Predictive factors for final pathologic ureteral sections on 700 radical cystectomy specimens: Implications for intraoperative frozen section decision-making

French AFU Cancer Committee Guidelines - Update 2022-2024: Muscle-Invasive Bladder Cancer (MIBC)

OBJECTIVE

To update the CCAFU recommendations for the management of muscle invasive bladder carcinoma (MIBC).

METHODS

A systematic review (Medline) of the literature from 2020 to 2022 was performed taking account of the diagnosis, treatment options and surveillance of NMIBC and MIBC, while evaluating the references with their levels of evidence.

RESULTS

MIBC is diagnosed after the most complete tumour resection possible. MIBC grading is based on CTU along with chest CT. Multiparametric pelvic MRI could be an alternative. Cystectomy with extensive lymphadenectomy is the gold standard treatment for non-metastatic MIBC. It should be preceded by platinum-based neoadjuvant chemotherapy in patients in good general health with satisfactory renal function. Enterocystoplasty is proposed in men and women in the absence of contraindications and when the urethral resection is negative on extemporaneous examination. Otherwise, transileal cutaneous ureterostomy is the recommended method of urinary diversion. Inclusion of all patients in an ERAS (Enhanced Recovery After Surgery) protocol is recommended. For metastatic MIBC, first line treatment with platinum-based chemotherapy (GC or MVAC) is recommended, if general health (PS>1) and renal function (clearance>60mL/min) so allow (only 50% of the cases). Pembrolizumab immunotherapy has demonstrated an overall survival benefit in second-line treatment.

CONCLUSION

Updating the ccAFU recommendations should contribute to improving patient management, as well as the diagnosis and decision-making concerning MIBC treatment.

Risk factors associated with positive surgical margins' location at radical cystectomy and their impact on bladder cancer survival

PURPOSE

To evaluate the risk factors associated with positive surgical margins' (PSMs) location and their impact on disease-specific survival (DSS) in patients with bladder cancer (BCa) undergoing radical cystectomy (RC).

METHODS

We analyzed a large multi-institutional cohort of patients treated with upfront RC for non-metastatic (cT1-4aN0M0) BCa. Multivariable binomial logistic regression analyses were used to assess the risk of PSMs at RC for each location after adjusting for clinicopathological covariates. The Kaplan-Meier method was used to estimate DSS stratified by margins' status and location. Log-rank statistics and Cox' regression models were used to determine significance.

RESULTS

A total of 1058 patients were included and 108 (10.2%) patients had PSMs. PSMs were located at soft-tissue, ureter(s), and urethra in 57 (5.4%), 30 (2.8%) and 21 (2.0%) patients, respectively. At multivariable analysis, soft-tissue PSMs were independently associated with pathological stage T4 (pT4) (Odds ratio (OR) 6.20, p  <  0.001) and lymph-node metastases (OR 1.86, p  =  0.04). Concomitant carcinoma-in-situ (CIS) was an independent risk factor for ureteric PSMs (OR 6.31, p  =  0.003). Finally, urethral PSMs were independently correlated with pT4-stage (OR 5.10, p  =  0.01). The estimated 3-years DSS rates were 58.2%, 32.4%, 50.1%, and 40.3% for negative SMs, soft-tissue-, ureteric- and urethral PSMs, respectively (log-rank; p  <  0.001).

CONCLUSIONS

PSMs' location represents distinct risk factors' patterns. Concomitant CIS was associated with ureteric PSMs. Urethral and soft-tissue PSM showed worse DSS rates. Our results suggest that clinical decision-making paradigms on adjuvant treatment and surveillance might be adapted based on PSM and their location.

[French ccAFU guidelines - update 2020-2022: bladder cancer]

OBJECTIVE

- To update French guidelines for the management of bladder cancer specifically non-muscle invasive (NMIBC) and muscle-invasive bladder cancers (MIBC).

METHODS

- A Medline search was achieved between 2018 and 2020, notably regarding diagnosis, options of treatment and follow-up of bladder cancer, to evaluate different references with levels of evidence.

RESULTS

- Diagnosis of NMIBC (Ta, T1, CIS) is based on a complete deep resection of the tumor. The use of fluorescence and a second-look indication are essential to improve initial diagnosis. Risks of both recurrence and progression can be estimated using the EORTC score. A stratification of patients into low, intermediate and high risk groups is pivotal for recommending adjuvant treatment: instillation of chemotherapy (immediate post-operative, standard schedule) or intravesical BCG (standard schedule and maintenance). Cystectomy is recommended in BCG-refractory patients. Extension evaluation of MIBC is based on contrast-enhanced pelvic-abdominal and thoracic CT-scan. Multiparametric MRI can be an alternative. Cystectomy associated with extended lymph nodes dissection is considered the gold standard for non-metastatic MIBC. It should be preceded by cisplatin-based neoadjuvant chemotherapy in eligible patients. An orthotopic bladder substitution should be proposed to both male and female patients with no contraindication and in cases of negative frozen urethral samples; otherwise transileal ureterostomy is recommended as urinary diversion. All patients should be included in an Early Recovery After Surgery (ERAS) protocol. For metastatic MIBC, first-line chemotherapy using platin is recommended (GC or MVAC), when performans status (PS <1) and renal function (creatinine clearance >60 mL/min) allow it (only in 50% of cases). In second line treatment, immunotherapy with pembrolizumab demonstrated a significant improvement in overall survival.

CONCLUSION

- These updated French guidelines will contribute to increase the level of urological care for the diagnosis and treatment of patients diagnosed with NMIBC and MIBC.

Achieving disease free distal ureteral margin at the time of radical cystectomy: Why and for whom? (an overview of literature)

OBJECTIVE

Achieving negative status of distal ureteral margin at the time of radical cystectomy (RC), and its therapeutic benefit, remains controversial. The aim of this review was to evaluate frequency, reliability and impact of positive distal ureteral margin after radical cystectomy for bladder cancer on upper tract recurrence, cancer specific and overall survival, and to identify best candidates for intraoperative frozen section analyses.

MATERIAL AND METHODS

A systemic review was performed following the PRISMA guideline. PubMed/Medline (with following terms; bladder cancer or cystectomy and frozen section or ureteral margin), and Cochrane Library were searched up to April 2020, to identify all papers evaluating distal ureteral margin and discussing clinical interest. Previous reviews and single case reports were excluded.

RESULTS

In total, thirty-two relevant studies were identified. Mean rate of positive ureteral frozen section after RC was close to 10% [1.1-25.4%]. Frozen section (FS) achieved a very good specificity [83-100%] and reserved sensibility [45-100%]. In many cases, an initial positive margin on FS can be converted to negative. Positive FS and/or PS (permanent section) were associated with upper urinary tract recurrence (UUTR). Conversion from positive FS to negative PS was associated with low UUTR frequency and better cancer survival in large retrospective studies. The relevant prognostic factor associated with positive FS and/or PS was CIS within the bladder.

CONCLUSION

FS should be recommended for patients with CIS within the bladder. Achieving negative FS/PS might be associated with lower rates of UUTR and better survival, for patients with higher life expectancy. Prospective randomized controlled studies need to be performed to provide definitive recommendations in this area.

[Usefulness of frozen section exams during radical cystectomy for urothelial carcinoma]

AIM

To determine the usefulness of the frozen section exams of lymph nodes dissection, ureteral and urethral section during radical cystectomy for urothelial carcinoma and define the impact on the surgical procedure.

METHOD

A retrospective, single-center study of data collected from 182 patients who underwent radical cystectomy for an cT=3bN0M0 urothelial bladder cancer between 2016 and 2018. Bladder cancer extension was determined by thoracoabdominal CT with contrast enhancement and urography and an 18-FDG PET scanner. No patient received neoadjuvant chemotherapy. The diagnostic performance of the frozen section exams was related to final examinations. The impact of the result on the initial intervention was determined.

RESULTS

The frozen section were positive in 29 lymph nodes dissections (15.9 %), 59 (16.6 %) ureteral and 20 (10.9 %) ureteral recessions. With lymph nodes exams, sensitivity, specificity and positive and negative predictive values were 93.5 %, 100 %, 100 %, and 98.7 %, respectively. With ureteral sections exams the same values were 91.5 %, 100 %, 100 %, and 98.4 % respectively. With urethral section exams, all the values were of 100 %. Finally, all the procedure has been modified for all patients with positive frozen section exam except one positive urethral section that did not give rise to radical urethrectomy.

CONCLUSION

Frozen section exams were useful to the urologist during radical cystectomy for urothelial carcinoma. The performances of the frozen section exams carried out were excellent. The information of the urologist of the positive frozen section leeds to modify its management during the intervention in all the studied cases with the exception of one case.