Outcomes of Patients with Clinical T1 Grade 3 Urothelial Cell Bladder Carcinoma Treated with Radical Cystectomy

Effectiveness of Early Radical Cystectomy for High-Risk Non-Muscle Invasive Bladder Cancer

Purpose: The purpose of this study is to compare perioperative and oncological outcomes of upfront vs. delayed early radical cystectomy (eRC) for high-risk non-muscle-invasive bladder cancer (HR-NMIBC). Methods: All consecutive HR-NMIBC patients who underwent eRC between 2001 and 2020 were retrospectively included and divided into upfront and delayed groups, according to the receipt or not of BCG. Perioperative outcomes were evaluated and the impact of upfront vs. delayed eRC on pathological upstaging, defined as ≥pT2N0 disease at final pathology, was assessed using multivariable logistic regression. Recurrence-free (RFS), cancer-specific (CSS) and overall survival (OS) were compared between upfront and delayed eRC groups using inverse probability of treatment weighting (IPTW)-adjusted Cox model. Results: Overall, 184 patients received either upfront (n = 87; 47%) or delayed (n = 97; 53%) eRC. No difference was observed in perioperative outcomes between the two treatment groups (all p > 0.05). Pathological upstaging occurred in 55 (30%) patients and upfront eRC was an independent predictor (HR = 2.65; 95% CI = (1.23−5.67); p = 0.012). In the IPTW-adjusted Cox analysis, there was no significant difference between upfront and delayed eRC in terms of RFS (HR = 1.31; 95% CI = (0.72−2.39); p = 0.38), CSS (HR = 1.09; 95% CI = (0.51−2.34); p = 0.82) and OS (HR = 1.19; 95% CI = (0.62−2.78); p = 0.60). Conclusion: our results suggest similar perioperative outcomes between upfront and delayed eRC, with an increased risk of upstaging after upfront eRC that did impact survival, as compared to delayed eRC.

Comparative Outcomes of Primary Versus Recurrent High-risk Non–muscle-invasive and Primary Versus Secondary Muscle-invasive Bladder Cancer After Radical Cystectomy: Results from a Retrospective Multicenter Study

Background

Radical cystectomy (RC) is indicated in primary or secondary muscle-invasive bladder cancer (primMIBC, secMIBC) and in primary or recurrent high- or very high-risk non–muscle-invasive bladder cancer (primHR-NMIBC, recHR-NMIBC). The optimal timing for RC along the disease spectrum of nonmetastatic urothelial carcinoma remains unclear.

Objective

To compare outcomes after RC between patients with primHR-NMIBC, recHR-NMIBC, primMIBC, and secMIBC.

Design, setting, and participants

This retrospective, multicenter study included patients with clinically nonmetastatic bladder cancer (BC) treated with RC.

Outcome measurements and statistical analysis

We assessed oncological outcomes for patients who underwent RC according to the natural history of their BC. primHR-NMIBC and primMIBC were defined as no prior history of BC, and recHR-NMIBC and secMIBC as previously treated NMIBC that recurred or progressed to MIBC, respectively. Log-rank analysis was used to compare survival outcomes, and univariable and multivariable Cox and logistic regression analyses were used to identify predictors for survival.

Results and limitations

Among the 908 patients included, 211 (23%) had primHR-NMIBC, 125 (14%) had recHR-NMIBC, 404 (44%) had primMIBC, and 168 (19%) had secMIBC. Lymph node involvement and pathological upstaging were more frequent in the secMIBC group than in the other groups (p < 0.001). The median follow-up was 37 mo. The 5-year recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were 77.9%, 83.2%, and 72.7% in primHR-NMIBC, 60.0%, 59%, and 48.9% in recHR-NMIBC, 60.9%, 64.5%, and 54.8% in primMIBC, and 41.3%, 46.5%, and 39% in secMIBC, respectively, with statistically significant differences across all survival outcomes except between recHR-NMIBC and primMIBC. On multivariable Cox regression, recHR-NMIBC was independently associated with shorter RFS (hazard ratio [HR] 1.64; p = 0.03), CSS (HR 1.79; p = 0.01), and OS (HR 1.45; p = 0.03), and secMIBC was associated with shorter CSS (HR 1.77; p = 0.01) and OS (HR 1.57; p = 0.006). Limitations include the biases inherent to the retrospective study design.

Conclusions

Patients with recHR-NMIBC and primHR-MIBC had similar survival outcomes, while those with sec-MIBC had the worst outcomes. Therefore, early radical intervention may be indicated in selected patients, and potentially neoadjuvant systemic therapies in some patients with recHR-NMIBC.

Patient summary

We compared cancer outcomes in different bladder cancer scenarios in a large, multinational series of patients who underwent removal of the bladder with curative intent. We found that patients who experienced recurrence of non–muscle-invasive bladder cancer (NMIBC) had similar survival outcomes to those with initial muscle-invasive bladder cancer (MIBC), while patients who experienced progression of NMIBC to MIBC had the worst outcomes. Selected patients with non–muscle-invasive disease may benefit from early radical surgery or from perioperative chemotherapy or immunotherapy.

Evaluating the efficacy of secondary transurethral resection of the bladder for high-grade Ta tumors

PURPOSE

The need for secondary transurethral resection of the bladder (re-TURB) in patients with high-grade Ta tumors has not been assessed. This study aimed to compare the outcomes of patients with high-grade Ta tumors who did and did not undergo re-TURB.

MATERIALS AND METHODS

This study used data from the Seoul National University Prospectively Enrolled Registry for Urothelial Cancer-Transurethral Bladder Tumor Resection (SUPER-UC-TURB). Patients with high-grade Ta tumors who underwent TURB between March 2016 and December 2019 were included. Following the initial TURB, if the pathology results showed a tumor grade higher than high-grade Ta, re-TURB was performed according to the surgeon's recommendation. The recurrence-free survival rate was assessed by Kaplan-Meier analysis and Cox regression analysis between patients who did and did not undergo re-TURB.

RESULTS

In total, 187 patients with high-grade Ta who underwent initial TURB were included, of whom 115 underwent re-TURB and 72 did not. Patients in the re-TURB group had a significantly higher 2-year recurrence-free survival rate than did those in the no re-TURB group (81.3% vs. 60.1%; p=0.005). Whether patients underwent re-TURB was a significant predictor of the risk of bladder cancer recurrence in both the univariate (HR, 0.52; 95% CI, 0.27-0.98; p=0.044) and multivariate (HR, 0.41; 95% CI, 0.19-0.97; p=0.041) analysis.

CONCLUSIONS

The risk for bladder cancer recurrence was increased, and the 2-year recurrence-free survival was significantly decreased, in patients with high-grade Ta tumors who did not undergo re-TURB. Thus, re-TURB is beneficial in patients with high-grade Ta bladder cancer.

Application of a multiplex urinalysis test for the prediction of intravesical BCG treatment response: A pilot study

BACKGROUND

Intravesical Bacillus Calmette-Guerin (BCG), a live attenuated tuberculosis vaccine that acts as a non-specific immune system stimulant, is the most effective adjuvant treatment for patients with intermediate or high-risk non-muscle-invasive bladder cancer (NMIBC). However, to date, there are no reliable tests that are predictive of BCG treatment response. In this study, we evaluated the performance of OncuriaTM, a bladder cancer detection test, to predict response to intravesical BCG.

METHODS

OncuriaTM data was evaluated in voided urine samples obtained from a prospectively collected cohort of 64 subjects with intermediate or high risk NMIBC prior to treatment with intravesical BCG. The OncuriaTM test, which measures 10 cancer-associated biomarkers was performed in an independent clinical laboratory. The ability of the test to identify those patients in whom BCG is ineffective against tumor recurrence was tested. Predictive models were derived using supervised learning and cross-validation analyses. Model performance was assessed using ROC curves.

RESULTS

Pre-treatment urinary concentrations of MMP9, VEGFA, CA9, SDC1, PAI1, APOE, A1AT, ANG and MMP10 were increased in patients who developed disease recurrence. A combinatorial predictive model of treatment outcome achieved an AUROC 0.89 [95% CI: 0.80-0.99], outperforming any single biomarker, with a test sensitivity of 81.8% and a specificity of 84.9%. Hazard ratio analysis revealed that patients with higher urinary levels of ANG, CA9 and MMP10 had a significantly higher risk of disease recurrence.

CONCLUSIONS

Monitoring the urinary levels of a cancer-associated biomarker panel enabled the discrimination of patients who did not respond to intravesical BCG therapy. With further study, the multiplex OncuriaTM test may be applicable for the clinical evaluation of bladder cancer patients considering intravesical BCG treatment.

Contemporary Treatment Patterns for Non-muscle-invasive Bladder Cancer: Has the Use of Radical Cystectomy Changed in the BCG Shortage Era?

OBJECTIVE

To examine recent treatment trends for non-muscle-invasive bladder cancer (NMIBC), and specifically, to assess whether there was a change in use radical cystectomy (RC) between 2008 and 2015 using data from the Surveillance, Epidemiology, and End Results database.

METHODS

We identified patients presenting with high-grade T1 (T1HG) NMIBC at diagnosis during the study period. Treatment was dichotomized into "RC" and "local treatment" (which included transurethral resection and intravesical therapies). We then employed multivariable logistic regression models to assess the odds of undergoing RC across the study period. Additionally we examined the rates of RC for T1HG NMIBC during the period of BCG-shortage, defined as 2012-2015.

RESULTS

We identified 21,817 individuals diagnosed with T1HG bladder cancer during the study period. The majority of patients underwent local treatment (94.5%). During the shortage period, the rate of RC for T1HG NMIBC was significantly lower compared to the preshortage era (5.1% vs 5.9%, P = .007). Across the study period, the utilization of RC for T1HG NMIBC decreased significantly (odds ratio 0.99 per quarter, 95% confidence interval 0.98-0.99, P = .017).

CONCLUSION

In our cohort of patients diagnosed with T1HG bladder cancer, we found a significant decrease in the use of radical cystectomy across the study period. Contrary to the hypothesis of increasing rates of RC in the face of BCG shortage, the rate of RC was significantly higher in the pre-shortage era. Further examination of NMIBC treatment patterns will be necessary to assess the impact of BCG availability on therapeutic pathways and oncologic outcomes in patients with high-grade NMIBC.

Survival Outcomes of Early versus Deferred Cystectomy for High-Grade Non-Muscle-Invasive Bladder Cancer: A Systematic Review

Background

Studies report that survival outcomes in patients with non-muscle-invasive bladder cancer (NMIBC) are worse when cystectomy is delayed. However, no systematic evidence is available.

Objective

The aim of this study was to systematically review the literature to compare the long-term survival outcomes of patients with high-grade NMIBC (T1G3, including carcinoma in situ) who have early cystectomy compared to deferred radical cystectomy post-diagnosis.

Materials and Methods

A systematic review was carried out by searching MEDLINE and related databases (Google Scholar, National Health Service Evidence) for all relevant studies published from 1946 to present. Additional studies were identified through following the references of relevant papers. Studies were included if they met the following criteria: inclusion of at least 30 patients having high-grade NMIBC, 2 groups treated with either early or deferred cystectomy with a clear temporal cut-off between groups and reported data on survival rate of at least 5 years.

Results

Literature was systematically reviewed, and 10 studies were included, totaling 1,516 patients who underwent either primary cystectomy or deferred cystectomy. It was found that patients who underwent early cystectomy show improved 5- to 10-year cancer-specific survival (relative risk = 0.81, p = 0.029) suggesting a significant survival benefit when compared to deferred cystectomy.

Conclusions

This study provides systematically gathered evidence showing benefit of early cystectomy. Despite this result, radical cystectomy greatly impairs quality of life and represents overtreatment for a significant minority. This result highlights the importance of a decisive treatment plan to minimize treatment delay.

Quantifying the Overall Survival Benefit With Early Radical Cystectomy for Patients With Histologically Confirmed T1 Non-muscle-invasive Bladder Cancer

INTRODUCTION

The objective of this study was to examine the overall survival (OS) in patients diagnosed with high-grade T1 non-muscle-invasive bladder cancer treated with early radical cystectomy versus local treatment of the primary tumor, defined as endoscopic management with or without intravesical chemotherapy or immunotherapy.

PATIENTS AND METHODS

We identified 4900 patients with histologically confirmed, clinically non-metastatic high-grade T1 bladder cancer undergoing surgical intervention using the National Cancer Database for the period 2010 to 2015. Multivariable logistic regression was used to examine predictors for the receipt of early radical cystectomy (defined as radical cystectomy within 90 days of diagnosis). We then employed multivariable Cox proportional hazards regression models and Kaplan-Meier curves to evaluate the OS according to surgical treatment (early radical cystectomy vs. local treatment).

RESULTS

A minority (23.7%) of patients underwent early radical cystectomy. Independent predictors of undergoing early radical cystectomy included lower age, White race, and lower comorbidity status. The median OS was 74.0 months for patients diagnosed with high-grade T1 bladder cancer. The 1- and 5-year survival rates of patients undergoing early radical cystectomy were 94.8% and 71.0%, whereas they were 85.2% and 52.4%, for patients undergoing initial local treatment, respectively (P < .001). Compared with patients undergoing local treatment, patients undergoing early radical cystectomy had a lower risk of all-cause mortality (hazard ratio, 0.78; 95% confidence interval, 0.67-0.91; P = .002).

CONCLUSION

In this cohort of patients presenting with high-grade T1 non-muscle-invasive bladder cancer, we found that early radical cystectomy was associated with an OS benefit compared with initial local treatment.

Concomitant carcinoma in situ may not be a prognostic factor for patients with bladder cancer following radical cystectomy: a PRISMA-compliant systematic review and meta-analysis

BACKGROUND

Numerous recent studies have shown that concomitant carcinoma in situ (CIS) can be closely associated with the prognosis of patients with bladder cancer (BCa). However, the prognostic value of CIS in BCa is still not conclusive. Hence, we performed a systematic review and meta-analysis to explore the association between CIS and clinicopathological features and the prognostic value for BCa following radical cystectomy.

METHODS

We performed this study in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Relevant studies were systematically collected from PubMed, EMBASE, and Web of Science, with an expiration date of August 2018. Hazard ratios and 95% confidence intervals (CIs) were pooled to assess the intensity of association. All data were analyzed by Stata 12.0. Moreover, heterogeneity and publication bias were determined, and sensitivity analysis was performed to examine whether the findings of the meta-analysis were robust.

RESULTS

A total of 18,845 patients from 24 studies were included in the analysis. Our results indicated that CIS has no significant correlation with cancer-specific mortality (CSM) (pooled HR = 0.97, 95% CI 0.93-1.00, p = 0.059), overall mortality (OM) (pooled HR = 0.93, 95% CI 0.85-1.01, p = 0.076), overall survival (OS) (pooled HR = 1.04, 95% CI 0.96-1.12, p = 0.386), cancer-specific survival (CSS) (pooled HR = 1.06, 95% CI 0.97-1.16, p = 0.186), recurrence-free survival (RFS) (HR = 1.05, 95% CI 0.99-1.11, p = 0.098) or recurrence (pooled HR = 1.04, 95% CI 0.98-1.11, p = 0.212) in BCa patients. In addition, CIS was not correlated with gender (male vs. female, OR = 1.00, 95% CI 0.74-1.34, p = 0.978), pathological stage (III/IV vs. I/II: OR = 0.74, 95% CI 0.50-1.10, p = 0.132), tumor grade (1/2 vs. 3: OR = 3.38, 95% CI 0.73-15.65, p = 0.119), soft tissue surgical margin (STSM) (+ vs. - : OR = 1.20, 95% CI 0.97-1.48, p = 0.093) or lymphovascular invasion (LVI) (+ vs. - : OR = 0.92, 95% CI 0.62-1.38, p = 0.702),but was closely related to adjuvant chemotherapy (ACT) (yes vs. no, OR = 1.17, 95% CI 1.03-1.32, p = 0.019). Furthermore, these findings were demonstrated to be reliable by our sensitivity and subgroup analysis.

CONCLUSIONS

The prognostic value of CIS in BCa remains inconclusive in patients submitted to RC. Our data indicated that CIS may have no significant correlation with the prognosis and clinicopathological parameters of BCa patients, and also may not be applied to risk stratification or individualized therapy in BCa patients. Further research should be conducted to confirm our findings.

Predictors of oncological outcomes in T1G3 patients treated with BCG who undergo radical cystectomy

PURPOSE

To evaluate the oncological impact of postponing radical cystectomy (RC) to allow further conservative therapies prior to progression in a large multicentre retrospective cohort of T1-HG/G3 patients initially treated with BCG.

METHODS

According to the time of RC, the population was divided into 3 groups: patients who did not progress to muscle-invasive disease, patients who progressed before radical cystectomy and patients who experienced progression at the time of radical cystectomy. Clinical and pathological outcomes were compared across the three groups.

RESULTS

Of 2451 patients, 509 (20.8%) underwent RC. Patients with tumors > 3 cm or with CIS had earlier cystectomies (HR = 1.79, p = 0.001 and HR = 1.53, p = 0.02, respectively). Patients with tumors > 3 cm, multiple tumors or CIS had earlier T3/T4 or N + cystectomies. In patients who progressed, the timing of cystectomy did not affect the risk of T3/T4 or N + disease at RC. Patients with T3/T4 or N + disease at RC had a shorter disease-specific survival (HR = 4.38, p < 0.001), as did patients with CIS at cystectomy (HR = 2.39, p < 0.001). Patients who progressed prior to cystectomy had a shorter disease-specific survival than patients for whom progression was only detected at cystectomy (HR = 0.58, p = 0.024) CONCLUSIONS: Patients treated with RC before experiencing progression to muscle-invasive disease harbor better oncological and survival outcomes compared to those who progressed before RC and to those upstaged at surgery. Tumor size and concomitant CIS at diagnosis are the main predictors of surgical treatment while tumor size, CIS and tumor multiplicity are associated with extravesical disease at surgery.

A risk-stratified approach to the management of high-grade T1 bladder cancer

PURPOSE OF REVIEW

A bladder-preserving approach for high-grade nonmuscle invasive bladder cancer that has invaded the lamina propria (T1HG) may result in increased recurrence, progression, and even death from bladder cancer in some patients. Initial radical cystectomy does have increased cancer-specific survival (CSS), but represents significant overtreatment for many patients. An evidence-based, risk-stratified approach is required to select patients for immediate radical cystectomy in order to improve CSS.

RECENT FINDINGS

A restaging transurethral resection aids in optimal staging and treatment of T1HG. Intravesical Bacillus Calmette-Guerin induction followed by 3 years of maintenance is the standard adjuvant management. However, when very high-risk (hydronephrosis, abnormal bimanual examination, variant histology, lymphovascular invasion, or residual disease on re-resection, and Bacillus Calmette-Guerin failure or early recurrence) or multiple high-risk factors (concomitant CIS, size >3 cm, multifocality, unfavorable tumor location, extensive lamina propria invasion, and elderly) are present, the risk of progression often outweighs the risk associated with radical cystectomy. In these cases, an immediate radical cystectomy likely provides an improved opportunity for cure compared to a bladder-preserving strategy.

SUMMARY

In order to increase the CSS of patients diagnosed with T1HG bladder cancer, an aggressive approach may benefit those with increased risk of progression.

Validation of Neutrophil-to-lymphocyte Ratio in a Multi-institutional Cohort of Patients With T1G3 Non-muscle-invasive Bladder Cancer

INTRODUCTION

The aim of this multicenter study was to investigate the prognostic role of neutrophil-to-lymphocyte ratio (NLR) and to validate the NLR cutoff of 3 in a large multi-institutional cohort of patients with primary T1 HG/G3 non-muscle-invasive bladder cancer (NMIBC).

PATIENTS AND METHODS

The study period was from January 2002 through December 2012. A total of 1046 patients with primary T1 HG/G3 who had NMIBC on re-transurethral bladder resection (TURB) who received adjuvant intravesical bacillus Calmette-Guérin therapy with maintenance from 13 academic institutions were included. Endpoints were time to disease, and recurrence-free (RFS), progression-free (PFS), overall (OS), and cancer-specific survival (CSS).

RESULTS

A total of 512 (48.9%) of patients had NLR ≥ 3 prior to TURB. High pretreatment NLR was associated with female gender and residual T1HG/G3 on re-TURB. The 5-year RFS estimates were 9.4% (95% confidence interval [CI], 6.8%-12.4%) in patients with NLR ≥ 3 compared with 58.8% (95% CI, 54%-63.2%) in patients with NLR < 3; the 5-year PFS estimates were 57.1% (95% CI, 51.5%-62.2%) versus 79.2% (95% CI, 74.7%-83%; P < .0001); the 10-year OS estimates were 63.6% (95% CI, 55%-71%) versus 66.5% (95% CI, 56.8%-74.5%; P = .03); the 10-year CSS estimates were 77.4% (95% CI, 68.4%-84.2%) versus 84.3% (95% CI, 76.6%-89.7%; P = .004). NLR was independently associated with disease recurrence (hazard ratio [HR], 3.34; 95% CI, 2.82-3.95; P < .001), progression (HR, 2.18; 95% CI, 1.71-2.78; P < .001) and CSS (HR, 1.65; 95% CI, 1.02-2.66; P = .03). The addition of NLR to a multivariable model that included established features increased its discrimination for predicting of RFS (+6.9%), PFS (+1.8%), and CSS (+1.7%).

CONCLUSIONS

Pretreatment NLR ≥ 3 was a strong predictor for RFS, PFS, and CSS in patients with primary T1 HG/G3 NMIBC. It could help in the decision-making regarding intensity of therapy and follow-up.

Prognostic Effect of Carcinoma In Situ in Muscle-invasive Urothelial Carcinoma Patients Receiving Neoadjuvant Chemotherapy

BACKGROUND

Carcinoma in situ (CIS) is a poor prognostic finding in urothelial carcinoma. However, its significance in muscle-invasive urothelial carcinoma (MIUC) treated with neoadjuvant chemotherapy (NAC) is uncertain. We assessed the effect of CIS found in pretreatment transurethral resection of bladder tumor (TURBT) biopsies on the pathologic and clinical outcomes.

MATERIALS AND METHODS

Subjects with MIUC treated with NAC before cystectomy were identified. The pathologic complete response (pCR) rates stratified by TURBT CIS status were compared. The secondary analyses included tumor response, progression-free survival (PFS), overall survival (OS), and an exploratory post hoc analysis of patients with pathologic CIS only (pTisN0) at cystectomy.

RESULTS

A total of 137 patients with MIUC were identified. TURBT CIS was noted in 30.7% of the patients. The absence of TURBT CIS was associated with a significantly increased pCR rate (23.2% vs. 9.5%; odds ratio, 4.08; 95% confidence interval, 1.19-13.98; P = .025). Stage pTisN0 disease was observed in 19.0% of the TURBT CIS patients. TURBT CIS status did not significantly affect the PFS or OS outcomes. Post hoc analysis of the pTisN0 patients revealed prolonged median PFS (104.5 vs. 139.9 months; P = .055) and OS (104.5 vs. 152.3 months; P = .091) outcomes similar to those for the pCR patients.

CONCLUSION

The absence of CIS on pretreatment TURBT in patients with MIUC undergoing NAC was associated with increased pCR rates, with no observed differences in PFS or OS. Isolated CIS at cystectomy was frequently observed, with lengthy PFS and OS durations similar to those for pCR patients. Further studies aimed at understanding the biology and clinical effect of CIS in MIUC are warranted.

Tackling non-muscle invasive bladder cancer in the clinic

INTRODUCTION

Non-muscle invasive bladder cancer (NMIBC) is a common disease process with a high propensity for recurrence and risk of progression to muscle-invasive or systemic disease. Optimal management of NMIBC depends on appropriate resection and staging, risk-based use of intravesical therapy and tailored surveillance. Current challenges include compliance with guideline recommendations and cancers which are refractory to standard therapies. Areas covered: This review summarizes the conventional management of NMIBC - which relies on strict cystoscopic surveillance and intravesical therapies with chemotherapy and/or immunotherapy in the form of bacillus Calmette-Guerin (BCG). As many patients will be resistant to conventional treatment, investigational therapies and novel prognostic models will also be discussed. Expert commentary: For decades, the management of NMIBC has been predicated on intravesical therapies, most often through the instillation of BCG which has proven clinical efficacy over transurethral resection alone. Despite this, many patients will recur or progress after BCG therapy. While radical cystectomy remains the standard for such patients, suitable alternatives are being actively investigated. An increased interest in immunotherapy for malignancy has reinvigorated this field and on-going advances in disease prognostication are likely to improve upon the existing treatment paradigms for NMIBC.

How do we manage high-grade T1 bladder cancer? Conservative or aggressive therapy?

High-grade T1 bladder cancer has a poor prognosis due to a higher incidence of recurrence and progression than other nonmuscle invasive bladder cancer; thus patients with high-grade T1 have to be carefully monitored and managed. If patients are diagnosed with high-grade T1 at initial transurethral resection (TUR), a second TUR is strongly recommended regardless of whether muscle layer is present in the specimen because of the possibility of understating due to incomplete resection. Since high-grade T1 disease shows diverse clinical courses, individual approaches are recommended for treatment. In cases with low risk of progression, cystectomy could represent overtreatment and deteriorate quality of life irreversibly, while, in those with high risk, bacillus Calmette-Guérin (BCG) therapy may worsen survival by delaying definitive therapy. Therefore, a strategy for predicting prognosis based on the risk of progression is needed for managing high-grade T1 disease. Molecular risk classifiers predicting the risk of progression and response to BCG may help identify the optimal management of high-grade T1 disease for each individual.

Bacille-Calmette-Guerin non-responders: how to manage

Intravesical immunotherapy with bacille-Calmette-Guerin (BCG) is indicated in the treatment of high-risk and intermediate-risk non-muscle invasive bladder cancer (NMIBC). Our goal is to describe the various disease states following induction and maintenance BCG and to describe contemporary treatment options and the current and projected clinical trial landscape for patients who recur following BCG therapy.

Treatment and management of high-grade T1 bladder cancer: what should we do after second TUR?

Most T1 bladder cancers are high grade and have the potential to progress to muscle invasion and extravesical dissemination. Many studies reported that ∼50% of patients displayed residual tumors when a second transurethral resection was performed 2-6 weeks after the initial resection for patients who were diagnosed with T1 bladder cancer. Furthermore, muscle-invasive disease was detected by the second transurethral resection in 10-25% of those patients. Therefore, a second transurethral resection is strongly recommended for patients newly diagnosed with high-grade T1 bladder cancer in various guidelines. T1 bladder cancers are heterogeneous in terms of progression and prognosis after the second transurethral resection. Optimal management and treatment should be considered for patients with T1 bladder cancer based on the pathological findings for the second transurethral resection specimen. If the second transurethral resection reveals residual tumors, aggressive treatments based on the pathological findings should be performed. Conversely, overtreatment with respect to the tumor status should be avoided. Since the evidence of pathological diagnosis at the second transurethral resection is insufficient and many retrospective studies were carried out before the second transurethral resection era, prospective randomized studies should be conducted.

The effect of concomitant carcinoma in situ on neoadjuvant chemotherapy for urothelial cell carcinoma of the bladder: inferior pathological outcomes but no effect on survival

PURPOSE

It is generally believed that carcinoma in situ is refractory to chemotherapy but specific data are lacking to validate this. We evaluated the effect of concomitant clinical carcinoma in situ on cancer specific outcomes after neoadjuvant chemotherapy for muscle invasive bladder cancer.

MATERIALS AND METHODS

We performed an institutional review board approved, multi-institutional, retrospective review of the records of patients treated with neoadjuvant chemotherapy followed by radical cystectomy for muscle invasive bladder cancer from 2008 to 2012. Pretreatment clinical variables were collected and patients were stratified by the presence of clinical carcinoma in situ on precystectomy transurethral bladder tumor resection specimens. Pathological outcomes, including the complete response rate (pT0N0Mx) after neoadjuvant chemotherapy, were compared between the 2 groups. Recurrence-free, cancer specific and overall survival was analyzed.

RESULTS

Of 189 patients who met study criteria 56 (29.6%) had concomitant carcinoma in situ. The condition was associated with a significant decrease in the pathological complete response rate (10.7% vs 26.3%, p = 0.02). This difference was significant on univariate and multivariable analysis (OR 0.34, 95% CI 0.13-0.85, p = 0.02 and OR 0.31, 95% CI 0.12-0.81, p = 0.02, respectively). Despite the decreased complete response rate clinical carcinoma in situ was not associated with a difference in recurrence-free, cancer specific or overall survival. Additionally, when down-staging to pathological carcinoma in situ only disease was considered a complete response, there was no significant change in recurrence-free, cancer specific or overall survival.

CONCLUSIONS

Concomitant carcinoma in situ is associated with a decrease in the complete response rate but this does not appear to impact the survival outcome.

Impact of concomitant carcinoma in situ on upstaging and outcome following radical cystectomy for bladder cancer

PURPOSE

To evaluate the impact of concomitant carcinoma in situ (CIS) on upstaging and outcome of patients treated with radical cystectomy with pelvic lymph node dissection.

METHODS

We collected and pooled a database of 1,968 patients who have undergone radical cystectomy between 1998 and 2008 in eight academic centers across Canada. Collected variables included patient's age, gender, tumor grade, histology and the presence of concomitant CIS with either cTa-1 or cT2 disease, dates of recurrence and death.

RESULTS

In the presence of concomitant CIS, upstaging following radical cystectomy occurred in 48 and 55 % of patients with cTa-1 and cT2 disease, respectively. On univariate analysis, the presence of concomitant CIS with cT2 disease was associated with upstaging (p < 0.0001), and the presence of concomitant CIS with cTa-1 disease was also associated with upstaging but did not reach statistical significance (p = 0.0526). On multivariate analyses, the presence of concomitant CIS with either cTa-1 or cT2 tumors was independently prognostic of disease upstaging (p = 0.0001 and 0.0186, respectively). However, on multivariate analysis that incorporates pathologic stage, concomitant CIS was not significantly associated with worse overall, recurrence-free or disease-specific survival.

CONCLUSION

These results demonstrate that while the presence of concomitant CIS on cystectomy specimens does not independently affect outcomes, its presence is significantly predictive of a higher rate of upstaging at radical cystectomy.

Restaging transurethral resection for non-muscle invasive bladder cancer: who, why, when, and how?

The rate of clinical understaging in non-muscle invasive bladder cancer (NMIBC) after an initial transurethral resection (TUR) is significant, particularly for high-grade disease, and this has a major impact on prognosis. A repeat TUR, 2 to 6 weeks following the initial resection, is recommended in appropriately selected cases to avoid diagnostic inaccuracy and improve treatment allocation. This article summarizes the rationale and indications for performing a repeat TUR in NMIBC and also provides information regarding patient selection and technique.

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.

Comprehensive handbook for developing a bladder cancer cystectomy database

OBJECTIVE

In an effort to standardize data collection for research regarding bladder cancer, the Bladder Cancer Working Group sought to provide a handbook that can be used as a guide for prospective or retrospective data collection.

METHODS

Expert opinions for various data groups were compiled through a team of researchers at the BCAN. Peer review of each data group was performed from within the group.

RESULTS

Essential and comprehensive data elements are provided for 9 groups of data elements, including demographics, comorbidities, staging, laboratory data, operative details, pathology, complications, outcomes, and quality of life measurements.

CONCLUSIONS

Establishment of a comprehensive bladder cancer database is important in initiating multicenter collaborations. While not every data point is critical, this review may be useful in serving as a reference in initiating projects and providing a framework for collaborations.

Radical cystectomy for the treatment of T1 bladder cancer: the Canadian Bladder Cancer Network experience

BACKGROUND

Radical cystectomy may provide optimal survival outcomes in the management of clinical T1 bladder cancer. We present our data from a large, multi-institutional, contemporary Canadian series of patients who underwent radical cystectomy for clinical T1 bladder cancer in a single-payer health care system.

METHODS

We collected a pooled database of 2287 patients who underwent radical cystectomy between 1993 and 2008 in 8 different centres across Canada; 306 of these patients had clinical T1 bladder cancer. Survival data were analyzed using Kaplan-Meier method and Cox regression analysis.

RESULTS

The median age of patients was 67 years with a mean follow-up time of 35 months. The 5-year overall, disease-specific and disease-free survival was 71%, 77% and 59%, respectively. The 10-year overall and disease-specific survival were 60% and 67%, respectively. Pathologic stage distribution was p0: 32 (11%), pT1: 78 (26%), pT2: 55 (19%), pT3: 60 (20%), pT4: 27 (9%), pTa: 16 (5%), pTis: 28 (10%), pN0: 215 (74%) and pN1-3: 78 (26%). Only 12% of patients were given adjuvant chemotherapy. On multivariate analysis, only margin status and pN stage were independently associated with overall, disease-specific and disease-free survival.

INTERPRETATION

These results indicate that clinical T1 bladder cancer may be significantly understaged. Identifying factors associated with understaged and/or disease destined to progress (despite any prior intravesical or repeat transurethral therapies prior to radical cystectomy) will be critical to improve survival outcomes without over-treating clinical T1 disease that can be successfully managed with bladder preservation strategies.

Older patients suffer from adverse histopathological features after radical cystectomy

OBJECTIVES

Radical cystectomy (RC) remains a complex procedure in older patients. Perioperative morbidity can be significant and it can represent a limitation for its indication in this population. The aim of the present study was to evaluate the outcomes of RC in elderly patients from a large single-center cohort.

METHODS

A total of 447 patients who underwent RC between 1996 and 2009 at our institution were considered. Patients were stratified by age (≤70 vs >70 years). Logistic regression analyses were carried out comparing both groups regarding clinical, perioperative and histopathological findings, as well as complications according to the modified Clavien system and survival.

RESULTS

Data of 390 patients were available for the analysis. Of these, 265 (67.9%) versus 125 (32.1%) patients were <70 versus ≥70 years-of-age. The median age was 61 and 75 years, respectively. In the elderly, ASA score (P < 0.001), delay between transurethral resection of the bladder (TURBT) and RC (P = 0.004), and number of perioperative blood transfusions (P = 0.002) were significantly higher. Additionally, a clear trend towards higher stages (pT3-4) was observed (P = 0.04). However, complications, and overall and cancer-specific mortality were not increased in older patients. Finally, age was identified as a significant risk factor for upstaging (P = 0.04). Upstaging between TURBT and final histopathology in patients <70 versus ≥70 years occurred in 45% versus 58%, respectively (P = 0.03).

CONCLUSIONS

RC is equally feasible in older patients without increasing morbidity or mortality. On the contrary, older patients have a higher risk of significant upstaging and advanced stages at final histopathology. These findings suggest that RC should neither be delayed in nor withheld from elderly patients.

Does the presence of muscularis propria on transurethral resection of bladder tumour specimens affect the rate of upstaging in cT1 bladder cancer?

OBJECTIVE • To determine how the presence of MP on T1 biopsy specimens affects the outcome of patients undergoing RC as compared to when no MP is identified in the TURBT specimen.

PATIENTS AND METHODS

• Patients were retrospectively identified from the Columbia University Urologic Oncology Database. • From January 1986 to October 2009, 114 patients diagnosed with cT1N0M0 bladder cancer who underwent RC within 4 months of their last biopsy were identified. • Patients were stratified based on the presence of MP on T1 biopsy, and upstaging was defined as any tumor T2 or greater, N+, or M+ at the time of radical cystectomy. • The rate of upstaging was assessed using univariate and multivariate regression models; Kaplan meier curves were also extrapolated for each cohort to compare disease specific and overall survival patterns.

RESULTS

• Of the 114 patients evaluated in this study, 24 (20.2%) did not have MP on their T1 biopsy before RC. The rate of upstaging (>=pT2) stratified by the presence of MP on biopsy was 50% and 78%, respectively (p = 0.017). • On univariate analysis, lack of MP on biopsy was associated with an increased risk of upstaging (HR 3.52, p = 0.021, CI 1.2-10.3), however did not reach significance as an independent predictor (HR 2.9, p = 0.056, CI 0.97-8.9). • At a mean follow-up of 33.5 months, there was no difference in disease specific (p = 0.41) and overall survival (p = 0.68) between groups.

CONCLUSIONS

• The lack of MP on TURBT for high grade cT1N0M0 bladder cancer portends a high likelihood of upstaging at RC, although this risk did not translate into a detectable increased risk of disease specific mortality.

Detection of circulating tumour cells in peripheral blood of patients with advanced non-metastatic bladder cancer

OBJECTIVE

• To prospectively detect and evaluate the biological significance of circulating tumour cells (CTC) in patients with bladder cancer, especially in those patients with non-metastatic, advanced bladder cancer (NMABC).

PATIENTS AND METHODS

• Between July 2007 and January 2009, blood samples of 50 consecutive patients with localized bladder cancer and five patients with metastatic disease scheduled for cystectomy were prospectively investigated for CTC. Peripheral blood (7.5 ml) was drawn before cystectomy. • Detection of CTC was performed using the USA Food and Drug Administration-approved CellSearch(TM) system. Data were compared with the clinical and histopathological findings.

RESULTS

• CTC were detected in 15 of 50 patients (30%) with non-metastatic disease and five of five patients with metastatic disease. The overall mean number of CTC was 33.7 (range: 1-372; median: 2). In non-metastatic patients, the mean number of CTC was 3.1 (range: 1-11; median: 1). Except for a univariate association between CTC with vessel infiltration (P= 0.047), all other common clinical and histopathological parameters did not reveal a significant correlation with CTC detection. • A median 1-year follow up was available for 53 patients (96.4%). Ten out of 19 preoperatively CTC-positive patients died as a result of cancer progression. • CTC-positive patients showed significantly worse overall (P = 0.001), progression-free (P < 0.001) and cancer specific survival (P < 0.001) compared to preoperatively CTC-negative patients.

CONCLUSION

• This is the largest study demonstrating that detection of CTC in NMABC patients is feasible using the CellSearch(TM) system. Our findings suggest that the presence of CTC may be predictive for early systemic disease.

CIS is a surrogate marker of genetic instability and field carcinogenesis in the urothelial mucosa

OBJECTIVE

To investigate whether carcinoma in situ (CIS) lesion could be considered a surrogate marker of urothelium genetic instability and field carcinogenesis or not, we evaluated DNA content, p53 overexpression, and proliferative index (Ki-67 expression) in primary tumor, in tumor-adjacent mucosa, and distant urothelial mucosa with and without presence of CIS.

PATIENTS AND METHODS

A retrospective study in radical cystectomy specimens from 49 patients was carried out. All the lesions present in each cystectomy specimen were studied, including the tumor area and the adjacent mucosa (AM). Whenever possible, the distant mucosa (DM) was also studied. When CIS was detected, this lesion and the surrounding normal mucosa were also studied. The 49 tumor areas included high grade papillary urothelial carcinoma (HGP) in 19 cases (38.8%) and invasive urothelial cell carcinomas in 30 cases (61.2%). The nuclear DNA content of cancer cells was evaluated using image cytometry allowing the determination of the DNA ploidy and 5cER parameters. The p53 and Ki-67 immunoexpression was evaluated by immunohistochemistry.

RESULTS

CIS lesions were observed in the AM and DM of both tumor groups: 15.8% and 15.4% in AM and DM, for each one of them, in HGP group and 26.7% and 22.2% in AM and DM, for each one of them, in invasive tumors group. In CIS lesion aneuploid DNA content, p53 overexpression and high proliferative labeling index were observed. The so-called normal mucosa (AM and DM) with and without focus of CIS lesions were compared for genetic instability and molecular alterations profile. Statistical differences were observed between the normal mucosa with and without CIS: the so-called normal mucosa areas with focus of CIS revealed significantly higher frequencies of DNA content alterations, p53 overexpression, and higher proliferative index. These differences were significantly different in the invasive UCC group, but this profile it is also present in HPG group.

CONCLUSION

This study points out that CIS is a marker of genetic instability of the urothelium mucosa. The CIS surrounding morphologically normal urothelium showed a high frequency of abnormal DNA content, with high percentage of clear aneuploid cells (high 5cER), p53 mutated protein expression, and a proliferative status underlying a field carcinogenesis. These alterations in normal mucosa were not found when CIS was not present.

Pathological upstaging during radical cystectomy is associated with worse recurrence-free survival in patients with bacillus Calmette-Guerin-refractory bladder cancer

OBJECTIVES

To compare the outcomes of patients who were upstaged to pT2 at the time of radical cystectomy (RC) to those who were correctly staged as T2 before RC.

METHODS

The clinical and pathologic data were reviewed of 496 patients who underwent RC from 1994 to 2008. Patients who underwent RC for high-grade T1 (HGT1) or carcinoma in situ (CIS) (184) were compared with those with known muscle-invasive cancer (312) before RC. Patients were substratified based on preoperative intravesical therapy status. Recurrence-free survival (RFS) for patients who were upstaged to muscle-invasive disease was compared with patients who were correctly staged T2 preoperatively.

RESULTS

Patients who were upstaged to pT2 disease had significantly worse 3- and 5-year RFS compared with those who where accurately staged (cT2 = pT2) (64% and 61% vs 83% and 74%, respectively; P = .04). Upstaging to pT2 in patients with a history of bacillus Calmette-Guerin treatment resulted in worse 3- and 5-year RFS rates compared with those accurately staged (69% and 57% vs 100% and 86%, respectively; P = .03).

CONCLUSIONS

Upstaging to pT2 among patients with HGT1 or CIS is associated with worse RFS compared with patients with known muscle invasion before RC (HGT1/CIS = pT2 vs cT2 = pT2). This finding was most significant among patients with a history of bacillus Calmette-Guerin treatment. Factors such as understaging of disease or treatment delay may contribute to worse outcomes among this subset of patients and should be considered when discussing treatment options.

Bladder cancer

PURPOSE OF REVIEW

To review the diagnosis and management of all stages of bladder cancer with an emphasis on studies and developments within the last year.

RECENT FINDINGS

Cystoscopy remains the mainstay in the detection and surveillance of bladder cancer, though fluorescent light may enhance detection as well as prolong recurrence-free survival. Urine cytology remains the gold standard for diagnosis and surveillance of bladder cancer; however, there are continued efforts in the development of urinary bladder cancer markers. Transurethral resection and instillation of perioperative chemotherapy remains the treatment of choice for superficial bladder cancer in most patients. Data supports the use of intravesical Bacillus Calmette-Guerin (including a maintenance regimen) for those at high risk for disease progression. Radical cystectomy with thorough pelvic lymphadenectomy remains the gold standard for management of muscle invasive disease. Research on the use of laparoscopy, robot-assisted laparoscopy, the effect on patient's health-related quality of life, and the potential role for bladder preservation strategies is ongoing. The value of neoadjuvant versus adjuvant chemotherapy around the time of cystectomy is still debated, though the best level-one evidence supports the use of neoadjuvant methotrexate, vinblastine, doxorubicin, and cisplatin followed by cystectomy. Platinum-based chemotherapeutic agents are most commonly used in the community setting. Work is ongoing to develop new regimens, especially in patients who cannot take cisplatin. Research in the development of targeted therapies alone or in combination with chemotherapeutic regimens continues and will hopefully broaden our treatment strategy for patients with advanced/metastatic disease.

SUMMARY

We are encouraged by the progress in bladder cancer diagnosis and management; however, continued research is needed in order to improve the lives of our patients with this disease.

Recurrence and progression of disease in non-muscle-invasive bladder cancer: from epidemiology to treatment strategy

CONTEXT

This review focuses on the prediction of recurrence and progression in non-muscle invasive bladder cancer (NMIBC) and the treatments advocated for this disease.

OBJECTIVE

To review the current status of epidemiology, recurrence, and progression of NMIBC and the state-of-the art treatment for this disease.

EVIDENCE ACQUISITION

A literature search in English was performed using PubMed and the guidelines of the European Association of Urology and the American Urological Association. Relevant papers on epidemiology, recurrence, progression, and management of NMIBC were selected. Special attention was given to fluorescent cystoscopy, the new World Health Organisation 2004 classification system for grade, and the role of substaging of T1 NMIBC.

EVIDENCE SYNTHESIS

In NMIBC, approximately 70% of patients present as pTa, 20% as pT1, and 10% with carcinoma in situ (CIS) lesions. Bladder cancer (BCa) is the fifth most frequent type of cancer in western society and the most expensive cancer per patient. Recurrence (in < or = 80% of patients) is the main problem for pTa NMIBC patients, whereas progression (in < or = 45% of patients) is the main threat in pT1 and CIS NMIBC. In a recent European Organisation for Research and Treatment of Cancer analysis, multiplicity, tumour size, and prior recurrence rate are the most important variables for recurrence. Tumour grade, stage, and CIS are the most important variables for progression. Treatment ranges from transurethral resection (TUR) followed by a single chemotherapy instillation in low-risk NMIBC to, sometimes, re-TUR and adjuvant intravesical therapy in intermediate- and high-risk patients to early cystectomy for treatment-refractory high-risk NMIBC.

CONCLUSIONS

NMIBC is a heterogeneous disease with varying therapies, follow-up strategies, and oncologic outcomes for an individual patient.