The impact of variant histological differentiation on extranodal extension and survival in node positive bladder cancer treated with radical cystectomy

[Pathological pelvic lymph node involvement in muscle-invasive bladder cancer patients treated with radical cystectomy: A narrative review]

OBJECTIVE

To perform a narrative review of the contemporary literature on the diagnosis, prognosis and adjuvant management of muscle-invasive bladder cancer (MIBC) patients with pathological pelvic lymph node involvement (pN+) at radical cystectomy.

METHOD

A narrative review of the contemporary literature available on Medline was conducted to report studies evaluating the diagnosis, prognosis and/or adjuvant treatments for MIBC patients with pN+ disease at radical cystectomy.

RESULTS

Open or robotic extended pelvic lymph node dissection up to the crossing of the ureter with common iliac vessels can enhance the diagnosis of pN+ MIBC, especially using separate packages for the submission of a maximum number of lymph nodes. The main prognosis factors for pN+ patients are the number of positive and retrieved lymph nodes, lymph node density, extranodal extension as well as lymph node metastasis diameter. Adjuvant chemotherapy is likely to prolong overall survival in pN+ patients treated with radical cystectomy alone while adjuvant immunotherapy using nivolumab has been shown to decrease the risk of recurrence in all pN+ patients, especially those with ypN+ disease after neoadjuvant chemotherapy followed by radical cystectomy. However, few data are currently available on the role of adjuvant radiation therapy, which remains currently experimental for these patients.

CONCLUSION

Multiple parameters have been reported to impact the diagnosis and prognosis of patients with pN+ MIBC at radical cystectomy. Adjuvant management is currently based on chemotherapy and immunotherapy with preliminary data on radiation therapy.

Overview of histologic variants of urothelial carcinoma: current trends and narrative review on treatment outcomes

Background and Objective

The histologic variants of urothelial carcinoma (UC) are tumors arising from within the urothelium in which some component of the tumor morphology is other than urothelial. They are underdiagnosed, aggressive and have varying pathologic response rates to systemic chemotherapy. There are no consensus guidelines on the use of systemic chemotherapy in variant histology (VH) of UC. We performed a contemporary review on pathologic response rates to neoadjuvant systemic therapy and survival outcomes following radical cystectomy in order to provide a rationale for clinical practice recommendations on the management of UC with VH.

Methods

A PubMed literature search was conducted for all English articles from inception reporting either pathological response rates to neoadjuvant treatment or survival outcomes after radical cystectomy in non-metastatic VH of UC.

Key Content and Findings

Neoadjuvant chemotherapy (NAC) prior to radical cystectomy was shown to be a beneficial treatment strategy in UC with VH. The micropapillary, plasmacytoid, nested and sarcomatoid histologic variants were associated with worse survival outcomes compared to conventional UC and UC with squamous or glandular differentiation despite initial downstaging with chemotherapy. There is evidence of improved survival in patients with sarcomatoid differentiation receiving NAC compared to RC alone. The major prognostic factors that affect survival outcomes in VH of UC include histologic variant subtype, patient age, presence of lymphovascular invasion, hydronephrosis, nodal metastasis and advanced T stage at diagnosis. Recent studies demonstrate that VH of UC are heterogenous tumors and responsiveness to NAC may be a function of the molecular subtypes present.

Conclusions

Based on these findings, NAC to achieve pathologic downstaging prior to radical cystectomy is recommended for MIBC with VH. Biomarkers identified by molecular profiling with immunohistochemistry will need to be validated as predictors of response to NAC in future trials.

The Significance of Squamous Histology on Clinical Outcomes and PD-L1 Expression in Bladder Cancer

Objectives. To compare the clinicopathologic characteristics of urothelial carcinoma (UC), urothelial carcinoma with squamous differentiation (UCSD), and squamous cell carcinoma (SCC) of the bladder, which have been suggested to differ in terms of risk factors, immunophenotype, and prognosis. Methods. We evaluated the clinicopathologic features of radical cystectomy specimens between 1980 and 2015 with a diagnosis of SCC, UCSD, and UC. PD-L1 immunohistochemistry (clinically available clones 22C3, SP142, and SP263) was performed on SCC and UCSD. Multivariate Cox regression was used to identify prognostic factors. Kaplan-Meier curves were plotted to assess cancer-specific survival (CSS). Results. Of the 1478 cases, there were 1126 UC (76%), 217 UCSD (15%), and 135 SCC (9%). Bladder cancer was more common in men than women (80% vs 20%, P < .0001). However, a higher proportion of SCC and UCSD occurred in women (SCC-36%, UCSD-22%, UC-18%). Women were significantly more likely to be never smokers in all 3 cohorts (UC: 45% vs 16%, UCSD: 44% vs 12%, SCC: 40% vs 18%, P < .0001). Patients with SCC and UCSD were at a higher pathologic stage (>pT2) at the time of cystectomy (UCSD-74%, SCC 71%, UC-44%, P < .0001) and had worse CSS compared to patients with UC (P = 0.006). SCC had higher PD-L1 scores (all clones) than UCSD (P < .0001). PD-L1 22C3 (P = .02, HR: 0.36) and SP142 scores (P = .046, HR: 0.27) predicted CSS on Kaplan-Meier analysis for SCC cases. Conclusions. UC, UCSD, and SCC are associated with different risk factors, gender distributions, and clinical outcomes. PD-L1 is expressed in SCC and UCSD, suggesting some patients may benefit from targeted therapy.

Contemporary Trends and Efficacy of Pelvic Lymph Node Dissection at Radical Cystectomy for Urothelial and Variant Histology Carcinoma of the Urinary Bladder

OBJECTIVE

To test 1) contemporary pelvic lymph node dissection (PLND) trends at radical cystectomy (RC) in variant histology bladder cancer (VHBC) patients and urothelial carcinoma of the urinary bladder (UCUB), as well as 2) to test the effect of PLND extent on cancer specific mortality (CSM) after RC.

METHODS

Within the Surveillance, Epidemiology and End Results Registry (SEER, 2004-2016), we identified non-metastatic stage T_1-2 or T_3-4 VHBC and UCUB patients, who underwent RC. CSM and lymph node invasion (LNI) rates were stratified according to PLND extent, as well as coded continuously in multivariate Cox and logistic regression models.

RESULTS

Of 19,020 patients, 1736 (9.1%) were coded as having VHBC (46.9% squamous cell carcinoma, 22.5% adenocarcinoma, 18.9% neuroendocrine carcinoma, 11.7% not otherwise specified) vs 17,284 (90.9%) UCUB. PLND was performed in 80.1 of VHBC vs. 83.5% UCUB patients. In both histological groups, PLND rates increased over time (70.9-89.6% and 76.2%-90.1%, both P < .01). PLND extent did not significantly affect CSM in stage T_1-2 or T_3-4 VHBC patients. Conversely, PLND extent was associated with lower CSM in T_1-2, as well as in T_3-4 UCUB patients, which was confirmed in multivariate Cox analyses (Hazard ratio [HR] 0.99, P < .001). Rates of LNI increased with extent of PLND in logistic regression analyses in stage T_3-4 VHBC (Odds ratio [OR] 1.01, P = .001), stage T_1-2 UCUB (OR 1.01, P < .001) and T_3-4 UCUB (OR 1.01, P < .001), but not in stage T_1-2 VHBC (OR 1.01, P = .3).

CONCLUSION

PLND rates do not differ between VHBC and UCUB patients. A potential survival benefit related to more extensive PLND is operational in UCUB patients, but not in VHBC patients.

Evaluation of the Extent of Variant Histology in Urothelial Carcinoma as a Predictive Marker of Clinical Outcomes After Radical Cystectomy

BACKGROUND/AIM

This study investigated the impact of the extent of variant histology (VH) on the prognosis of patients with bladder cancer (BC).

PATIENTS AND METHODS

We retrospectively evaluated consecutive patients with muscle-invasive BC who were treated with radical cystectomy (RC) at our institution between 2005 and 2018. Recurrence-free survival (RFS) and overall survival (OS) rates were evaluated using Kaplan-Meier analysis and Cox regression.

RESULTS

We identified 103 and 47 patients with pure urothelial carcinoma (UC) and a VH in UC, respectively. At the cutoff of 80%, univariate analysis identified significant differences in RFS (p=0.046) and OS (p=0.038) between patients with ≥80% VH (n=21) and those with <80% VH (n=26). Multivariate analysis revealed that the presence of ≥80% VH was significantly associated with RFS and OS.

CONCLUSION

The presence of ≥80% VH in UC could be an independent predictor of recurrence and mortality after RC.

PD-L1 Expression in Muscle Invasive Urothelial Carcinomas as Assessed via Immunohistochemistry: Correlations with Specific Clinical and Pathological Features, with Emphasis on Prognosis after Radical Cystectomy

In the present study, we analyzed Programmed Death Ligand-1 (PD-L1) expression in radical cystectomy (RC) specimens from patients with muscle-invasive urothelial carcinoma (UC), in order to assess any correlations with specific clinicopathological features and its potential prognostic value. A multi-institutional study was performed within the departments of urology and pathology at the Mureș County Hospital, Romania, and Centre Hospitalier Lyon Sud, France. Sixty-nine patients with MIBC were included, for whom tumor histology (conventional versus histological variant/differentiation), tumor extension (T), lymph node involvement (N), and distant metastases (M) were recorded. PD-L1 immunostaining was performed using the 22C3 clone and was interpreted using the combined positive score (CPS) as recommended (Dako Agilent, Santa Clara, CA, USA). Positive PD-L1 immunostaining was more prevalent among UCs with squamous differentiation compared to conventional UCs and trended towards an improved OS (p = 0.366). We found the T stage to be a risk factor for poor survival in PD-L1-positive patients (HR 2.9, p = 0.021), along with the N stage in PD-L1-negative patients (HR 1.98, p = 0.007). No other clinicopathological factor was found to be significantly associated with PD-L1 positivity. Thus, we confirm the need for PD-L1 immunostaining prior to initiating immune checkpoint inhibitor therapy for a more accurate assessment of the patients’ chances of responding to treatment.

Pelvic Lymph Node Dissection During Cystectomy for Patients With Bladder Carcinoma With Variant Histology: Does Histologic Type Matter?

Purpose

Adding pelvic lymph node dissection (PLND) to cystectomy offers significant survival benefit. However, it remains unclear whether this benefit persists in all histologic types. The aim of the study was to examine the impact of PLND on overall survival (OS) after cystectomy in bladder carcinoma patients with histological variants.

Methods

Within the Surveillance, Epidemiology and End Results database, we identified 16,880 bladder carcinoma patients receiving cystectomy between 2004 and 2015. Patients were stratified according to the following histologic types: transitional cell carcinoma, squamous cell carcinoma, adenocarcinoma, small cell carcinoma, neuroendocrine carcinoma, signet ring cell carcinoma, pseudosarcomatous carcinoma, and other histology. Cox regression models were used to evaluate the effect of PLND on OS stratified by histologic type.

Results

Histologic types were significantly associated with the presence of lymph node metastasis in patients with bladder carcinoma (P < 0.001). In multivariable Cox regression analyses, PLND compared with non-PLND was associated with OS benefit in patients with transitional cell carcinoma (hazard ratio [HR], 0.595; 95% confidence interval [95% CI], 0.557-0.634 [P < 0.001]), squamous cell carcinoma (HR, 0.646; 95% CI, 0.494-0.846 [P = 0.002]), and signet ring cell carcinoma (HR, 0.233; 95% CI, 0.107-0.504 [P < 0.001]), whereas no significant differences in OS were observed in other histological subsets.

Discussion

Our analyses revealed a significant OS benefit from PLND in patients with transitional cell carcinoma, squamous cell carcinoma, and signet ring cell carcinoma. However, a survival benefit of PLND in patients with other histologic types was not demonstrated.

Clinical significance of extranodal extension in sentinel lymph node positive breast cancer

The precise stage of lymph node (LN) metastasis is a strong prognostic factor in breast cancers, and sentinel lymph node (SLN) is the first station of nodal metastasis. A number of patients have extranodal extension (ENE) in SLN, whereas the clinical values of ENE in SLN in breast cancers are still in exploration. The aim of our study was to evaluate the predictive and prognostic values of ENE in SLN in breast cancers, and to investigate the feasibility of ENE to predict non-SLN metastasis, nodal burden, disease free survival (DFS) and overall survival (OS) in clinical practice. 266 cases of primary invasive breast cancer (cT1-2N0 breast cancer) underwent SLN biopsy and axillary lymph node dissection (ALND) between 2008 and 2015 were extracted from the pathology database of Fudan University Shanghai Cancer Center. ENE in SLN was defined as extension of neoplastic cells through the lymph-nodal capsule into the peri-nodal adipose tissue, and was classified as no larger than 2 mm and larger than 2 mm group. The associations between ENE and clinicopathological features, non-SLN metastasis, nodal burden, DFS, and OS were analyzed. In the 266 patients with involved SLN, 100(37.6%) were positive for ENE in SLN. 67 (25.2%) cases had ENE no larger than 2 mm in diameter, and 33(12.4%) had ENE larger than 2 mm. Among the clinicopathological characteristics, the presence of ENE in SLN was associated with higher pT and pN stages, PR status, lympho-vascular invasion. Logistic regression analysis indicated that patients with ENE in SLN had higher rate of non-SLN metastasis (OR4.80, 95% CI 2.47–9.34, P < 0.001). Meanwhile, in patients with SLN micrometastasis or 1–2 SLNs involvement, ENE positive patients had higher rate of non-SLN metastasis, comparing with ENE negative patients (P < 0.001, P = 0.004 respectively). The presence of ENE in SLN was correlated with nodal burden, including the pattern and number of involved SLN (P < 0.001, P < 0.001 respectively), the number of involved non-SLN and total positive LNs (P < 0.001, P < 0.001 respectively). Patients with ENE had significantly higher frequency of pN2 disease (P < 0.001). For the disease recurrence and survival status, Cox regression analysis showed that patients with ENE in SLN had significantly reduced DFS (HR 3.05, 95%CI 1.13–10.48, P = 0.008) and OS (HR 3.34, 95%CI 0.74–14.52, P = 0.092) in multivariate analysis. Kaplan–Meier curves and log-rank test showed that patients with ENE in SLN had lower DFS and OS (for DFS: P < 0.001; and for OS: P < 0.001 respectively). Whereas no significant difference was found in nodal burden between ENE ≤ 2 mm and > 2 mm groups, except the number of SLN metastasis was higher in patients with ENE > 2 mm. Cox regression analysis, Kaplan–Meier curves and log-rank test indicated that the size of ENE was not an independent factor of DFS and OS. Our study indicated that ENE in SLN was a predictor for non-SLN metastasis, nodal burden and prognosis in breast cancers. Patients with ENE in SLN had a higher rate of non-SLN metastasis, higher frequency of pN2 disease, and poorer prognosis. Patients with ENE in SLN may benefit from additional ALND, even in SLN micrometastasis or 1–2 SLNs involvement patients. The presence of ENE in SLN should be evaluated in clinical practice. Size of ENE which was classified by a 2 mm cutoff value had no significant predictive and prognostic values in this study. The cutoff values of ENE in SLN need further investigation.

Bladder Cancer: A Comparison Between Non-urothelial Variant Histology and Urothelial Carcinoma Across All Stages and Treatment Modalities

BACKGROUND

The purpose of this study was to evaluate stage at presentation, treatment rates, and cancer-specific mortality (CSM) of non-urothelial variant histology (VH) bladder cancer (BCa) relative to urothelial carcinoma of the urinary bladder (UCUB).

MATERIALS AND METHODS

Within the Surveillance, Epidemiology, and End Results registry (SEER, 2004-2016), patients with VH BCa and UCUB were identified. Stage at presentation and treatment rates, as well as multivariably adjusted and matched CSM rates according to TNM stage within each histologic subtype, were reported.

RESULTS

Of all 222,435 eligible patients with BCa, 11,147 (5.0%) harbored VH. Among those, squamous cell carcinoma accounted for 3666 (1.6%) patients, adenocarcinoma for 1862 (0.8%), neuroendocrine carcinoma for 1857 (0.8%), and other VH BCa for 3762 (1.7%) of the study cohort. Patients with VH BCa showed invariably more advanced TNM stage at presentation compared with patients with UCUB. Treatment rates according to TNM stages showed similar distribution of cystectomy rates in VH BCa and UCUB. However, important differences in the distribution of radiotherapy and chemotherapy rates existed within VH BCa and in comparison with UCUB. Furthermore, even after multivariable adjustment and matching with UCUB, squamous cell carcinoma exhibited higher CSM (hazard ratios, 1.43-1.95; all P < .01) across all stages. All other VH predominantly exhibited higher CSM than UCUB in either non-muscle-invasive or muscle-invasive nonmetastatic stages.

CONCLUSION

TNM stage at diagnosis is invariably more advanced in all patients with VH BCa versus patients with UCUB. Of all VH BCa, in multivariably adjusted stage for stage analyses, squamous cell carcinoma appears to have the worst natural history. All other VH subgroups exhibited more aggressive natural history than UCUB in nonmetastatic stages only.

Improving Estimates of Perioperative Morbidity After Radical Cystectomy Using the European Association of Urology Quality Criteria for Standardized Reporting and Introducing the Comprehensive Complication Index

BACKGROUND

No procedure-specific definitions in complication reporting have been universally accepted in urological surgery, and conventional classification systems do not reflect cumulative morbidity.

OBJECTIVE

To conduct a rigorous assessment of 30-d complications after radical cystectomy and improve morbidity estimates by introducing the novel Comprehensive Complication Index (CCI).

DESIGN, SETTING, AND PARTICIPANTS

A retrospective proof-of-concept study of 506 patients with bladder cancer between 2009 and 2017.

INTERVENTION

Radical cystectomy with pelvic lymph node dissection.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES

Thirty-day complications were extracted from digital charts based on a procedure-specific catalog. Each complication was graded by the Clavien-Dindo classification (CDC), and each individual CCI was calculated. We evaluated traditional morbidity endpoints and tested the ability of both classification tools to mirror cumulative morbidity. Multivariable regression analyses were employed for risk modeling using conventional and novel endpoints. The study fulfilled all the European Association of Urology (EAU) criteria of standardized reporting. Limitations include restricted follow-up of 30 d.

RESULTS AND LIMITATIONS

Of 506 patients, 503 (99%) experienced a total of 2485 complications, of which the majority was classified as "minor" (CDC grade ≤ IIIa; 89%). Overall, 29 (5.7%), 20 (4.0%), and 12 (2.4%) patients were reoperated, readmitted, and died within 30 d, respectively. When using the CCI to capture cumulative morbidity, the proportion of patients with most severe complication burden (CDC grade ≥ IIIb or corresponding CCI > 33.7) increased to 31% as compared with 11% when considering only the highest-grade complication according to the CDC. Age-adjusted comorbidity and delta hemoglobin were the main drivers of perioperative complications for all outcomes in multivariable models.

CONCLUSIONS

The assessment of short-term morbidity after radical cystectomy may be refined and optimized by employing the EAU criteria of standardized reporting and using the CCI to capture cumulative morbidity. These are the cornerstones of urgently needed procedure-tailored benchmarking to improve comparability and quality control.

PATIENT SUMMARY

Characterization of short-term morbidity after radical cystectomy was improved by using several validated assessment tools and adhering to existing guidelines for reporting surgical complications.