan
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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2
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Alonso JCC, de Souza BR, Reis IB, de Arruda Camargo GC, de Oliveira G, de Barros Frazão Salmazo MI, Gonçalves JM, de Castro Roston JR, Caria PHF, da Silva Santos A, de Freitas LLL, Billis A, Durán N, Fávaro WJ. OncoTherad ® (MRB-CFI-1) Nanoimmunotherapy: A Promising Strategy to Treat Bacillus Calmette-Guérin-Unresponsive Non-Muscle-Invasive Bladder Cancer: Crosstalk among T-Cell CX3CR1, Immune Checkpoints, and the Toll-Like Receptor 4 Signaling Pathway. Int J Mol Sci 2023; 24:17535. [PMID: 38139364 PMCID: PMC10743608 DOI: 10.3390/ijms242417535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/09/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
This study assessed the safety and efficacy of OncoTherad® (MRB-CFI-1) nanoimmunotherapy for non-muscle invasive bladder cancer (NMIBC) patients unresponsive to Bacillus Calmette-Guérin (BCG) and explored its mechanisms of action in a bladder cancer microenvironment. A single-arm phase I/II study was conducted with 44 patients with NMIBC who were unresponsive to BCG treatment. Primary outcomes were pathological complete response (pCR) and relapse-free survival (RFS). Secondary outcomes comprised response duration and therapy safety. Patients' mean age was 65 years; 59.1% of them were refractory, 31.8% relapsed, and 9.1% were intolerant to BCG. Moreover, the pCR rate after 24 months reached 72.7% (95% CI), whereas the mean RFS reached 21.4 months. Mean response duration in the pCR group was 14.3 months. No patient developed muscle-invasive or metastatic disease during treatment. Treatment-related adverse events occurred in 77.3% of patients, mostly grade 1-2 events. OncoTherad® activated the innate immune system through toll-like receptor 4, leading to increased interferon signaling. This activation played a crucial role in activating CX3CR1+ CD8 T cells, decreasing immune checkpoint molecules, and reversing immunosuppression in the bladder microenvironment. OncoTherad® has proved to be a safe and effective therapeutic option for patients with BCG-unresponsive NMIBC, besides showing likely advantages in tumor relapse prevention processes.
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Affiliation(s)
- João Carlos Cardoso Alonso
- Laboratory of Urogenital Carcinogenesis and Immunotherapy (LCURGIN), Universidade Estadual de Campinas (UNICAMP), Campinas 13083-865, São Paulo, Brazil; (G.C.d.A.C.); (G.d.O.); (M.I.d.B.F.S.); (J.M.G.); (J.R.d.C.R.); (P.H.F.C.); (A.d.S.S.); (N.D.)
- Paulínia Municipal Hospital, Paulínia 13140-000, São Paulo, Brazil
| | - Bianca Ribeiro de Souza
- Obstetrics & Gynecology Department, Ovarian Cancer Research Group University of British Columbia, Vancouver, BC V6Z 2K8, Canada;
| | - Ianny Brum Reis
- Diagnosis and Surgery Department, Dentistry School, São Paulo State University (UNESP), Araraquara 14801-903, São Paulo, Brazil;
| | - Gabriela Cardoso de Arruda Camargo
- Laboratory of Urogenital Carcinogenesis and Immunotherapy (LCURGIN), Universidade Estadual de Campinas (UNICAMP), Campinas 13083-865, São Paulo, Brazil; (G.C.d.A.C.); (G.d.O.); (M.I.d.B.F.S.); (J.M.G.); (J.R.d.C.R.); (P.H.F.C.); (A.d.S.S.); (N.D.)
| | - Gabriela de Oliveira
- Laboratory of Urogenital Carcinogenesis and Immunotherapy (LCURGIN), Universidade Estadual de Campinas (UNICAMP), Campinas 13083-865, São Paulo, Brazil; (G.C.d.A.C.); (G.d.O.); (M.I.d.B.F.S.); (J.M.G.); (J.R.d.C.R.); (P.H.F.C.); (A.d.S.S.); (N.D.)
| | - Maria Izabel de Barros Frazão Salmazo
- Laboratory of Urogenital Carcinogenesis and Immunotherapy (LCURGIN), Universidade Estadual de Campinas (UNICAMP), Campinas 13083-865, São Paulo, Brazil; (G.C.d.A.C.); (G.d.O.); (M.I.d.B.F.S.); (J.M.G.); (J.R.d.C.R.); (P.H.F.C.); (A.d.S.S.); (N.D.)
| | - Juliana Mattoso Gonçalves
- Laboratory of Urogenital Carcinogenesis and Immunotherapy (LCURGIN), Universidade Estadual de Campinas (UNICAMP), Campinas 13083-865, São Paulo, Brazil; (G.C.d.A.C.); (G.d.O.); (M.I.d.B.F.S.); (J.M.G.); (J.R.d.C.R.); (P.H.F.C.); (A.d.S.S.); (N.D.)
| | - José Ronaldo de Castro Roston
- Laboratory of Urogenital Carcinogenesis and Immunotherapy (LCURGIN), Universidade Estadual de Campinas (UNICAMP), Campinas 13083-865, São Paulo, Brazil; (G.C.d.A.C.); (G.d.O.); (M.I.d.B.F.S.); (J.M.G.); (J.R.d.C.R.); (P.H.F.C.); (A.d.S.S.); (N.D.)
| | - Paulo Henrique Ferreira Caria
- Laboratory of Urogenital Carcinogenesis and Immunotherapy (LCURGIN), Universidade Estadual de Campinas (UNICAMP), Campinas 13083-865, São Paulo, Brazil; (G.C.d.A.C.); (G.d.O.); (M.I.d.B.F.S.); (J.M.G.); (J.R.d.C.R.); (P.H.F.C.); (A.d.S.S.); (N.D.)
| | - André da Silva Santos
- Laboratory of Urogenital Carcinogenesis and Immunotherapy (LCURGIN), Universidade Estadual de Campinas (UNICAMP), Campinas 13083-865, São Paulo, Brazil; (G.C.d.A.C.); (G.d.O.); (M.I.d.B.F.S.); (J.M.G.); (J.R.d.C.R.); (P.H.F.C.); (A.d.S.S.); (N.D.)
| | - Leandro Luiz Lopes de Freitas
- Pathology Department, Medical School, Universidade Estadual de Campinas (UNICAMP), Campinas 13083-888, São Paulo, Brazil; (L.L.L.d.F.); (A.B.)
| | - Athanase Billis
- Pathology Department, Medical School, Universidade Estadual de Campinas (UNICAMP), Campinas 13083-888, São Paulo, Brazil; (L.L.L.d.F.); (A.B.)
| | - Nelson Durán
- Laboratory of Urogenital Carcinogenesis and Immunotherapy (LCURGIN), Universidade Estadual de Campinas (UNICAMP), Campinas 13083-865, São Paulo, Brazil; (G.C.d.A.C.); (G.d.O.); (M.I.d.B.F.S.); (J.M.G.); (J.R.d.C.R.); (P.H.F.C.); (A.d.S.S.); (N.D.)
| | - Wagner José Fávaro
- Laboratory of Urogenital Carcinogenesis and Immunotherapy (LCURGIN), Universidade Estadual de Campinas (UNICAMP), Campinas 13083-865, São Paulo, Brazil; (G.C.d.A.C.); (G.d.O.); (M.I.d.B.F.S.); (J.M.G.); (J.R.d.C.R.); (P.H.F.C.); (A.d.S.S.); (N.D.)
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Abou Chakra M, Packiam VT, O'Donnell MA. Real-world efficacy of adjuvant single-agent intravesical gemcitabine for non-muscle invasive bladder cancer. Expert Opin Pharmacother 2023; 24:2081-2091. [PMID: 37842956 DOI: 10.1080/14656566.2023.2271396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 10/12/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION Failure, intolerance, or shortage of bacillus Calmette-Guerin (BCG) treatment for patients with high-risk (HR) non-muscle invasive bladder cancer (NMIBC) leave many facing the prospect of radical cystectomy (RC). However, despite the lack of large-scale randomized controlled studies with single-agent intravesical gemcitabine (Gem), it has emerged as a popular salvage agent after BCG failure or even a treatment alternative to BCG. AREAS COVERED 1. Characterization of treatment regimen details pertaining to single-agent intravesical adjuvant Gem use among disease states of NMIBC characterized by risk and BCG exposure. 2. Comparison of safety and efficacy of Gem according to risk category, type of tumor (papillary vs. carcinoma in situ (CIS)), and tumor grades. EXPERT OPINION Two randomized studies in early BCG failure disease demonstrate that single-agent Gem has superior efficacy versus repeated BCG therapy or mitomycin C. Studies enrolling patients with predominantly papillary disease without CIS, intermediate-risk (IR) disease, and less BCG exposure appear to derive the highest benefits from adjuvant Gem in terms of recurrence and progression. However, studies with cohorts enriched for a predominance of CIS, HR disease and/or more extensive BCG failure have poorer 2-year recurrence free survival and a somewhat higher risk of progression and RC.
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Affiliation(s)
| | - Vignesh T Packiam
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Jersey, USA
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4
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Tan WS, Grajales V, Contieri R, Hensley P, Bree K, Msaouel P, Guo CC, Nogueras-Gonzalez GM, Navai N, Dinney CP, Kamat AM. Bladder-sparing Treatment in Patients with Bacillus Calmette-Guerin-unresponsive Non-muscle-invasive Bladder Cancer: An Analysis of Long-term Survival Outcomes. EUR UROL SUPPL 2023; 53:16-22. [PMID: 37441349 PMCID: PMC10334230 DOI: 10.1016/j.euros.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2023] [Indexed: 07/15/2023] Open
Abstract
Background Data for bladder-sparing treatment (BST) in bacillus Calmette-Guerin (BCG)-unresponsive non-muscle-invasive bladder cancer (NMIBC) patients report short-term outcomes limited to 1-2 yr. Objective To assess long-term survival outcomes of BCG-unresponsive NMIBC patients treated with BST. Design setting and participants BCG-unresponsive NMIBC patients diagnosed between January 2000 and September 2021 from an institutional NMIBC registry were evaluated. Intervention Long-term survival outcomes for patients receiving BST, early radical cystectomy (RC), and delayed RC were compared. Outcome measurements and statistical analysis The primary endpoints were overall survival (OS) and cancer-specific survival (CSS). Results and limitations In total, 114 patients with a median follow-up of 71.2 mo (interquartile range: 32.6-132.2) were analyzed. There were no significant differences in OS (hazard ratio [HR]: 1.40, 95% confidence interval [CI]: 0.68-2.89, p = 0.4) or CSS (HR: 0.88, 95% CI: 0.22-3.55, p = 0.9) between patients undergoing early RC (n = 38) and BST (n = 76). At 60 mo, BST patients had a high-grade recurrence-free rate, muscle-invasive disease/metastasis progression-free rate, and avoidance of RC rate of 37%, 83%, and 58%, respectively. Current smoker status (HR: 4.44, 95% CI: 1.41-13.97, p = 0.011) was the only variable predictive of high-grade recurrence following a multivariable analysis. The median time to RC from BCG-unresponsive date was 2.1 and 11.7 mo for those undergoing early RC and delayed RC (after BST), respectively. Patients treated with early RC had a higher incidence of cT1 disease (53% vs 36%, p = 0.049) and lymphovascular invasion (LVI; 11% vs 0%, p = 0.011) compared to patients treated with BST. Survival outcomes were similar between groups: 10-yr OS-58% versus 50% (HR: 1.40, 95% CI: 0.68-2.89, p = 0.4), and 10-yr CSS-81% versus 85% (HR: 0.88, 95% CI: 0.22-3.55, p = 0.9). Conclusions An analysis of long-term survival of BCG-unresponsive NMIBC patients receiving BST suggests that it may be safe in patients without LVI and/or variant histology and nonsmokers. Survival outcomes for patients treated with BST may not be inferior to those receiving early RC. Patient summary Bladder-sparing treatment can be offered to appropriately selected patients who have bacillus Calmette-Guerin (BCG)-unresponsive non-muscle-invasive bladder cancer. Long-term outcomes may not be inferior to those for patients who opt for early radical cystectomy.
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Affiliation(s)
- Wei Shen Tan
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Valentina Grajales
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Roberto Contieri
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Patrick Hensley
- Department of Urology, University of Kentucky, Lexington, KY, USA
| | - Kelly Bree
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pavlos Msaouel
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charles C. Guo
- Department of Genitourinary Pathology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Neema Navai
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Colin P. Dinney
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ashish M. Kamat
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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5
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Anderson CB, Chen L, Chang SS, McKiernan JM, Wright J. Intravesical Therapy Compared to Radical Cystectomy Among Patients With Non-Muscle Invasive Bladder Cancer Requiring Additional Treatment After Induction BCG. Clin Genitourin Cancer 2022; 20:595-603. [PMID: 35948482 DOI: 10.1016/j.clgc.2022.07.001] [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: 05/23/2022] [Accepted: 07/05/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Many patients with recurrent high-risk non-muscle invasive bladder cancer after intravesical bacillus calmette-guerin (BCG) face a difficult decision between radical cystectomy (RC) or salvage intravesical therapy (IVT). We sought to determine if there is a difference in overall survival RC and IVT after previous treatment with BCG. METHODS We performed a retrospective cohort study of patients with Ta, T1, and Tis bladder cancer treated with induction BCG in the SEER-Medicare dataset from 2000 to 2015. We used a proportional hazards regression model to compare differences in survival between patients having RC and IVT. We adjusted for confounding using a propensity score and stratified our analysis according to timing of treatment and stage at diagnosis. RESULTS We identified 3940 patients who received either IVT (79%) or RC (21%) following induction BCG. Among patients treated within 12 months of BCG, there was no significant difference in survival between RC and IVT (HR 0.92, 95% CI 0.81-1.04) and 17% of patients having early IVT ultimately required RC. Among patients treated at least 12 months after BCG, RC was associated with worse survival than IVT (HR 1.19, 95% CI 1.06-1.35) and 10% of patients having late IVT ultimately required RC. CONCLUSION Among patients with bladder cancer who required additional treatments after induction BCG, we did not observe a difference in overall survival between IVT and RC within 12 months of starting BCG. While RC remains the gold-standard for high risk recurrent NMIBC after BCG, bladder preservation with IVT may be appropriate for well-selected patients.
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Affiliation(s)
- Christopher B Anderson
- Department of Urology, Columbia University Irving Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY.
| | - Ling Chen
- Department of Gynecology, Columbia University Irving Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY
| | - Sam S Chang
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN
| | - James M McKiernan
- Department of Urology, Columbia University Irving Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY
| | - Jason Wright
- Department of Gynecology, Columbia University Irving Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY
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Leow JJ, Tan WS, Tan WP, Tan TW, Chan VWS, Tikkinen KAO, Kamat A, Sengupta S, Meng MV, Shariat S, Roupret M, Decaestecker K, Vasdev N, Chong YL, Enikeev D, Giannarini G, Ficarra V, Teoh JYC. A systematic review and meta-analysis on delaying surgery for urothelial carcinoma of bladder and upper tract urothelial carcinoma: Implications for the COVID19 pandemic and beyond. Front Surg 2022; 9:879774. [PMID: 36268209 PMCID: PMC9577485 DOI: 10.3389/fsurg.2022.879774] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 08/23/2022] [Indexed: 11/07/2022] Open
Abstract
Purpose The COVID-19 pandemic has led to competing strains on hospital resources and healthcare personnel. Patients with newly diagnosed invasive urothelial carcinomas of bladder (UCB) upper tract (UTUC) may experience delays to definitive radical cystectomy (RC) or radical nephro-ureterectomy (RNU) respectively. We evaluate the impact of delaying definitive surgery on survival outcomes for invasive UCB and UTUC. Methods We searched for all studies investigating delayed urologic cancer surgery in Medline and Embase up to June 2020. A systematic review and meta-analysis was performed. Results We identified a total of 30 studies with 32,591 patients. Across 13 studies (n = 12,201), a delay from diagnosis of bladder cancer/TURBT to RC was associated with poorer overall survival (HR 1.25, 95% CI: 1.09–1.45, p = 0.002). For patients who underwent neoadjuvant chemotherapy before RC, across the 5 studies (n = 4,316 patients), a delay between neoadjuvant chemotherapy and radical cystectomy was not found to be significantly associated with overall survival (pooled HR 1.37, 95% CI: 0.96–1.94, p = 0.08). For UTUC, 6 studies (n = 4,629) found that delay between diagnosis of UTUC to RNU was associated with poorer overall survival (pooled HR 1.55, 95% CI: 1.19–2.02, p = 0.001) and cancer-specific survival (pooled HR of 2.56, 95% CI: 1.50–4.37, p = 0.001). Limitations included between-study heterogeneity, particularly in the definitions of delay cut-off periods between diagnosis to surgery. Conclusions A delay from diagnosis of UCB or UTUC to definitive RC or RNU was associated with poorer survival outcomes. This was not the case for patients who received neoadjuvant chemotherapy.
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Affiliation(s)
- Jeffrey J. Leow
- Department of Urology, Tan Tock Seng Hospital, Singapore, Singapore,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Wei Shen Tan
- Division of Surgery and Interventional Science, University College London, London, United Kingdom,Department of Urology, University College London Hospital, London, United Kingdom
| | - Wei Phin Tan
- Department of Urology, NYU Langone Health, New York City, NY, United States
| | - Teck Wei Tan
- Department of Urology, Tan Tock Seng Hospital, Singapore, Singapore,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Vinson Wai-Shun Chan
- Royal Derby Hospital, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, United Kingdom,Leeds Institute of Medical Research, University of Leeds, Leeds, United Kindgom,Division of Surgery and Interventional Sciences, University College London, United Kingdom
| | - Kari A. O. Tikkinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland,Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
| | - Ashish Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Shomik Sengupta
- Urology Department, Eastern Health, Box Hill, Victoria, Australia,Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia
| | - Maxwell V. Meng
- Department of Urology, University of California San Francisco, San Francisco, CA, United States
| | - Shahrokh Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria,Department of Urology, Weill Cornell Medical College, New York, New York, USA,Department of Urology, University of Texas Southwestern, Dallas, Texas, USA,Department of Urology, Second Faculty of Medicine, Charles University, Prag, Czech Republic,Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan
| | - Morgan Roupret
- Sorbonne University, GRC N 5, Predicitive Onco-uro, AP-HP, Hôpital Pitié-Salpêtriére, Paris, France
| | - Karel Decaestecker
- Department of Urology, AZ Maria Middelares Hospital, Ghent, Belgium,Department of Urology, Ghent University Hospital, Ghent, Belgium,Department of Human Structure and Repair, Ghent University, Belgium
| | - Nikhil Vasdev
- Department of Urology, Hertfordshire and Bedfordshire Urological Cancer Centre, Lister Hospital Stevenage, School of Medicine and Life Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | - Yew Lam Chong
- Department of Urology, Tan Tock Seng Hospital, Singapore, Singapore,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Dmitry Enikeev
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria,Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Gianluca Giannarini
- Urology Unit, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Vincenzo Ficarra
- Department of Human and Pediatric Pathology “Gaetano Barresi”, Urologic Section, University of Messina, Messina, Italy
| | - Jeremy Yuen-Chun Teoh
- S.H. Ho Urology Centre, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China,European Association of Urology – Young Academic Urologists Urothelial Carcinoma Working Group (EAU-YAU), Arnhem, Netherlands,Correspondence: Jeremy Yuen-Chun Teoh
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Robotic cystectomy histopathology outcomes in patients who have ‘failed’ Bacillus Calmette–Guérin: A case series. JOURNAL OF CLINICAL UROLOGY 2022. [DOI: 10.1177/2051415820977993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: Robot-assisted radical cystectomy (RARC) is considered the gold-standard for patients who fail Bacillus Calmette–Guérin (BCG) treatment for high-grade non-muscle-invasive bladder cancer. We reviewed our histopathological outcomes to assess whether we are proceeding to cystectomy at an appropriate time. Methods: A retrospective analysis of the RARC database (2015–2020) was performed to identify patients who received intravesical BCG before cystectomy. Data regarding demographics, number of BCG instillations and staging were collected. Histopathological stage at cystectomy was compared between patients who received an induction course of BCG only (group A), and those who had continued maintenance doses (group B). Results: A total of 73 patients (57 males and 16 females) met the final inclusion criteria, with 24 patients in group A and 49 patients in group B. At cystectomy, 19 patients had ⩾T2 disease (group A: 7; group B: 12). There was no significant difference between groups ( p=0.78). Pelvic lymph node dissection was performed in 68 patients, with six patients found to have lymph node metastases. Conclusion: RARC plays a key role in managing BCG failure, considering the number of patients with muscle-invasive disease at final staging. However, prolonged BCG treatment was not associated with more advanced disease in our case series. Thus, persistence with intravesical treatment warrants consideration for selected patients. Level of evidence: Level 4.
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8
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Yassaie O, Chehroudi C, Black PC. Novel and emerging approaches in the management of non-muscle invasive urothelial carcinoma. Ther Adv Med Oncol 2021; 13:17588359211039052. [PMID: 34408797 PMCID: PMC8366114 DOI: 10.1177/17588359211039052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/26/2021] [Indexed: 11/16/2022] Open
Abstract
Non-muscle invasive bladder cancer (NMIBC) has traditionally been managed with transurethral resection followed by intravesical chemotherapy and/or bacillus Calmette-Guerin (BCG) in a risk-adapted manner. These tumors commonly recur and can progress potentially to lethal muscle invasive disease. A major unmet need in the field of NMIBC is bladder preserving therapy for recurrent high-grade NMIBC after adequate intravesical BCG therapy. The current gold standard treatment for these BCG-unresponsive patients is radical cystectomy, which is associated with considerable morbidity and mortality, particularly in older and frailer patients. It is therefore critical to provide alternative treatment options with acceptable oncological outcomes. In this review we explore novel bladder-sparing treatment options including combination intravesical therapy, enhanced instillation methods, immunotherapy, gene therapy, targeted therapy, photodynamic therapy and BCG variants across the spectrum of NMIBC disease states, ranging from low grade BCG-naïve patients through to high-grade BCG-unresponsive NMIBC.
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Affiliation(s)
- Omid Yassaie
- Department of Urologic Sciences, University British Columbia, Vancouver, BC, Canada
| | - Cyrus Chehroudi
- Department of Urologic Sciences, University British Columbia, Vancouver, BC, Canada
| | - Peter C Black
- Department of Urologic Sciences, University British Columbia, Level 6, 2775 Laurel St, Vancouver, BC V5Z 1M9, Canada
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9
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Packiam VT, Labbate CV, Boorjian SA, Tarrell R, Cheville JC, Avulova S, Sharma V, Tsivian M, Adamic B, Mahmoud M, Werntz RP, Smith ND, Karnes RJ, Tollefson MK, Steinberg GD, Frank I. The association of salvage intravesical therapy following BCG with pathologic outcomes and survival after radical cystectomy for patients with high-grade non-muscle invasive bladder cancer: A multi-institution analysis. Urol Oncol 2021; 39:436.e1-436.e8. [PMID: 33485764 DOI: 10.1016/j.urolonc.2021.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 12/13/2020] [Accepted: 01/03/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION While numerous current clinical trials are testing novel salvage therapies (ST) for patients with recurrent nonmuscle invasive bladder cancer (NMIBC) after bacillus Calmette-Guérin (BCG), the natural history of this disease state has been poorly defined to date. Herein, we evaluated oncologic outcomes in patients previously treated with BCG and ST who subsequently underwent radical cystectomy (RC). METHODS We identified 378 patients with high-grade NMIBC who received at least one complete induction course of BCG (n = 378) with (n = 62) or without (n = 316) additional ST and who then underwent RC between 2000 and 2018. Oncologic outcomes were compared using the Kaplan-Meier method and Cox proportional hazards models. Sensitivity analyses were conducted stratifying by presenting tumor stage, matched 1:3 for receipt vs. no receipt of ST. RESULTS Patients receiving ST were more likely to initially present with CIS (26% vs. 17%) and less likely with T1 disease (34% vs. 50%, P = 0.06) compared to patients not treated with ST. Receipt of ST was not associated with increased risk of adverse pathology (≥pT2 or pN+) at RC (31% vs. 41%, P = 0.14). Likewise, 5-year cancer-specific survival did not significantly differ between groups on univariable Kaplan-Meier analysis (73% for ST and 74% for no ST, P = 0.7). Moreover, on multivariable analysis, receipt of ST was not significantly associated the risk of death from bladder cancer (HR 1.12; 95% CI 0.60-2.09, P = 0.7). Results were unchanged on sensitivity analysis. CONCLUSIONS These data suggest that, in carefully selected patients, ST following BCG for high grade NMIBC does not compromise oncologic outcomes for patients who ultimately undergo RC.
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Affiliation(s)
| | - Craig V Labbate
- Division of Urology, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | | | - Robert Tarrell
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - John C Cheville
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Vidit Sharma
- Department of Urology, Mayo Clinic, Rochester, MN
| | | | - Brittany Adamic
- Division of Urology, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Mohammad Mahmoud
- Division of Urology, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Ryan P Werntz
- Division of Urology, Department of Surgery, Prisma Health-Upstate, University of South Carolina-Greenville, Greenville, SC
| | - Norm D Smith
- Division of Urology, Department of Surgery, Northshore University Health System, Evanston, IL
| | | | | | | | - Igor Frank
- Department of Urology, Mayo Clinic, Rochester, MN.
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10
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Intravesical Salvage Therapy After BCG/Regular Chemo. Bladder Cancer 2021. [DOI: 10.1007/978-3-030-70646-3_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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11
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Wallis CJD, Novara G, Marandino L, Bex A, Kamat AM, Karnes RJ, Morgan TM, Mottet N, Gillessen S, Bossi A, Roupret M, Powles T, Necchi A, Catto JWF, Klaassen Z. Risks from Deferring Treatment for Genitourinary Cancers: A Collaborative Review to Aid Triage and Management During the COVID-19 Pandemic. Eur Urol 2020; 78:29-42. [PMID: 32414626 PMCID: PMC7196384 DOI: 10.1016/j.eururo.2020.04.063] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 04/24/2020] [Indexed: 12/19/2022]
Abstract
Context The coronavirus disease 2019 (COVID-19) pandemic is leading to delays in the treatment of many urologic cancers. Objective To provide a contemporary picture of the risks from delayed treatment for urologic cancers to assist with triage. Evidence acquisition A collaborative review using literature published as of April 2, 2020. Evidence synthesis Patients with low-grade non–muscle-invasive bladder cancer are unlikely to suffer from a 3–6-month delay. Patients with muscle-invasive bladder cancer are at risk of disease progression, with radical cystectomy delays beyond 12 wk from diagnosis or completion of neoadjuvant chemotherapy. Prioritization of these patients for surgery or management with radiochemotherapy is encouraged. Active surveillance should be used for low-risk prostate cancer (PCa). Treatment of most patients with intermediate- and high-risk PCa can be deferred 3–6 mo without change in outcomes. The same may be true for cancers with the highest risk of progression. With radiotherapy, neoadjuvant androgen deprivation therapy (ADT) is the standard of care. For surgery, although the added value of neoadjuvant ADT is questionable, it may be considered if a patient is interested in such an approach. Intervention may be safely deferred for T1/T2 renal masses, while locally advanced renal tumors (≥T3) should be treated expeditiously. Patients with metastatic renal cancer may consider vascular endothelial growth factor targeted therapy over immunotherapy. Risks for delay in the treatment of upper tract urothelial cancer depend on grade and stage. For patients with high-grade disease, delays of 12 wk in nephroureterectomy are not associated with adverse survival outcomes. Expert guidance recommends expedient local treatment of testis cancer. In penile cancer, adverse outcomes have been observed with delays of ≥3 mo before inguinal lymphadenectomy. Limitations include a paucity of data and methodologic variations for many cancers. Conclusions Patients and clinicians should consider the oncologic risk of delayed cancer intervention versus the risks of COVID-19 to the patient, treating health care professionals, and the health care system. Patient summary The coronavirus disease 2019 pandemic has led to delays in the treatment of patients with urologic malignancies. Based on a review of the literature, patients with high-grade urothelial carcinoma, advanced kidney cancer, testicular cancer, and penile cancer should be prioritized for treatment during these challenging times.
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Affiliation(s)
| | - Giacomo Novara
- Department of Surgery, Oncology, and Gastroenterology-Urology Clinic, University of Padua, Padua, Italy
| | - Laura Marandino
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Axel Bex
- Royal Free London NHS Foundation Trust, UCL Division of Surgery and Interventional Science, London, UK
| | - Ashish M Kamat
- Department of Urology, MD Anderson Cancer Center, Houston, TX, USA
| | | | - Todd M Morgan
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Nicolas Mottet
- Department of Urology, University hospital Nord, St Etienne, France
| | - Silke Gillessen
- Department of Medical Oncology, Istituto Oncologico della Svizzera Italiana, Bellinzona, Switzerland; Università della Svizzera Italiana, Lugano, Switzerland
| | - Alberto Bossi
- Department of Radiation Oncology, Institut Gustave Roussy, Villejuif, France
| | - Morgan Roupret
- Urology, GRC n°5, PREDICTIVE ONCO-URO, AP-HP, Pitié Salpetriere Hospital, Sorbonne University, Paris, France; European Section of Onco Urology, EAU
| | - Thomas Powles
- Barts Cancer Center, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Andrea Necchi
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - James W F Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK.
| | - Zachary Klaassen
- Department of Surgery, Division of Urology, Augusta University-Medical College of Georgia, Augusta, GA, USA; Georgia Cancer Center, Augusta, GA, USA.
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12
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Shah P, Kim FJ, Mian BM. Genitourinary cancer management during a severe pandemic: Utility of rapid communication tools and evidence-based guidelines. BJUI COMPASS 2020; 1:45-59. [PMID: 32537615 PMCID: PMC7280667 DOI: 10.1002/bco2.18] [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] [Received: 04/24/2020] [Revised: 05/06/2020] [Accepted: 05/06/2020] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES To determine the usefulness of social media for rapid communication with experts to discuss strategies for prioritization and safety of deferred treatment for urologic malignancies during COVID-19 pandemic, and to determine whether the discourse and recommendations made through discussions on social media (Twitter) were consistent with the current peer-reviewed literature regarding the safety of delayed treatment. METHODS We reviewed and compiled the responses to our questions on Twitter regarding the management and safety of deferred treatment in the setting of COVID-19 related constraints on non-urgent care. We chronicled the guidance published on this subject by various health authorities and professional organizations. Further, we analyzed peerreviewed literature on the safety of deferred treatment (surgery or systemic therapy) to make made evidence-based recommendations. RESULTS Due to the rapidly changing information about epidemiology and infectious characteristics of COVID-19, the health authorities and professional societies guidance required frequent revisions which by design take days or weeks to produce. Several active discussions on Twitter provided real-time updates on the changing landscape of the restrictions being placed on non-urgent care. For separate discussion threads on prostate cancer and bladder cancer, dozens of specialists with expertise in treating urologic cancers could be engaged in providing their expert opinions as well as share evidence to support their recommendations. Our analysis of published studies addressing the safety and extent to which delayed cancer care does not compromise oncological outcome revealed that most prostate cancer care and certain aspects of the bladder and kidney cancer care can be safely deferred for 2-6 months. Urothelial bladder cancer and advanced kidney cancer require a higher priority for timely surgical care. We did not find evidence to support the idea of using nonsurgical therapies, such as hormone therapy for prostate cancer or chemotherapy for bladder cancer for safer deferment of previously planned surgery. We noted that the comments and recommendations made by the participants in the Twitter discussions were generally consistent with our evidence-based recommendations for safely postponing cancer care for certain types of urologic cancers. CONCLUSION The use of social media platforms, such as Twitter, where the comments and recommendations are subject to review and critique by other specialists is not only feasible but quite useful in addressing the situations requiring urgent resolution, often supported by published evidence. In circumstances such as natural disasters, this may be a preferable approach than the traditional expert panels due to its ability to harness the collective intellect to available experts to provide responses and solutions in real-time. These real-time communications via Twitter provided sound guidance which was readily available to the public and participants, and was generally in concordance with the peerreviewed data on safety of deferred treatment.
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Affiliation(s)
- P. Shah
- Department of UrologyMayo ClinicRochesterMNUSA
| | - F. J. Kim
- Division of UrologyUniversity of ColoradoDenverCOUSA
| | - B. M. Mian
- Division of UrologyAlbany Medical CenterAlbanyNYUSA
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13
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Wettstein MS, Naimark D, Hermanns T, Herrera-Caceres JO, Ahmad A, Jewett MAS, Kulkarni GS. Required efficacy for novel therapies in BCG-unresponsive non-muscle invasive bladder cancer: Do current recommendations really reflect clinically meaningful outcomes? Cancer Med 2020; 9:3287-3296. [PMID: 32163677 PMCID: PMC7221312 DOI: 10.1002/cam4.2980] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 02/26/2020] [Accepted: 02/26/2020] [Indexed: 11/11/2022] Open
Abstract
Background Single‐arm trials are currently an accepted study design to investigate the efficacy of novel therapies (NT) in non‐muscle invasive bladder cancer (NMIBC) unresponsive to intravesical Bacillus Calmette‐Guérin (BCG) immunotherapy as randomized controlled trials are either unfeasible (comparator: early radical cystectomy; ERC), or unethical (comparator: placebo). To guide the design of such single‐arm trials, expert groups published recommendations for clinically meaningful outcomes. The aim of this study was to quantitatively verify the appropriateness of these recommendations. Methods We used a discrete event simulation framework in combination with a supercomputer to find the required efficacy at which a NT can compete with ERC when it comes to quality‐adjusted life expectancy (QALE). In total, 24 different efficacy thresholds (including the recommendations) were investigated. Results After ascertaining face validity with content experts, repeated verification, external validation, and calibration we considered our model valid. Both recommendations rarely showed an incremental benefit of the NT over ERC. In the most optimistic scenario, an increase in the IBCG recommendation by 10% and an increase in the FDA/AUA recommendation by 5% would yield results at which a NT could compete with ERC from a QALE perspective. Conclusions This simulation study demonstrated that the current recommendations regarding clinically meaningful outcomes for single‐arm trials evaluating the efficacy of NT in BCG‐unresponsive NMIBC may be too low. Based on our quantitative approach, we propose increasing these thresholds to at least 45%‐55% at 6 months and 35% at 18‐24 months (complete response rates/recurrence‐free survival) to promote the development of clinically truly meaningful NT.
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Affiliation(s)
- Marian S Wettstein
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Department of Urology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - David Naimark
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Thomas Hermanns
- Department of Urology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Jaime O Herrera-Caceres
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Ardalan Ahmad
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Michael A S Jewett
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Girish S Kulkarni
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
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14
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Chehroudi AC, Black PC. Emerging intravesical therapies for the management of bacillus Calmette-Guérin (BCG)-unresponsive non-muscle-invasive bladder cancer: Charting a path forward. Can Urol Assoc J 2020; 14:204-213. [PMID: 31977307 DOI: 10.5489/cuaj.6101] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Management of patients with bacillus Calmette-Guérin (BCG)-unresponsive, high-risk, non-muscle-invasive bladder cancer (NMIBC) presents a formidable clinical challenge that requires urologists to weigh the competing risks of progression during further intravesical therapy vs. the morbidity of radical cystectomy. The prognosis of high-risk NMIBC recurring after BCG depends on the adequacy of prior BCG, timing of recurrence, and tumor histology. The standard of care is currently radical cystectomy, as effective salvage intravesical therapy has not been established. The development of bladder-sparing treatments has been hampered to date by inconsistent definitions of BCG failure and difficulties in identifying appropriate control treatments in clinical trials. Despite these limitations, the spectrum of salvage therapy is expanding to include enhanced intravesical chemo-, gene, and immuno-therapies. In this review, we provide an overview of these emerging agents in the context of our current understanding of BCG failure and the unique considerations for clinical trial design in this disease state.
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Affiliation(s)
- Ali Cyrus Chehroudi
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Peter C Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
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15
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How Should I Manage a Patient with Tumor Recurrence Despite Adequate Bacille Calmette-Guérin? Eur Urol Oncol 2019; 3:252-257. [PMID: 31307960 DOI: 10.1016/j.euo.2019.06.013] [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: 03/26/2019] [Revised: 05/31/2019] [Accepted: 06/14/2019] [Indexed: 11/24/2022]
Abstract
Intravesical immunotherapy with bacille Calmette-Guérin (BCG) vaccine is the main treatment for non-muscle-invasive bladder cancer (NMIBC), with proven effects on reducing recurrence, progression, and death from NMIBC. However, it is not effective in all patients, and recurrence after adequate BCG therapy can frequently lead to progression to more life-threatening disease. This point-counterpoint review considers how to treat a healthy 60-yr-old patient with T1 high-grade NMIBC fitting the new definition of BCG-unresponsive disease, that is, persistent high-grade disease at 6-12mo, despite an adequate course of induction and maintenance with BCG. PATIENT SUMMARY: When T1 high-grade non-muscle-invasive bladder cancer is persistent or recurs shortly after a full course of bacille Calmette-Guérin (BCG) plus maintenance, further BCG is not likely to work; this meets the new definition of a "BCG unresponsive" disease. For this situation, the safest (curative) option is removal of the bladder. If that is not an accepted alternative, then a clinical trial or combination intravesical chemotherapy or hyperchemotherapy may be another option.
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16
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Monteiro LL, Witjes JA, Agarwal PK, Anderson CB, Bivalacqua TJ, Bochner BH, Boormans JL, Chang SS, Domínguez-Escrig JL, McKiernan JM, Dinney C, Godoy G, Kulkarni GS, Mariappan P, O'Donnell MA, Rentsch CA, Shah JB, Solsona E, Svatek RS, van der Heijden AG, van Valenberg FJP, Kassouf W. ICUD-SIU International Consultation on Bladder Cancer 2017: management of non-muscle invasive bladder cancer. World J Urol 2018; 37:51-60. [PMID: 30109483 DOI: 10.1007/s00345-018-2438-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 08/06/2018] [Indexed: 01/24/2023] Open
Abstract
PURPOSE To provide a summary of the Third International Consultation on Bladder Cancer recommendations for the management of non-muscle invasive bladder cancer (NMIBC). METHODS A detailed review of the literature was performed focusing on original articles for the management of NMIBC. An international committee assessed and graded the articles based on the Oxford Centre for Evidence-based Medicine system. The entire spectrum of NMIBC was covered such as prognostic factors of recurrence and progression, risk stratification, staging, management of positive urine cytology with negative white light cystoscopy, indications of bladder and prostatic urethral biopsies, management of Ta low grade (LG) and high risk tumors (Ta high grade [HG], T1, carcinoma in situ [CIS]), impact of BCG strain and host on outcomes, management of complications of intravesical therapy, role of alternative therapies, indications for early cystectomy, surveillance strategies, and new treatments. The working group provides several recommendations on the management of NMIBC. RESULTS Recommendations were summarized with regard to staging; management of primary and recurrent LG Ta and high risk disease, positive urine cytology with negative white light cystoscopy and prostatic urethral involvement; indications for timely cystectomy; and surveillance strategies. CONCLUSION NMIBC remains a common and challenging malignancy to manage. Accurate staging, grading, and risk stratification are critical determinants of the management and outcomes of these patients. Current tools for risk stratification are limited but informative, and should be used in clinical practice when determining diagnosis, surveillance, and treatment of NMIBC.
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Affiliation(s)
- Leonardo L Monteiro
- Division of Urology, McGill University Health Center-Glen Site, 1001 Decarie Blvd, Montreal, QC, H3A 3J1, Canada
| | - J Alfred Witjes
- Department of Urology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Piyush K Agarwal
- Urologic Oncology Branch, National Cancer Institute, Bethesda, MD, USA
| | | | - Trinity J Bivalacqua
- The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bernard H Bochner
- Urology Service, Department of Surgery, Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Joost L Boormans
- Department of Urology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Sam S Chang
- Ingram Cancer Center, Vanderbilt University, Tennessee, USA
| | | | | | - Colin Dinney
- Department of Urology, MD Anderson Cancer Center, Houston, USA
| | - Guilherme Godoy
- Scott Department of Urology, Baylor College of Medicine, Houston, USA
| | - Girish S Kulkarni
- Division of Urology, Department of Surgery and Surgical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | | | | | | | - Jay B Shah
- Department of Urology, Stanford University School of Medicine, Stanford, USA
| | - Eduardo Solsona
- Department of Urology, Instituto Valenciano de Oncología, Valencia, Spain
| | - Robert S Svatek
- Department of Urology, Division of Urologic Oncology, The University of Texas Health San Antonio, San Antonio, USA
| | | | | | - Wassim Kassouf
- Division of Urology, McGill University Health Center-Glen Site, 1001 Decarie Blvd, Montreal, QC, H3A 3J1, Canada.
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17
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Mari A, Kimura S, Foerster B, Abufaraj M, D'Andrea D, Hassler M, Minervini A, Rouprêt M, Babjuk M, Shariat SF. A systematic review and meta-analysis of the impact of lymphovascular invasion in bladder cancer transurethral resection specimens. BJU Int 2018; 123:11-21. [PMID: 29807387 PMCID: PMC7379926 DOI: 10.1111/bju.14417] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The aim of the present review was to assess the prognostic impact of lymphovascular invasion (LVI) in transurethral resection (TUR) of bladder cancer (BCa) specimens on clinical outcomes. A systematic review and meta-analysis of the available literature from the past 10 years was performed using MEDLINE, EMBASE and Cochrane library in August 2017. The protocol for this systematic review was registered on PROSPERO (Central Registration Depository: CRD42018084876) and is available in full on the University of York website. Overall, 33 studies (including 6194 patients) evaluating the presence of LVI at TUR were retrieved. LVI was detected in 17.3% of TUR specimens. In 19 studies, including 2941 patients with ≤cT1 stage only, LVI was detected in 15% of specimens. In patients with ≤cT1 stage, LVI at TUR of the bladder tumour (TURBT) was a significant prognostic factor for disease recurrence (pooled hazard ratio [HR] 1.97, 95% CI: 1.47-2.62) and progression (pooled HR 2.95, 95% CI: 2.11-4.13), without heterogeneity (I2 = 0.0%, P = 0.84 and I2 = 0.0%, P = 0.93, respectively). For patients with cT1-2 disease, LVI was significantly associated with upstaging at time of radical cystectomy (pooled odds ratio 2.39, 95% CI: 1.45-3.96), with heterogeneity among studies (I2 = 53.6%, P = 0.044). LVI at TURBT is a robust prognostic factor of disease recurrence and progression in non-muscle invasive BCa. Furthermore, LVI has a strong impact on upstaging in patients with organ-confined disease. The assessment of LVI should be standardized, reported, and considered for inclusion in the TNM classification system, helping clinicians in decision-making and patient counselling.
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Affiliation(s)
- Andrea Mari
- Department of Urology, Comprehensive Cancer Centre, Medical University of Vienna, Vienna, Austria.,Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Shoji Kimura
- Department of Urology, Comprehensive Cancer Centre, Medical University of Vienna, Vienna, Austria.,Department of Urology, Jikei University School of Medicine, Tokyo, Japan
| | - Beat Foerster
- Department of Urology, Comprehensive Cancer Centre, Medical University of Vienna, Vienna, Austria.,Department of Urology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Mohammad Abufaraj
- Department of Urology, Comprehensive Cancer Centre, Medical University of Vienna, Vienna, Austria.,Department of Special Surgery, Jordan University Hospital, University of Jordan, Amman, Jordan
| | - David D'Andrea
- Department of Urology, Comprehensive Cancer Centre, Medical University of Vienna, Vienna, Austria
| | - Melanie Hassler
- Department of Urology, Comprehensive Cancer Centre, Medical University of Vienna, Vienna, Austria
| | - Andrea Minervini
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Morgan Rouprêt
- GRC no 5, ONCOTYPE-URO, AP-HP, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Marko Babjuk
- Department of Urology, Second Faculty of Medicine, Hospital Motol, Charles University, Praha, Czech Republic
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Centre, Medical University of Vienna, Vienna, Austria.,Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria.,Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Department of Urology, Weill Cornell Medical College, New York, NY, USA
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18
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Nadal R, Apolo AB. Overview of Current and Future Adjuvant Therapy for Muscle-Invasive Urothelial Carcinoma. Curr Treat Options Oncol 2018; 19:36. [DOI: 10.1007/s11864-018-0551-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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19
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Re: Intravesical bacillus Calmette-Guérin with Interferon-Alpha versus Intravesical bacillus Calmette-Guérin for Treating Non-Muscle-Invasive Bladder Cancer. J Urol 2018. [DOI: 10.1016/j.juro.2017.11.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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20
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Abstract
Administration of neoadjuvant chemotherapy preceding radical cystectomy in patients with bladder cancer remains a matter of debate. Results of prospective, randomized studies have demonstrated an overall absolute survival benefit of 5% at 5 years, provided cisplatin-based combination regimens are used. Owing to the perception of a modest survival benefit, the medical community has been slow to adopt the use of neoadjuvant chemotherapy. Other reasons for the underuse of neoadjuvant chemotherapy range from patient ineligibility to fear of delaying potentially curative surgery in nonresponders. Instead, several institutions have adopted an individualized, risk-adapted approach, in which the decision to administer chemotherapy is based on clinical stage and patient comorbidity profile. The development of new cytotoxic and targeted therapies, in particular immune checkpoint inhibitors, warrants well-designed prospective studies to test their efficacy alone or in combination in the neoadjuvant setting. Moving forward, genomic characterization of muscle-invasive bladder cancer could offer information that aids clinicians in selecting the appropriate chemotherapy regimen. Following neoadjuvant therapy, every effort should be made to ensure optimal surgery, as surgical margins and the number of removed lymph nodes are prognostic factors; thus, radical cystectomy and a meticulous extended pelvic lymph node dissection should be performed by expert surgeons.
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21
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BCG-unresponsive non-muscle-invasive bladder cancer: recommendations from the IBCG. Nat Rev Urol 2017; 14:244-255. [DOI: 10.1038/nrurol.2017.16] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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