Radical Cystectomy for Bladder Cancer: The Case for Early Intervention

Predictors of Response to Intravesical Therapy

Despite the 40-year reign of bacillus Calmette-Guérin (BCG) as the most effective immunotherapy in urologic cancers, a lack of clinical tools to predict treatment response has hampered progress in the field. Acting as an immunostimulatory agent against a multitude of phenotypically diverse non-muscle-invasive bladder cancers, response to BCG likely depends on both tumor characteristics as well as host factors. With a deeper understanding of the tumor biology as well as the mechanism of action underpinning immunotherapy, newer and more effective clinical tools are being constructed to improve patient selection.

Metastatic non-muscle invasive bladder can-cer with cervical lymph node metastasis

Bladder cancer is a common cancer that may present as superficial, invasive, or metastatic disease. Non-muscle-invasive bladder cancer (NMIBC) represents the majority of bladder cancer diagnoses, but represents a spectrum of disease with a variable clinical course, notably for significant risk of recurrence and potential for progression. NMIBC metastasis to distant organs without local invasion or regional metastasis is a very rare occurrence, so there are limi-ted case reports about early metastasis in the literature.

Metastatic non-muscle invasive bladder cancer with cervical lymph node metastasis

Bladder cancer is a common cancer that may present as superficial, invasive, or metastatic disease. Non-muscle-invasive bladder cancer (NMIBC) represents the majority of bladder cancer diagnoses, but represents a spectrum of disease with a variable clinical course, notably for significant risk of recurrence and potential for progression. NMIBC metastasis to distant organs without local invasion or regional metastasis is a very rare occurrence, so there are limited case reports about early metastasis in the literature.

Enhanced metastatic potential in the MB49 urothelial carcinoma model

Recent data suggest that patients with a basal/stem-like bladder cancer (BC) subtype tend to have metastatic disease, but this is unconfirmed. Here we report the identification of murine MB49 cell line sub-clones with stem-like characteristics in culture. Subcutaneous implantation of S2 and S4 MB49 sub-clones into immunocompetent mice resulted in lung metastases in 50% and 80% of mice respectively, whereas none of the mice implanted with the parental cells developed metastasis. Gene profiling of cells cultured from S2 and S4 primary and metastatic tumors revealed that a panel of genes with basal/stem-like/EMT properties is amplified during metastatic progression. Among them, ITGB1, TWIST1 and KRT6B are consistently up-regulated in metastatic tumors of both MB49 sub-clones. To evaluate clinical relevance, we examined these genes in a human public dataset and found that ITGB1 and KRT6B expression in BC patient tumor samples are positively correlated with tumor grade. Likewise, the expression levels of these three genes are correlated with worse clinical outcomes. This MB49 BC metastatic pre-clinical model provides a unique opportunity to validate and recapitulate results discovered in patient studies and to pursue future mechanistic therapeutic interventions for BC metastasis.

Management of High-grade T1 Urothelial Carcinoma

PURPOSE OF REVIEW

The optimal management of high-grade T1 (HGT1) urothelial carcinoma (UC) is complex given its high rate of recurrence, progression, and cancer-specific mortality as well as its clinical variability. Our current treatment paradigm has been supplemented by recent data describing the expanding options for salvage intravesical therapy, bladder preservation, and the promising role of molecular epidemiology. In the current review, we attempt to summarize and critically analyze these studies.

RECENT FINDINGS

Evidence describing new intravesical therapies has demonstrated an adequate safety profile and some efficacy in BCG-unresponsive patients who desire bladder preservation. However, response rates are still poor in this high-risk patient population, and it is important to keep these data in perspective when counseling patients. Concomitantly, the continued molecular characterization of non-muscle-invasive bladder cancer may suggest potential therapeutic targets as well as predictors of treatment response in the future. The integration of new intravesical therapies and molecular data into the current treatment paradigm for HGT1 urothelial carcinoma will be critical to improving oncologic outcomes in this particularly high-risk population.

Management of carcinoma in situ of the bladder: best practice and recent developments

Management of carcinoma in situ of the bladder remains a complex and challenging endeavor due to its high rate of recurrence and progression. Although it is typically grouped with other nonmuscle invasive bladder cancers, its higher grade and aggressiveness make it a unique clinical entity. Intravesical bacillus Calmette-Guérin is the standard first-line treatment given its superiority to other agents. However, high rates of bacillus Calmette-Guérin failure highlight the need for additional therapies. Radical cystectomy has traditional been the standard second-line therapy, but additional intravesical therapies may be more appealing for non-surgical candidates and patients refusing cystectomy. The subject of this review is the treatment strategies and available therapies currently available for carcinoma in situ of the bladder. It discusses alternative intravesical treatment options for patients whose condition has failed to respond to bacillus Calmette-Guérin therapy and who are unfit or unwilling to undergo cystectomy.

Neobladders and continent catheterizable stomas for the bladder cancer survivor

PURPOSE OF REVIEW

Health-related quality of life (HRQOL) following radical cystectomy for bladder cancer is an important outcome measure following radical cystectomy. Understanding HRQOL issues related to continent urinary diversion is crucial in the care and counseling of patients undergoing radical cystectomy. The goals of this review are to give a broad overview of the major types of continent urinary diversions and to review recent literature examining HRQOL in patients undergoing orthotopic neobladders and continent catheterizable urinary reservoirs following radical cystectomy.

RECENT FINDINGS

Generic questionnaires that broadly address physical, social, and mental functioning and bladder cancer-specific questionnaires that more specifically address urinary, bowel, and sexual function have been utilized to measure HRQOL following radical cystectomy. Although existing studies indicate that overall quality of life may be similar in patients with continent and noncontinent urinary diversions, more specific comparisons of urinary and sexual function are conflicting and complicated by sex-specific concerns. Uterine preservation may improve urinary function in women with continent urinary diversions.

SUMMARY

Although the development of disease-specific validated questionnaires has improved our understanding of HRQOL following radical cystectomy, a lack of prospective studies limits conclusions regarding the superiority of diversion type. Appropriate preoperative consultation may facilitate realistic expectations, thereby optimizing outcomes.

Timing and outcomes for radical cystectomy in nonmuscle invasive bladder cancer

PURPOSE OF REVIEW

To provide an overview on the available clinical and pathological factors in high-risk nonmuscle invasive bladder cancer (NMIBC) patients that help to approximate the risk of progression to muscle invasion and identify 'the' patients requiring timely cystectomy. The value of a high-quality transurethral tumor resection is pointed out. Outcomes following radical cystectomy are compared with a primarily bladder preserving strategy.

RECENT FINDINGS

Carcinoma in situ within the prostatic urethra of NMIBC patients impacts on patient's outcome. Therefore, biopsies taken from the prostatic urethra improve the initial tumor staging accuracy. Lamina propria substaging may provide more detailed prognostic information. Lympho-vascular invasion within the transurethral resection specimen may help to detect patients who benefit from timely cystectomy. Recent findings from patients undergoing radical cystectomy including super-extended lymphadenectomy for clinically NMIBC confirm the substantial rate (25%) of tumor understaging. The fact that almost 10% were found to harbor lymph node metastases underlines the necessity to perform a meticulous lymphadenectomy in NMIBC patients undergoing radical cystectomy.

SUMMARY

High-quality transurethral bladder tumor resection including underlying muscle fibers is of utmost importance. Nevertheless, tumor understaging remains an issue of concern and warrants the value of a second transurethral resection in high-risk NMIBC patients. There is a persisting lack of rigid therapeutic recommendations in patients with high-risk NMIBC. Instead, treatment strategy is based on individual risk factors. However, irrespective of initial treatment strategy, there is a subgroup of high-risk NMIBC patients with progressive disease, leading almost inevitably to death.

Role of maximal endoscopic resection before cystectomy for invasive urothelial bladder cancer

INTRODUCTION/BACKGROUND

The aim of this study was to examine whether TUR of all visible endophytic tumors performed before RC, with or without NC, affects final pathologic staging.

PATIENTS AND METHODS

We retrospectively reviewed data from patients with clinical T2-T4N0-1 urothelial carcinoma of the bladder who underwent RC at our institution between July 2005 and November 2011. Degree of TUR was derived from review of operative reports. We used multivariate logistic regression to assess the association of maximal TUR on pT0 status at time of RC.

RESULTS

Of 165 eligible RC patients, 81 received NC. Reported TUR of all visible tumors was performed in 38% of patients who did not receive NC and 48% of NC patients (P = .19). Nine percent of patients who underwent maximal TUR and did not receive NC were pT0, whereas among NC patients, pT0 was seen in 39% and 19% of those with and without maximal TUR, respectively (P = .05). On multivariate analysis in all patients, maximal TUR was associated with a nonsignificant increased likelihood of pT0 status (odds ratio [OR], 2.03; 95% confidence interval [CI], 0.84-4.94), which was significant when we restricted the analysis to NC patients (OR, 3.17; 95% CI, 1.02-9.83).

CONCLUSION

Maximal TUR of all endophytic tumors before NC is associated with complete pathologic tumor response at RC. Candidates for NC before RC should undergo resection of all endophytic tumors when feasible. Larger series are warranted to see if maximal TUR leads to improved overall and disease-specific survival.

Role of immediate radical cystectomy in the treatment of patients with residual T1 bladder cancer on restaging transurethral resection

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Bladder cancer patients with lamina propria invasion (T1 disease) and residual T1 disease on restaging transurethral resection of bladder tumour (re-TURBT) are at a very high risk for recurrence and progression. Despite this risk, most patients are treated with a bladder preserving approach and not immediate radical cystectomy (RC). In this study we have shown that a quarter of patients with T1 bladder cancer and residual T1 on re-TURBT who are treated with immediate RC are found to have carcinoma invading bladder muscle at RC and 5% have lymph node metastases. We have also found that >30% of patients treated with deferred RC after initial bladder-preserving therapy harbour carcinoma invading bladder muscle and almost 20% of these patients have lymph node metastases. Thus, immediate RC should be considered in all patients with T1 bladder cancer and residual T1 on re-TURBT.

OBJECTIVE

To report the overall survival (OS) and cancer-specific survival (CSS) of patients with residual T1 bladder cancer on restaging transurethral resection of the bladder tumour (re-TURBT).

MATERIALS AND METHODS

We performed a retrospective review of 150 evaluable patients treated for T1 bladder cancer with residual T1 disease found on re-TURBT between 1990 and 2007. Patients were treated with immediate radical cystectomy (RC) or a bladder-preserving approach (deferred or no RC). A univariate Cox proportional hazards regression model was used to test the association between treatment approach and survival.

RESULTS

Residual T1 bladder cancer was found in 150 evaluable patients, of whom 57 received immediate RC and 93 were treated with a bladder-preserving approach. Fourteen out of 57 patients receiving immediate RC and 8/26 patients receiving deferred RC had carcinoma invading bladder muscle in the RC specimen. Three out of 57 and 5/26 patients had lymph node metastases in the RC specimen. Median follow-up was 3.74 years. Thirty-nine patients died during follow-up, 16 from bladder cancer. There was no significant association between immediate RC and CSS (hazard ratio [HR] 1.15, 95% confidence interval [CI] 0.43-3.09, P = 0.8) or OS (HR 0.79, 95% CI 0.4-1.53, P = 0.5).

CONCLUSIONS

Because of the low number of events we cannot conclude whether RC offers a survival advantage in patients with residual T1 bladder cancer on re-TURBT. Since a quarter of patients had carcinoma invading bladder muscle, RC should be considered in these patients. A larger, preferably randomized, study with longer follow-up is needed.

Surveillance and treatment of non-muscle-invasive bladder cancer in the USA

Seventy percent of newly diagnosed bladder cancers are classified as non-muscle-invasive bladder cancer (NMIBC) and are often associated with high rates of recurrence that require lifelong surveillance. Currently available treatment options for NMIBC are associated with toxicities that limit their use, and actual practice patterns vary depending upon physician and patient characteristics. In addition, bladder cancer has a high economic and humanistic burden in the United States (US) population and has been cited as one of the most costly cancers to treat. An unmet need exists for new treatment options associated with fewer complications, better patient compliance, and decreased healthcare costs. Increased prevention of recurrence through greater adherence to evidence-based guidelines and the development of novel therapies could therefore result in substantial savings to the healthcare system.

Urothelial tumor initiation requires deregulation of multiple signaling pathways: implications in target-based therapies

Although formation of urothelial carcinoma of the bladder (UCB) requires multiple steps and proceeds along divergent pathways, the underlying genetic and molecular determinants for each step and pathway remain undefined. By developing transgenic mice expressing single or combinatorial genetic alterations in urothelium, we demonstrated here that overcoming oncogene-induced compensatory tumor barriers was critical for urothelial tumor initiation. Constitutively active Ha-ras (Ras*) elicited urothelial hyperplasia that was persistent and did not progress to tumors over a 10 months period. This resistance to tumorigenesis coincided with increased expression of p53 and all pRb family proteins. Expression of a Simian virus 40 T antigen (SV40T), which disables p53 and pRb family proteins, in urothelial cells expressing Ras* triggered early-onset, rapidly-growing and high-grade papillary UCB that strongly resembled the human counterpart (pTaG3). Urothelial cells expressing both Ras* and SV40T had defective G(1)/S checkpoint, elevated Ras-GTPase and hyperactivated AKT-mTOR signaling. Inhibition of the AKT-mTOR pathway with rapamycin significantly reduced the size of high-grade papillary UCB but hyperactivated mitogen-activated protein kinase (MAPK). Inhibition of AKT-mTOR, MAPK and STAT3 altogether resulted in much greater tumor reduction and longer survival than did inhibition of AKT-mTOR pathway alone. Our studies provide the first experimental evidence delineating the combinatorial genetic events required for initiating high-grade papillary UCB, a poorly defined and highly challenging clinical entity. Furthermore, they suggest that targeted therapy using a single agent such as rapamycin may not be highly effective in controlling high-grade UCB and that combination therapy employing inhibitors against multiple targets are more likely to achieve desirable therapeutic outcomes.

Survival after primary and deferred cystectomy for stage T1 transitional cell carcinoma of the bladder

Context:

The optimal time of cystectomy for nonmuscle invasive bladder cancer (NMIBC) is controversial.

Aim:

This study aims at comparing cancer-specific survival in primary versus deferred cystectomy for T1 bladder cancer.

Settings and Design:

Between 1990 and 2004, a retrospective cohort of 204 patients was studied.

Materials and Methods:

Primary cystectomy at the diagnosis of NMIBC was performed in 134 patients (group 1) and deferred cystectomy was done after failed conservative treatment in 70 (group 2) Both groups were compared regarding patient and tumor characteristics and cancer-specific survival.

Statistical Analysis Used:

Cancer-specific survival was calculated using the Kaplan-Meier method.

Results:

Mean follow-up was 79 and 66 months, respectively, in the two groups. Tumor multiplicity was more frequent in group 2; otherwise, both groups were comparable in all characteristics. The definitive stage was T1 in all patients. Although the 3-year (84% in group 1 vs. 79% in group 2), 5-year (78% vs. 71%) and 10-year (69% vs. 64%) cancer-specific survival rates were lower in the deferred cystectomy group, the difference was not statistically significant. In group 2, survival was significantly lower in cases undergoing more than three transurethral resections of bladder tumors (TURBT) than in cases with fewer TURBTs.

Conclusions:

Cancer-specific survival is statistically comparable for primary and deferred cystectomy in T1 bladder cancer, although there is a non-significant difference in favor of primary cystectomy. In the deferred cystectomy group, the number of TURBTs beyond three is associated with lower survival. Conservative treatment should be adopted for most cases in this category.

Clusterin immunoreactivity as a predictive factor for progression of non-muscle-invasive bladder carcinoma

INTRODUCTION

There is a need for prognostic markers which can predict the subset of patients who will not respond sufficiently to conservative management in non-muscle-invasive bladder carcinoma. We analyzed the association of clusterin (CLU) with clinicopathological factors.

MATERIALS AND METHODS

Immunohistochemical CLU expression was investigated in paraffin-embedded archival tissues of initial transurethral resection specimens of 46 patients with non-muscle-invasive bladder carcinoma. The result was expressed as the proportion of the number of CLU-containing tumor cells to the total number of tumor cells detected in each slide and 'percent CLU expression' was calculated for each patient.

RESULTS

Of the 46 cases (35 male, 11 female), 18 were ≥ 65 years of age. CLU expression was significantly higher in male and elderly patients. Following the initial transurethral resection, 39 patients showed tumor recurrence, and progression was seen in 25 patients, of whom 17 progressed to muscle invasion during follow-up. Although there was no significant correlation between CLU expression and recurrence, significant correlation with overall progression and progression to muscle-invasive disease was observed in this cohort of patients (p = 0.001 and p = 0.014, respectively). Among the patients with progression to muscle invasion, 13 underwent radical cystectomy with pT2 tumor in 5 patients in the final pathology of surgical specimens and pT3 and higher in the remainder.

CONCLUSIONS

CLU immunoreactivity showed correlation with age, gender and progression, mainly progression to muscle invasion. Thus, CLU can be used as a molecular marker to predict the potential of progression to muscle-invasive disease in a particular tumor which in turn may prove useful in the decision-making process for early cystectomy without losing time with conservative management.

[Bladder urothelial carcinoma stage T1: substaging, invasion morphological patterns and its prognosis significance]

Since 1990 when the first series on substaging were published, they have published numerous publications on the invasion sublevel of high degree T1 carcinomas. The deep invasion entails a high risk of progression (around 30-35% of cases progress) as opposed to the cases of superficial invasion over "muscularis mucosae", in which the progression is around 10%, reason why most authors consider subT1, in patient management. In this revision the more exhaustive series that have evaluated substaging are shown and also the different methods to carry out this staging considering the inherent difficulty to the samples that come from transurethral resection (RTU).

Assessing intraepithelial neoplasia and drug safety in cancer-preventive drug development

Despite significant interest from the research community and the population in general, drug approvals for cancer prevention and/or cancer risk reduction are few. This is due, in part, to the requirement that new cancer-preventive drugs must first be shown to be efficacious in reducing cancer incidence or mortality. Moreover, such drugs need to have proven safety for long-term administration. This process can be improved by focusing on precancer (intraepithelial neoplasia) to identify subjects at risk and prove efficacy in shorter, smaller trials as well as on detecting early markers of potential toxicities of chronic exposure to cancer-preventive drug regimens.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Treatment paradigm shift may improve survival of patients with high risk superficial bladder cancer

PURPOSE

Historically patients with recurrent T1 bladder tumors after bacillus Calmette-Guerin have been treated with bladder sparing approaches. Recently a paradigm shift has occurred since patients are increasingly offered radical cystectomy before disease progression to muscle invasion. In this study we explored the effect of this paradigm shift on progression rates and disease specific survival.

MATERIALS AND METHODS

The historical cohort consisted of 307 patients from 3 prospective intravesical bacillus Calmette-Guerin protocols from 1980 to 1989. An institutional review board approved review identified 589 patients treated with bacillus Calmette-Guerin in a contemporary cohort from 1992 to 2004.

RESULTS

In the historical cohort the 85 patients with documented T1 recurrence were initially treated with repeat transurethral resection and intravesical bacillus Calmette-Guerin. Of these 85 patients 60 had progression to muscle invasive disease. At 5 years after T1 recurrence, the cumulative incidence of progression to T2 disease was 71% (95% CI 61%, 81%) and the cumulative incidence of death from disease was 48% (95% CI 39%, 60%). In the contemporary cohort 129 patients had documented T1 recurrence. In this cohort 65 of the 129 patients with recurrent T1 underwent immediate radical cystectomy. At 5 years after T1 recurrence, the cumulative incidence of progression to muscle invasive disease was 28% (95% CI 20%, 38%) and the cumulative incidence of death from disease was 31% (95% CI 22%, 42%).

CONCLUSIONS

Preemptive radical cystectomy performed for recurrent T1 disease following intravesical bacillus Calmette-Guerin therapy may be associated with better disease specific survival.

Delay in the surgical treatment of bladder cancer and survival: systematic review of the literature

OBJECTIVES

Eighty per cent of the newly diagnosed invasive bladder tumours are invasive from the outset. Half of these patients already have occult distant metastases reflecting the rapid nature of progression. The aim of the current study was to review the literature to determine if delay in cystectomy leads to worse prognosis and to determine if a possible cutoff point for delay exists, after which a worse outcome would be expected.

METHODS

We performed a systematic review of publications indexed in Medline and other scientific databases by analyzing types and causes of delay in performing radical cystectomy. Information on the impact of such delays on tumour recurrence and survival was collected and summarized. Papers that described only delay without any outcome correlation were excluded from the study.

RESULTS

A total of 13 papers published from 1965 to 2006 were included in this study. Three (23%) papers did not find any correlation between pretreatment delays and survival. Two (15%) papers reported a trend towards worse survival with delay. Eight (62%) papers documented significant association between delay and worse prognosis. Delay influenced survival as an independent variable in two (25%) of these eight papers. In the remaining six (75%) manuscripts, delay was significantly associated with a higher pathologic stage.

CONCLUSIONS

Although studies on bladder cancer failed to show a linear relationship between delay and prognosis, the majority confirmed that delays are associated with worse outcome. Studies suggested a window of opportunity of less than 12 weeks from diagnosis of invasive disease to radical cystectomy.

A re-staging transurethral resection predicts early progression of superficial bladder cancer

OBJECTIVE

To determine whether pathology on a re-staging transurethral resection (TUR) predicts the early progression of superficial bladder cancer.

PATIENTS AND METHODS

In all, 710 patients presenting with multiple superficial bladder cancers were evaluated by re-staging TUR and followed for 5 years. Tumours were classified by stage as confined to mucosa (Ta) or invading submucosa (T1), and by grade (low- or high-grade). Pathology on re-staging TUR was correlated with the endpoints of tumour recurrence and stage progression.

RESULTS

Of the 710 patients, 490 (69%) had a recurrence and 149 (21%) progressed over 5 years. Eighty patients had high-grade invasive (T1G3) cancer on re-staging TUR and 61 (76%) progressed to muscle invasion (median time to progression 15 months), compared with 88 of 630 (14%) who had no evidence of tumour (T0) or other than T1 tumours detected on re-staging TUR.

CONCLUSION

A re-staging TUR identifies patients with superficial bladder cancer who are at high risk of early tumour progression.