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Calleris G, von Deimling M, Kesch C, Soria F, Gontero P, Ploussard G, Laukhtina E, Pradere B. Definitions, outcomes and perspectives for oligometastatic bladder cancer: towards a standardized terminology. Curr Opin Urol 2024; 34:217-224. [PMID: 38426242 DOI: 10.1097/mou.0000000000001170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
PURPOSE OF REVIEW Oligometastatic (om) cancer is considered as a transitional state in between locally confined disease and widespread metastases, accessible to a multimodal treatment, combining systemic and local therapy. In urothelial bladder cancer (BCa), the definitions and the approaches to this condition are poorly standardised and mainly based on retrospective data. We aim to portray the framework for uro-oncologic terminology in omBCa and go through the latest evidence and the future perspectives. RECENT FINDINGS Retrospective and registry data support the potential benefits of multimodality treatment for carefully selected omBCa patients, especially following a good response to systemic treatment. In 2023, a Delphi consensus has defined omBCa, allowing maximum three metastatic lesions, theoretically amenable to radical local treatment. In de-novo omBCa, surgical treatment of primary tumour might improve overall survival (OS), according to a matched registry analysis; also, consolidative radiotherapy was associated with better OS in two recent cohorts. Furthermore, metastasis-directed therapy (MDT) has shown high local control rates and promising OS (14.9-51 months) in a meta-analysis; benefits might be more pronounced for single-site omBCa and nodal or lung lesions. SUMMARY From a clinical perspective, in de-novo omBCa, the local treatment of primary and metastatic sites might improve disease control and survival, in selected patients; in the oligorecurrent setting, MDT achieves good local symptom control with limited side effects; in selected cases, it could convey a survival benefit, too. From a research perspective, well designed prospective evidence is eagerly awaited, based on recently adopted shared definitions for omBCa.
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Affiliation(s)
- Giorgio Calleris
- Department of Urology UROSUD, La Croix du Sud Hospital, Quint-Fonsegrives, France
- Polytechnic and University of Turin, Turin, Italy
| | - Markus von Deimling
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Claudia Kesch
- Department of Urology UROSUD, La Croix du Sud Hospital, Quint-Fonsegrives, France
- Department of Urology and West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Francesco Soria
- Division of Urology, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Paolo Gontero
- Division of Urology, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Guillaume Ploussard
- Department of Urology UROSUD, La Croix du Sud Hospital, Quint-Fonsegrives, France
| | - Ekaterina Laukhtina
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Benjamin Pradere
- Department of Urology UROSUD, La Croix du Sud Hospital, Quint-Fonsegrives, France
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2
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Mohammed MH, Mardnly F, Ghrer M, Alia L, Assad LW. Unusual metastasis after radical cystectomy: case report. J Surg Case Rep 2024; 2024:rjae112. [PMID: 38455984 PMCID: PMC10918444 DOI: 10.1093/jscr/rjae112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 02/11/2024] [Indexed: 03/09/2024] Open
Abstract
Cutaneous metastasis of urothelial carcinoma after radical cystectomy is extremely rare. We present the case of a 57-year-old man who underwent a radical cystectomy with ileal conduit for the presence of a bladder tumor. He developed a cheek lesion after 2 months, which was diagnosed as a metastatic nodule along with bone metastases from high-grade bladder urothelial carcinoma. This nodule was treated with surgical removal with subsequent chemotherapy, but he succumbed after 10 months due to widespread metastatic disease.
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Affiliation(s)
- Mohammed H Mohammed
- Urology, Damascus University, Al Assad University Hospital, Damascus 30621, Syria
| | - Fadel Mardnly
- Urology, Damascus University, Al Assad University Hospital, Damascus 30621, Syria
| | - Mohamad Ghrer
- Urology, Damascus University, Al Assad University Hospital, Damascus 30621, Syria
| | - Louei Alia
- Urology, Damascus University, Al Assad University Hospital, Damascus 30621, Syria
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3
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Aboudaram A, Chaltiel L, Pouessel D, Graff-Cailleaud P, Benziane-Ouaritini N, Sargos P, Schick U, Créhange G, Cohen-Jonathan Moyal E, Chevreau C, Khalifa J. Consolidative Radiotherapy for Metastatic Urothelial Bladder Cancer Patients with No Progression and with No More than Five Residual Metastatic Lesions Following First-Line Systemic Therapy: A Retrospective Analysis. Cancers (Basel) 2023; 15:cancers15041161. [PMID: 36831503 PMCID: PMC9954747 DOI: 10.3390/cancers15041161] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/03/2023] [Accepted: 02/10/2023] [Indexed: 02/15/2023] Open
Abstract
Local consolidative radiotherapy in the treatment of metastatic malignancies has shown promising results in several types of tumors. The objective of this study was to assess consolidative radiotherapy to the bladder and to residual metastases in metastatic urothelial bladder cancer with no progression following first-line systemic therapy. MATERIALS/METHODS Patients who received first-line therapy for the treatment of metastatic urothelial bladder cancer (mUBC) and who were progression-free following treatment with no more than five residual metastases were retrospectively identified through the database of four Comprehensive Cancer Centers, between January 2005 and December 2018. Among them, patients who received subsequent definitive radiotherapy (of EQD2Gy > 45Gy) to the bladder and residual metastases were included in the consolidative group (irradiated (IR) group), and the other patients were included in the observation group (NIR group). Progression-free survival (PFS) and overall survival (OS) were determined from the start of the first-line chemotherapy using the Kaplan-Meier method. To prevent immortal time bias, a Cox model with time-dependent covariates and 6-month landmark analyses were performed to examine OS and PFS. RESULTS A total of 91 patients with at least stable disease following first-line therapy and with no more than five residual metastases were analyzed: 51 in the IR group and 40 in the NIR group. Metachronous metastatic disease was more frequent in the NIR group (19% vs. 5%, p = 0.02); the median number of metastases in the IR group vs. in the NIR group was 2 (1-9) vs. 3 (1-5) (p = 0.04) at metastatic presentation, and 1 (0-5) vs. 2 (0-5) (p = 0.18) after completion of chemotherapy (residual lesions), respectively. Two grade 3 toxicities (3.9%) and no grade 4 toxicity were reported in the IR group related to radiotherapy. With a median follow up of 85.9 months (95% IC (36.7; 101.6)), median OS and PFS were 21.7 months (95% IC (17.1; 29.7)) and 11.1 months (95% IC (9.9; 14.1)) for the whole cohort, respectively. In multivariable analysis, consolidative radiotherapy conferred a benefit in both PFS (HR = 0.49, p = 0.007) and OS (HR = 0.47, p = 0.015) in the whole population; in the landmark analysis at 6 months, radiotherapy was associated with improved OS (HR = 0.48, p = 0.026), with a trend for PFS (HR = 0.57, p = 0.082). CONCLUSION Consolidative radiotherapy for mUBC patients who have not progressed after first-line therapy and with limited residual disease seems to confer both OS and PFS benefits. The role of consolidative radiotherapy in the context of avelumab maintenance should be addressed prospectively.
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Affiliation(s)
- Amélie Aboudaram
- Department of Radiation Oncology, Institut Claudius Regaud/Institut Universitaire du Cancer de Toulouse—Oncopole, 31000 Toulouse, France
| | - Léonor Chaltiel
- Department of Biostatistics, Institut Claudius Regaud/Institut Universitaire du Cancer de Toulouse—Oncopole, 31059 Toulouse, France
| | - Damien Pouessel
- Department of Medical Oncology, Institut Claudius Regaud/Institut Universitaire du Cancer de Toulouse—Oncopole, 31059 Toulouse, France
| | | | | | - Paul Sargos
- Department of Radiation Oncology, Institut Bergonié, 33000 Bordeaux, France
| | - Ulrike Schick
- Department of Radiation Oncology, CHU Brest, 29200 Brest, France
| | - Gilles Créhange
- Department of Radiation Oncology, Institut Curie, 75248 Paris, France
| | - Elizabeth Cohen-Jonathan Moyal
- Department of Radiation Oncology, Institut Claudius Regaud/Institut Universitaire du Cancer de Toulouse—Oncopole, 31000 Toulouse, France
| | - Christine Chevreau
- Department of Medical Oncology, Institut Claudius Regaud/Institut Universitaire du Cancer de Toulouse—Oncopole, 31059 Toulouse, France
| | - Jonathan Khalifa
- Department of Radiation Oncology, Institut Claudius Regaud/Institut Universitaire du Cancer de Toulouse—Oncopole, 31000 Toulouse, France
- Correspondence: ; Tel.: +33-5-31-15-54-01
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The oligometastatic spectrum in the era of improved detection and modern systemic therapy. Nat Rev Clin Oncol 2022; 19:585-599. [PMID: 35831494 DOI: 10.1038/s41571-022-00655-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2022] [Indexed: 12/11/2022]
Abstract
Metastases remain the leading cause of cancer-related mortality. The oligometastasis hypothesis postulates that a spectrum of metastatic spread exists and that some patients with a limited burden of metastases can be cured with ablative therapy. Over the past decade, substantial advances in systemic therapies have resulted in considerable improvements in the outcomes of patients with metastatic cancers, warranting re-examination of the oligometastatic paradigm and the role of local ablative therapies within the context of the improved therapeutic responses, shifting patterns of disease recurrence and possible synergy with systemic treatments. Herein, we reframe the oligometastatic phenotype as a dynamic state for which locally ablative, metastasis-directed therapy improves clinical outcomes, including by prolonging survival and increasing cure rates. Important risk factors defining the metastatic spectrum are highlighted that inform both staging and therapy. Finally, we synthesize the literature on combining local therapies with modern systemic treatments, identifying general themes to optimally integrate ablative therapies in this context.
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5
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[Locally advanced or oligometastatic bladder cancer-role of local treatment of the primary tumor and metastases]. Urologe A 2021; 60:1555-1560. [PMID: 34825935 PMCID: PMC8654709 DOI: 10.1007/s00120-021-01712-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 11/15/2022]
Abstract
Hintergrund Das muskelinvasive Blasenkarzinom stellt in seiner Behandlung eine besondere Herausforderung dar, da die Therapie mit signifikanten Nebenwirkungen und Komplikationsraten einhergeht, insbesondere bei Patienten mit relevanten Begleiterkrankungen. Im metastasierten Stadium besteht der Therapiezweck in der Palliation, wobei das Vorliegen einer Oligometastasierung eine gesonderte Rolle einnimmt. In diesem Stadium kann auch die Therapie des Primärtumors relevant sein, wenn die Metastasen neben einer systemischen Therapie ebenso lokal behandelt werden können – insbesondere auch in Hinblick auf die über die letzten Jahre die Therapielandschaft erweiternden neuen medikamentösen Möglichkeiten. Ziel der Arbeit In diesem Reviewartikel sollen die Einflüsse einer definitiven Therapie des Primärtumors bei Patienten mit oligometastasiertem Urothelkarzinom der Harnblase dargelegt werden. Material und Methoden Basierend auf einer nicht-systemischen Literaturrecherche soll ein Überblick über bestehende Ergebnisse zur Therapie des oligometastasierten Blasenkarzinoms in Hinblick auf den Einfluss der Therapie des Primärtumors geben, wobei die Daten meist auf retrospektiven Studien und Metaanalysen bestehen. Schlussfolgerung Eine Lokaltherapie des Primärtumors im Rahmen eines multimodalen Therapiekonzepts kann bei selektionierten Patienten mit lymphogen metastasiertem und oligometastasiertem Blasenkarzinom einen positiven Einfluss auf Überleben, Lebensqualität und Vermeidung von Lokalkomplikationen nehmen, wobei für die Wahl der lokalen Therapie dieselben Kriterien angewendet werden sollten wie im nicht-metastasierten Stadium.
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6
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Otsuka I, Ueno T, Terada N, Mukai S, Fukushima T, Kiwaki T, Nagano M. Cutaneous metastasis emerging during chemotherapy and progressing during immunotherapy for urothelial carcinoma. IJU Case Rep 2021; 4:363-366. [PMID: 34755057 PMCID: PMC8560435 DOI: 10.1002/iju5.12350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 07/02/2021] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Cutaneous metastasis of urothelial carcinoma is uncommon. We experienced a case of cutaneous metastasis that emerged during chemotherapy and progressed rapidly during immunotherapy for bladder tumor with lymph node metastasis. CASE PRESENTATION A 77-year-old female patient received chemotherapy using gemcitabine and cisplatin for bladder urothelial carcinoma with para-aortic and pelvic lymph node metastases (clinical stage T2N1M1). After eight courses of chemotherapy, skin rash appeared in the lower abdomen with leg edema caused by multiple lymphadenopathy. Skin biopsy revealed cutaneous metastasis of urothelial carcinoma. The cutaneous tumor progressed rapidly and the patient died 5 weeks after the start of second-line pembrolizumab treatment. CONCLUSION A patient with cutaneous metastasis of urothelial carcinoma that emerged during chemotherapy had poor prognosis and lack of efficacy of an immune checkpoint inhibitor.
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Affiliation(s)
- Isamu Otsuka
- Department of UrologyFujimoto General HospitalMiyakonojoDepartments ofJapan
| | - Takashi Ueno
- Department of UrologyFujimoto General HospitalMiyakonojoDepartments ofJapan
| | - Naoki Terada
- Departments ofUrologyFaculty of MedicineUniversity of MiyazakiKiyotakeMiyazakiJapan
| | - Shoichiro Mukai
- Departments ofUrologyFaculty of MedicineUniversity of MiyazakiKiyotakeMiyazakiJapan
| | - Tsuyoshi Fukushima
- Department ofPathologyFaculty of MedicineUniversity of MiyazakiKiyotakeMiyazakiJapan
| | - Takumi Kiwaki
- Department ofPathologyFaculty of MedicineUniversity of MiyazakiKiyotakeMiyazakiJapan
| | - Masafumi Nagano
- Department of UrologyFujimoto General HospitalMiyakonojoDepartments ofJapan
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7
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Iwamoto H, Kano H, Shimada T, Naito R, Makino T, Kadomoto S, Yaegashi H, Shigehara K, Izumi K, Kadono Y, Mizokami A. Sarcopenia and Visceral Metastasis at Cabazitaxel Initiation Predict Prognosis in Patients With Castration-resistant Prostate Cancer Receiving Cabazitaxel Chemotherapy. In Vivo 2021; 35:1703-1709. [PMID: 33910855 DOI: 10.21873/invivo.12430] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND/AIM Cabazitaxel is recommended as first-line treatment after docetaxel for metastatic castration-resistant prostate cancer. However, the efficacy, adverse events and prognostic factors associated with cabazitaxel are unclear. PATIENTS AND METHODS This single-centre retrospective study including 30 patients with CRPC treated with cabazitaxel between 2014 and 2020 investigated efficacy, outcomes and prognostic factors. RESULTS Fourteen patients had visceral metastases. The median cabazitaxel dose was 20 mg/m2 The prostate-specific antigen response rate, time to prostate-specific antigen response, and overall survival were 13.3%, 3.48 months, and 7.92 months, respectively. The rates of grade 3 or more neutropenia and febrile neutropenia were 20% and 6.7%, respectively. By multivariate analysis, sarcopenia and visceral metastasis at the time of cabazitaxel initiation were independent and significant factors conferring a poor prognosis. CONCLUSION The early introduction of cabazitaxel, prior to the development of sarcopenia and visceral metastasis, might contribute to improved prognosis in CRPC.
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Affiliation(s)
- Hiroaki Iwamoto
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Hiroshi Kano
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Takafumi Shimada
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Renato Naito
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Tomoyuki Makino
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Suguru Kadomoto
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Hiroshi Yaegashi
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Kazuyoshi Shigehara
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Kouji Izumi
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Yoshifumi Kadono
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Atsushi Mizokami
- Department of Integrative Cancer Therapy and Urology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
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8
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Jeong H, Park KJ, Lee YJ, Kim HD, Kim JH, Yoon S, Hong B, Lee JL. The Prognosis and the Role of Adjuvant Chemotherapy for Node-Positive Bladder Cancer Treated with Neoadjuvant Chemotherapy Followed by Surgery. Cancer Res Treat 2021; 54:226-233. [PMID: 33957019 PMCID: PMC8756114 DOI: 10.4143/crt.2021.365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 05/04/2021] [Indexed: 11/28/2022] Open
Abstract
Purpose This study aims to evaluate the prognosis of pathologically node-positive bladder cancer after neoadjuvant chemotherapy, the role of adjuvant chemotherapy in these patients, and the value of preoperative clinical evaluation for lymph node metastases. Materials and Methods Patients who received neoadjuvant chemotherapy followed by partial/radical cystectomy and had pathologically confirmed lymph node metastases between January 2007 and December 2019 were identified and analyzed. Results A total of 53 patients were included in the study. The median age was 61 years (range, 34 to 81 years) with males comprising 86.8%. Among the 52 patients with post-neoadjuvant/pre-operative computed tomography results, only 33 patients (63.5%) were considered positive for lymph node metastasis. Sixteen patients (30.2%) received adjuvant chemotherapy (AC group), and 37 patients did not (no AC group). With the median follow-up duration of 67.7 months, the median recurrence-free survival (RFS) and the median overall survival (OS) was 8.5 months and 16.2 months, respectively. The 2-year RFS and OS rates were 23.3% and 34.6%, respectively. RFS and OS did not differ between the AC group and no AC group (median RFS, 8.8 months vs. 6.8 months, p=0.772; median OS, 16.1 months vs. 16.3 months, p=0.479). Thirty-eight patients (71.7%) experienced recurrence. Distant metastases were the dominant pattern of failure in both the AC group (91.7%) and no AC group (76.9%). Conclusion Patients with lymph node-positive disease after neoadjuvant chemotherapy followed by surgery showed high recurrence rates with limited survival outcomes. Little benefit was observed with the addition of adjuvant chemotherapy.
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Affiliation(s)
- Hyehyun Jeong
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kye Jin Park
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong-Jun Lee
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Department of Internal Medicine Division of Oncology, Haeundae Paik Hospital Cancer Center, Inje University College of Medicine, Busan, Korea
| | - Hyung-Don Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jwa Hoon Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Division of Oncology/Hematology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Shinkyo Yoon
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bumsik Hong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Lyun Lee
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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9
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Mar N, Dayyani F. Management of Urothelial Bladder Cancer in Clinical Practice: Real-World Answers to Difficult Questions. J Oncol Pract 2020; 15:421-428. [PMID: 31404517 DOI: 10.1200/jop.19.00215] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Management of urothelial bladder cancer has historically been challenging as a result of a limited grasp of disease biology and few available systemic therapy options, mainly consisting of platinum-based chemotherapy. Improved understanding of molecular mechanisms underlying pathogenesis of muscle-invasive bladder cancer as well as their correlation with tumor behavior and response to treatment has emerged over the past few years. Remarkable therapeutic advances have been made with the introduction of checkpoint inhibitors, which have changed the course of this disease. Multiple agents with novel mechanisms of action are also actively being explored in ongoing clinical trials. These advances are exciting but may prove challenging in terms of how to apply this constantly evolving plethora of data to actual patients. This review addresses the gray areas and challenging questions that frequently arise in clinical practice.
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10
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Weiner AB, Pham MN, Isaacson DS, Ko OS, Breen KJ, Nadler RB. Predictors of use and overall survival for patients undergoing metastasectomy for bladder cancer in a national cohort. Int J Urol 2020; 27:736-741. [PMID: 32588523 DOI: 10.1111/iju.14288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/18/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine the use of surgical resection of metastatic disease in a large national sample and its association with overall survival. METHODS The National Cancer Database was queried for patients with metastatic bladder cancer (2004-2016). Overall survival was assessed using Kaplan-Meier and multivariable Cox analyses. The associations between covariates and use of metastasectomy were assessed with multivariable logistic regression. RESULTS Of the 16 382 patients with metastatic bladder cancer included, 6.8% underwent metastasectomy. Its use increased over time (4.7% in 2004 to 6.6% in 2016; per year odds ratio 1.02, 95% confidence interval 1.00-1.04, P = 0.019). Median survival was 7.0 months for patients who received metastasectomy and 5.1 months for those who did not (hazard ratio 0.85, 95% confidence interval 0.79-0.91, P < 0.001). In subgroup analyses, metastasectomy predicted longer survival in patients with lung (hazard ratio 0.73, 95% confidence interval 0.61-0.88, P = 0.001) or brain metastases (hazard ratio 0.58, 95% confidence interval 0.35-0.96, P = 0.035) and in patients with variant histology (hazard ratio 0.80, 95% confidence interval 0.69-0.93, P = 0.003). CONCLUSIONS In a national sample, the use of metastasectomy for bladder cancer is low. Furthermore, metastasectomy is associated with longer survival overall and in multiple subgroups. However, these results should be validated in future studies.
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Affiliation(s)
- Adam B Weiner
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Minh N Pham
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dylan S Isaacson
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Oliver S Ko
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kieran J Breen
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Robert B Nadler
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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11
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Lemke E, Sahasrabudhe D, Guancial E, Bylow K, Johnson S, Messing E, Kilari D. The Role of Metastasectomy in Urothelial Carcinoma: Where Are We in 2020? Clin Genitourin Cancer 2020; 18:e478-e483. [PMID: 32085986 DOI: 10.1016/j.clgc.2020.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 01/13/2020] [Indexed: 10/25/2022]
Abstract
Systemic therapy is the mainstay of treatment for metastatic urothelial carcinoma (UC). Responses to first-line platinum-based therapy tend to be short-lived with potential toxicity. Despite the approval of checkpoint inhibitors, the long-term prognosis for patients with metastatic UC remains dismal. Herein we report the case of a patient with a solitary pulmonary metastatic lesion of urothelial origin as the only site of metastatic disease who remained free of disease for more than 2 years without systemic therapy after metastasectomy. We review the literature discussing the role of combined surgical and medical management of oligometastatic UC. As our case illustrates, a growing body of evidence suggests a potential role for a multimodal approach in patients with oligometastatic UC.
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Affiliation(s)
- Emily Lemke
- Department of Medicine, Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI.
| | - Deepak Sahasrabudhe
- Department of Medicine, Hematology/Oncology, University of Rochester Medical Center, Rochester, NY
| | | | - Kathryn Bylow
- Department of Medicine, Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Scott Johnson
- Department of Urology, Medical College of Wisconsin, Milwaukee, WI
| | - Edward Messing
- Department of Medicine, Hematology/Oncology, University of Rochester Medical Center, Rochester, NY
| | - Deepak Kilari
- Department of Medicine, Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI
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12
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The role of metastatic burden in cytoreductive/consolidative radical cystectomy. World J Urol 2019; 37:2691-2698. [PMID: 30864005 DOI: 10.1007/s00345-019-02693-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 02/18/2019] [Indexed: 02/05/2023] Open
Abstract
PURPOSE To describe our institutional experience with cytoreductive/consolidative radical cystectomy (CCRC) for metastatic urothelial carcinoma (UC) and to investigate clinicopathologic features predicting prolonged cancer specific survival (CSS) following CCRC. METHODS We performed IRB-approved review of our cystectomy database, and identified 43 patients with metastatic UC who underwent CCRC. Baseline demographics, chemotherapy regimen, clinicopathologic features, and perioperative complications were collected. Progression-free survival (PFS) and CSS were estimated from the time of CCRC. Univariate and multivariate Cox regression models were used to identify predictors of improved CSS after CCRC. RESULTS Of the 43 patients, 32 (74.4%) had clinical evidence of distant metastases, while 11 harbored occult metastases on the surgical specimen. The most common site of metastasis was the retroperitoneal lymph nodes, found in 30 patients. Solitary metastases were found in 22 patients (51.1%). Forty-one (95%) patients received chemotherapy prior to CCRC. Disease progression was detected in 35 patients after CCRC (median PFS 5.9 months), and 34 died of metastatic cancer (median CSS 12.3 months). On multivariate analysis, patients with solitary metastases were found to have improved CSS compared to those with multiple metastases (HR 2.62, 95% CI 1.16-5.90, p = 0.02), with median CSS of 26.0 months vs. 7.9 months (p < 0.001). Median postoperative length of stay was 10 days. Overall, 56% suffered postoperative complications, including one perioperative mortality. CONCLUSIONS CCRC is feasible in the setting of metastatic UC. Patients with solitary metastasis demonstrated longer CSS than those with multiple metastases, and should be considered candidates for future trials evaluating the role of CCRC for metastatic UC.
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Liu NW, Murray KS, Donat SM, Herr HW, Bochner BH, Dalbagni G. The Outcome of Post-Chemotherapy Retroperitoneal Lymph Node Dissection in Patients with Metastatic Bladder Cancer in the Retroperitoneum. Bladder Cancer 2019; 5:13-19. [PMID: 30854412 PMCID: PMC6401561 DOI: 10.3233/blc-180186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: While a definitive cure can be achieved by radical cystectomy and pelvic lymph node dissection in select patients with regional lymphadenopathy, the benefit remains uncertain in patients who present with non-regional metastases. We analyzed the survival outcomes of post-chemotherapy retroperitoneal lymph node dissection. Materials and Methods: We reviewed our institutional database and identified 13 patients with radiographically evident or biopsy proven retroperitoneal nodal metastases with a significant response to chemotherapy. These patients underwent consolidative surgery with concomitant or delayed retroperitoneal lymph node dissection. The primary endpoints were progression-free survival and disease-specific survival from the time of retroperitoneal lymph node dissection. Results: All patients had primary urothelial cell carcinoma. Twelve patients underwent concomitant radical cystectomy, pelvic and retroperitoneal lymph node dissection. Seven patients (54%) had residual disease in the retroperitoneum and the median number of retroperitoneal nodes containing metastases was 4 (IQR 2–6). Six (86%) developed disease recurrences within 2 years of surgery and 5 (71%) died of cancer. Of the 6 patients without residual disease in the retroperitoneum, 2 (33%) developed recurrences and died of disease progression. The 2-year disease-specific survival was worse for patients with residual disease in the retroperitoneum than those without residual retroperitoneal disease (34%, 95% CI 5–68 vs 50%, 95% CI 6–85). Conclusions: The presence of retroperitoneal nodal metastases at post-chemotherapy retroperitoneal lymph node dissection is a poor prognosticator. Consolidative surgery with retroperitoneal lymph node dissection provides important prognostic information and may be therapeutic in a very small subset of these patients.
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Affiliation(s)
- Nick W Liu
- Department of Urology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Katie S Murray
- Department of Surgery, Urology Division, University of Missouri School of Medicine, Columbia, MO, USA
| | - S Machele Donat
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Harry W Herr
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bernard H Bochner
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Guido Dalbagni
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Abstract
Since the development of systemic combination chemotherapy, postchemotherapy extirpation has been performed in selected patients mainly with locally advanced and/or initially unresectable bladder cancer, and, in very selected patients, surgical consolidation for visceral metastases has also been performed. The purpose of this article was to review and summarize the current evidence for the role of surgical consolidation in metastatic urothelial carcinoma.
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Li R, Metcalfe M, Kukreja J, Navai N. Role of Radical Cystectomy in Non-Organ Confined Bladder Cancer: A Systematic Review. Bladder Cancer 2018; 4:31-40. [PMID: 29430505 PMCID: PMC5798530 DOI: 10.3233/blc-170130] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background: Currently, a diagnosis of non-organ confined bladder cancer (NOCBCa) confers a grave prognosis. The mainstay of treatment consists of systemic chemotherapy. However, it must be recognized that NOCBCa is a heterogeneous disease state with important clinical distinctions. While surgical extirpation has traditionally been regarded as overly aggressive for all NOCBCa patients, its utility as part of a multimodal treatment strategy in various clinical scenarios has not been thoroughly investigated. Objective: To perform a review of the literature regarding the role of radical cystectomy and pelvic lymph node dissection (RC-LND) in the setting of NOCBCa. Methods: Medline, and Pubmed electronic database were queried for English language articles from January 1990 to Nov 2016 on RC-LND for cT4, lymph node positive, and metastatic urothelial cancer. NOCBCa was separated into four distinct clinical scenarios: 1. Locally advanced/unresectable disease (cT4bN0M0); 2. Occult pelvic nodal disease (pN+) (cTxN0M0 and pTxN1-3Mx); 3. Clinical node positive disease (cN+) (cTxN1-3M0); and 4. Distant metastatic disease (TxNxM1). Evidence for the role of RC-LND in each of these clinical scenarios was summarized. Results: cT4b may be more effectively treated by presurgical chemotherapy (PSC) than other forms of NOCBCa. Although clinical response predicted improved survival, surgical factors, such as surgical margin status may also play a role in determining outcomes. In well selected patients, 5-year CSS may reach 60% after consolidative RC-LND. Survival in patients found to have pathologic nodal metastases without PSC was dictated not only by the histologically verified metastatic nodal disease burden, but also by the meticulousness of the lymph node dissection. In these patients, adjuvant chemotherapy may improve survival. On the other hand, in patients undergoing RC-LND after PSC, pathologic complete response (pCR) was the strongest predictor of improved CSS. The results of population based studies have suggested a therapeutic role by consolidative RC-LND in both patients with cN+ and metastatic BCa (mBCa). For the cN+ population, 5-year OS was 31% in patients undergoing RC-LND after PSC vs. 14% in those receiving chemotherapy alone. Similarly, consolidative intensive local therapy improved OS by approximately 5 months in patients with mBCa. Metastasectomy has also been shown to be effective in small retrospective series and may especially be useful in patients with solitary pulmonary lesions. Conclusions: Extirpative treatment of the primary tumor may be an important step in the management of de novo NOCBCa. The current retrospective and population based studies have demonstrated improved survival outcomes in patients with NOCBCa following RC-LND, especially in those with favorable response to PSC. With the advent of minimally invasive surgery and the enhanced post-surgical recovery protocols, RC-LND has not only been demonstrated to be feasible, but also tolerable in the setting of advanced BCa. Well designed, prospective trials are needed to definitively assess the value of surgical extirpation for NOCBCa patients.
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Affiliation(s)
- Roger Li
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael Metcalfe
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Janet Kukreja
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Neema Navai
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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16
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Decaestecker K, Fonteyne V, Oosterlinck W. Perspective on cytoreduction and metastasis-directed therapy in node positive and metastatic urothelial carcinoma of the bladder. Transl Androl Urol 2017; 6:1117-1122. [PMID: 29354498 PMCID: PMC5760372 DOI: 10.21037/tau.2017.08.09] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
The outcome of node positive or metastatic urothelial carcinoma of the bladder (mUCB) is poor and palliative chemotherapy has long been considered the only treatment option for this patient group. Cytoreduction and metastasis-directed therapy, either by surgery or radiotherapy, has been successfully applied in other metastatic solid tumors in order to increase survival. In this article, we explore the literature supporting cytoreduction and metastasis-directed therapy in node positive and mUCB and try to define a patient cohort that could benefit from these treatments. From these data, it is clear that a selected group of patients survive a long time or could even be cured, however the data are scarce and the level of evidence is low. The criteria of a randomized clinical trial, to deliver the necessary evidence, are proposed.
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Affiliation(s)
- Karel Decaestecker
- Department of Urology, Ghent University Hospital, De Pintelaan, Ghent, Belgium
| | - Valérie Fonteyne
- Department of Radiation Oncology, Ghent University Hospital, De Pintelaan, Ghent, Belgium
| | - Willem Oosterlinck
- Department of Urology, Ghent University Hospital, De Pintelaan, Ghent, Belgium
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17
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Dong F, Shen Y, Gao F, Xu T, Wang X, Zhang X, Zhong S, Zhang M, Chen S, Shen Z. Prognostic value of site-specific metastases and therapeutic roles of surgery for patients with metastatic bladder cancer: a population-based study. Cancer Manag Res 2017; 9:611-626. [PMID: 29180897 PMCID: PMC5694197 DOI: 10.2147/cmar.s148856] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background We aimed to evaluate the prognostic value of site-specific metastases in patients with metastatic bladder cancer and analyze the roles that surgeries play in the treatment of this malignancy. Materials and methods A population-based retrospective study using Surveillance, Epidemiology and End Results dataset was performed and metastatic bladder cancer patients were classified according to the sites of metastases (bone, brain, liver, lung and distant lymph nodes). Kaplan–Meier analysis with log-rank test was used for survival comparisons. Multivariate Cox regression model was employed to analyze the effect of distant metastatic sites on overall survival (OS) and cancer-specific survival (CSS). Results A total of 1862 patients with metastatic bladder cancer from 2010 to 2014 were identified. Bone, lung and distant lymph nodes were the most common metastatic sites. Patients with bone, brain, liver and lung involvement had worse OS and CSS compared to patients without the corresponding sites of metastases. Multivariate analysis showed that bone, brain, liver and lung metastases were independent prognostic factors for both OS and CSS, while distant node metastasis was not. Moreover, patients with a single metastatic site had more favorable OS (p<0.001) and CSS (p<0.001) than patients with multisite metastases. Among single-site metastatic patients, distant nodes and liver metastases represented the best and the worst prognosis, respectively. Moreover, radical cystectomy was an independent predictor for better OS and CSS, while in patients with liver metastasis and multiple metastatic sites, RC did not bring benefits. Besides, in patients with a single metastatic site, metastasectomy seemed to be associated with favorable OS (p=0.042), especially for patients with age <65 years (p=0.006) and for muscle-invasive bladder cancer patients (p=0.031). Conclusion Distant metastatic sites have differential impact on survival outcomes in patients with metastatic bladder cancer. Surgeries, including radical cystectomy and metastasectomy, might still lead to survival benefits for highly selected patients.
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Affiliation(s)
- Fan Dong
- Department of Urology, Fudan Institute of Urology, Huashan Hospital, Fudan University, Shanghai
| | - Yifan Shen
- Department of Urology, Fudan Institute of Urology, Huashan Hospital, Fudan University, Shanghai
| | - Fengbin Gao
- Department of Urology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Tianyuan Xu
- Department of Urology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xianjin Wang
- Department of Urology, Fudan Institute of Urology, Huashan Hospital, Fudan University, Shanghai
| | - Xiaohua Zhang
- Department of Urology, Fudan Institute of Urology, Huashan Hospital, Fudan University, Shanghai
| | - Shan Zhong
- Department of Urology, Fudan Institute of Urology, Huashan Hospital, Fudan University, Shanghai
| | - Minguang Zhang
- Department of Urology, Fudan Institute of Urology, Huashan Hospital, Fudan University, Shanghai
| | - Shanwen Chen
- Department of Urology, Fudan Institute of Urology, Huashan Hospital, Fudan University, Shanghai
| | - Zhoujun Shen
- Department of Urology, Fudan Institute of Urology, Huashan Hospital, Fudan University, Shanghai
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Abufaraj M, Dalbagni G, Daneshmand S, Horenblas S, Kamat AM, Kanzaki R, Zlotta AR, Shariat SF. The Role of Surgery in Metastatic Bladder Cancer: A Systematic Review. Eur Urol 2017; 73:543-557. [PMID: 29122377 DOI: 10.1016/j.eururo.2017.09.030] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/28/2017] [Indexed: 12/27/2022]
Abstract
CONTEXT The role of surgery in metastatic bladder cancer (BCa) is unclear. OBJECTIVE In this collaborative review article, we reviewed the contemporary literature on the surgical management of metastatic BCa and factors associated with outcomes to support the development of clinical guidelines as well as informed clinical decision-making. EVIDENCE ACQUISITION A systematic search of English language literature using PubMed-Medline and Scopus from 1999 to 2016 was performed. EVIDENCE SYNTHESIS The beneficial role of consolidation surgery in metastatic BCa is still unproven. In patients with clinically evident lymph node metastasis, data suggest a survival advantage for patients undergoing postchemotherapy radical cystectomy with lymphadenectomy, especially in those with measurable response to chemotherapy (CHT). Intraoperatively identified enlarged pelvic lymph nodes should be removed. Anecdotal reports of resection of pulmonary metastasis as part of multimodal approach suggest possible improved survival in well-selected patients. Cytoreductive radical cystectomy as local treatment has also been explored in patients with metastatic disease, although its benefits remain to be assessed. CONCLUSIONS Consolidative extirpative surgery may be considered in patients with clinically evident pelvic or retroperitoneal lymph nodal metastases but only if they have had a response to CHT. Surgery for limited pulmonary metastases may also be considered in very selected cases. Best candidates are those with resectable disease who demonstrate measurable response to CHT with good performance status. In the absence of data from prospective randomized studies, each patient should be evaluated on an individual basis and decisions made together with the patient and multidisciplinary teams. PATIENT SUMMARY Surgical resection of metastases is technically feasible and can be safely performed. It may help improve cancer control and eventually survival in very selected patients with limited metastatic burden. In a patient who is motivated to receive chemotherapy and to undergo extirpative surgical intervention, surgery should be discussed with the patient among other consolidation therapies in the setting of multidisciplinary teams.
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Affiliation(s)
- Mohammad Abufaraj
- Department of Urology, Medical University of Vienna, Vienna, Austria; Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan
| | - Guido Dalbagni
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Siamak Daneshmand
- Institute of Urology, University of Southern California/ Norris Comprehensive Cancer Center, Los Angeles, CA, USA
| | - Simon Horenblas
- Department of Surgical Oncology, Division of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Ashish M Kamat
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ryu Kanzaki
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Alexandre R Zlotta
- Department of Surgery, Division of Urology, University of Toronto, Mount Sinai Hospital and University Health Network, Toronto, ON, Canada
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna, Austria; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Urology, Weill Cornell Medical College, New York, NY, USA.
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Hernández-Fernández C, Herranz-Amo F, Moralejo-Gárate M, Subirá-Ríos D, Caño-Velasco J, Barbas-Bernardos G. Infiltrating bladder cancer: prognostic factors, follow-up and treatment of relapses. Actas Urol Esp 2017; 41:352-358. [PMID: 27561847 DOI: 10.1016/j.acuro.2016.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 07/28/2016] [Indexed: 10/21/2022]
Abstract
CONTEXT Bladder cancer is the cause of more than 150,000 deaths per year. The overall rate of survival is approximately 45%, with a 10-year recurrence-free rate of 50-59%, with no changes in the last decade. OBJECTIVE Due to a lack of agreement on the follow-up of cystectomy or on a uniform treatment when faced with the various types of recurrence, we have analysed the most recent literature in an attempt to unify the criteria for the diagnosis and treatment of bladder cancer. ACQUISITION OF EVIDENCE Review of Spanish and English publications in the medical literature in the last 10 years, highlighting the most significant series in terms of the number of patients, follow-up time, as well as the existing meta-analyses. SYNTHESIS OF THE EVIDENCE Recurrence after cystectomy can occur in the urinary apparatus (upper urinary tract or distal urethra) and local (cystectomy bed) and/or distant metastases. Despite strict control, more than 60% of the relapses are discovered based on symptoms and not by the routine follow-up test. Locoregional and distant relapses are more common the more advanced the stage at the time of cystectomy, going from 11-21% in pT2N0 to 52-72% when there is lymphocytic N+ involvement. Recurrence in the urethra and/or upper urinary track has other prognostic factors such as multiplicity, the presence of Cis and involvement of prostatic stroma. There are various treatments for tumour relapses. Increasingly, the patient's comorbidity is considered when deciding on the therapeutic strategy. Treatments are typically multimodal and include surgery, radiotherapy and chemotherapy. CONCLUSION The follow-up of patients who undergo cystectomy should be individualised, taking into account the prognostic factors of recurrence and the patient's comorbidity, assuming that in some cases, multimodal treatment is indicated.
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Necchi A, Mariani L, Lo Vullo S, Yu EY, Woods ME, Wong YN, Harshman LC, Alva A, Sternberg CN, Bamias A, Grivas P, Koshkin VS, Roghmann F, Dobruch J, Eigl BJ, Nappi L, Milowsky MI, Niegisch G, Pal SK, De Giorgi U, Recine F, Vaishampayan U, Berthold DD, Bowles DW, Baniel J, Theodore C, Ladoire S, Srinivas S, Agarwal N, Crabb S, Sridhar S, Golshayan AR, Ohlmann C, Xylinas E, Powles T, Rosenberg JE, Bellmunt J, van Rhijn B, Galsky MD, Hendricksen K. Lack of Effectiveness of Postchemotherapy Lymphadenectomy in Bladder Cancer Patients with Clinical Evidence of Metastatic Pelvic or Retroperitoneal Lymph Nodes Only: A Propensity Score-based Analysis. Eur Urol Focus 2017; 5:242-249. [PMID: 28753897 DOI: 10.1016/j.euf.2017.05.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Revised: 05/04/2017] [Accepted: 05/22/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Limited data is available on the role, and extent of, postchemotherapy lymphadenectomy (PC-LND) in patients with clinical evidence of pelvic (cN1-3) or retroperitoneal (RP) lymph node spread from urothelial bladder carcinoma. OBJECTIVE To compare the outcomes of operated versus nonoperated patients after first-line chemotherapy. DESIGN, SETTING, AND PARTICIPANTS Data from 34 centers was collected, totaling 522 patients, treated between January 2000 and June 2015. Criteria for patient selection were the following: bladder primary tumor, lymph node metastases (pelvic±RP) only, first-line platinum-based chemotherapy given. INTERVENTION LND (with cystectomy) versus observation after first-line chemotherapy for metastatic urothelial bladder carcinoma. OUTCOME MEASURES AND STATISTICAL ANALYSIS Overall survival (OS) was the primary endpoint. Multiple propensity score techniques were adopted, including 1:1 propensity score matching and inverse probability of treatment weighting. Additionally, the inverse probability of treatment weighting analysis was performed with the inclusion of the covariates, that is, with doubly robust estimation. RESULTS AND LIMITATIONS Overall, 242 (46.4%) patients received PC-LND and 280 (53.6%) observation after chemotherapy. There were 177 (33.9%) and 345 (66.1%) patients with either RP or pelvic LND only, respectively. Doubly robust estimation-adjusted comparison was not significant for improved OS for PC-LND (hazard ratio [HR]: 0.86, 95% confidence interval [CI]: 0.56-1.31, p=0.479), confirmed by matched analysis (HR: 0.91, 95% CI: 0.60-1.36, p=0.628). This was also observed in the RP subgroup (HR: 1.12, 95% CI: 0.68-1.84). The retrospective nature of the data and the heterogeneous patient population were the major limitations. CONCLUSIONS Although there were substantial differences between the two groups, after accounting for major confounders we report a nonsignificant OS difference with PC-LND compared with observation only. These findings may be hypothesis-generating for future prospective trials. PATIENT SUMMARY We found no differences in survival by adding postchemotherapy lymphadenectomy in patients with pelvic or retroperitoneal lymph node metastatic bladder cancer. The indication to perform postchemotherapy lymphadenectomy in the most suitable patients requires additional studies.
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Affiliation(s)
- Andrea Necchi
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy.
| | - Luigi Mariani
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | | | - Evan Y Yu
- University of Washington, Seattle, WA, USA
| | - Michael E Woods
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, NC, USA
| | | | | | - Ajjaj Alva
- University of Michigan, Ann Arbor, MI, USA
| | | | | | - Petros Grivas
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Vadim S Koshkin
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Jakub Dobruch
- Centre of Postgraduate Medical Education, European Health Centre Otwock, Poland
| | - Bernie J Eigl
- British Columbia Cancer Agency, Vancouver, BC, Canada
| | - Lucia Nappi
- British Columbia Cancer Agency, Vancouver, BC, Canada
| | - Matthew I Milowsky
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, NC, USA
| | - Guenter Niegisch
- Heinrich-Heine-University, Medical faculty, Department of Urology, Düsseldorf, Germany
| | - Sumanta K Pal
- City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Ugo De Giorgi
- IRCCS Istituto Scientifico Romagnolo per lo studio e la Cura dei Tumori, Meldola, Italy
| | - Federica Recine
- IRCCS Istituto Scientifico Romagnolo per lo studio e la Cura dei Tumori, Meldola, Italy
| | | | | | - Daniel W Bowles
- Denver Veterans Affairs Medical Center, Eastern Colorado Health Care System, Denver, CO, USA
| | | | | | | | - Sandy Srinivas
- Stanford University School of Medicine, Stanford, CA, USA
| | | | - Simon Crabb
- University of Southampton, Southampton, United Kingdom
| | - Srikala Sridhar
- Princess Margaret Hospital, University Health Network, Toronto, Canada
| | | | | | - Evanguelos Xylinas
- Cochin Hospital, Assistance-Publique Hôpitaux de Paris, Paris Descartes University, Paris, France
| | - Thomas Powles
- Barts Health and the Royal Free NHS Trust, Queen Mary University of London, London, UK
| | | | | | - Bas van Rhijn
- The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Matthew D Galsky
- Mount Sinai School of Medicine, Tisch Cancer Institute, New York, NY, USA
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Patel V, Collazo Lorduy A, Stern A, Fahmy O, Pinotti R, Galsky MD, Gakis G. Survival after Metastasectomy for Metastatic Urothelial Carcinoma: A Systematic Review and Meta-Analysis. Bladder Cancer 2017; 3:121-132. [PMID: 28516157 PMCID: PMC5409038 DOI: 10.3233/blc-170108] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background: Cisplatin-based combination chemotherapy is standard treatment for metastatic urothelial carcinoma; however, the vast majority of patients experience disease progression. As systemic therapy alone is rarely curative for the treatment of metastatic urothelial cancer, not only are new therapies needed but also refinement of general treatment principles. Herein, we conducted a systematic review and meta-analysis to explore the role of metastasectomy in metastatic urothelial carcinoma. Methods: We conducted a systematic review of the literature regarding local treatment for metastatic urothelial carcinoma. An online electronic search of the PubMed/MEDLINE and EMBASE databases was performed to identify peer-reviewed articles. All procedures were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Information was then extracted including number of patients, gender, the site of the primary urothelial tumor, site of metastasis, chemotherapy before or after metastasectomy, overall survival (OS), and disease specific survival (DSS) after metastasectomy. A meta-analysis was performed with those studies with sufficient survival data to obtain pooled overall survival. The article quality was assessed using the Cochrane Handbook “risk of bias” tool. Results: Seventeen out of 3963 articles were eligible for review between 1990–2015, including a total of 412 patients. The mean time to recurrence after metastasectomy was 14.25 months. The overall survival from time of metastasectomy ranged from 2 to 60 months. Pooled analyses of studies reported survival data revealed an improved overall survival for patients treated with metastasectomy compared with non-surgical treatment of metastatic lesions (HR 0.63; 95% CI, 0.49–0.81). All, except for three studies, were retrospective and non-randomized, leading to a high risk of bias associated with patient selection, patient attrition, and reporting. Such high potential of selection bias may lead to higher OS than expected. Additionally, treatment and outcome details reported across studies was highly variable. Conclusions: Limited conclusions can be drawn from the available literature exploring the role of metastasectomy in the management of metastatic urothelial cancer due to lack of uniform reporting elements and multiple sources of bias particularly related to a lack of prospective randomized trials. As a subset of patients treated with metastasectomy achieve durable disease control, this approach may be considered for select patients.
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Affiliation(s)
- Vaibhav Patel
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ana Collazo Lorduy
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Spanish Society of Medical Oncology, Madrid, Spain
| | - Aaron Stern
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Omar Fahmy
- Department of Urology, Universiti Putra Malaysia, Selangor, Malaysia
| | - Rachel Pinotti
- Information and Education Service, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Matthew D Galsky
- Icahn School of Medicine at Mount Sinai, Division of Hematology and Medical Oncology, Tisch Cancer Institute, New York, NY, USA
| | - Georgios Gakis
- Urology and Nephrology Center, University of Mansoura, Mansoura, Egypt
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22
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[When is surgical treatment indicated in metastatic urothelial carcinoma and what is the scientific rationale?]. Urologe A 2017; 56:585-590. [PMID: 28321462 DOI: 10.1007/s00120-017-0362-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Patients with metastatic urothelial carcinoma have a poor prognosis. Standard of care is a systemic chemotherapy but surgical excision of metastasis can be performed in individual approaches. OBJECTIVES To evaluate treatment options and study results and to identify and discuss advantages and disadvantages of metastasectomy in urothelial carcinoma. MATERIALS AND METHODS Database analysis and discussion of clinical trials concerning metastasectomy in urothelial carcinoma. RESULTS In individual cases, metastasectomy can be a reasonable additional therapeutic approach to systemic chemotherapy. Especially patients suffering from symptomatic metastatic disease benefit from extended surgical effort but further effects on survival cannot be expected. CONCLUSIONS Patients undergoing metastasetomy should be well selected concerning general physical condition. Metastasectomy in urothelial carcinoma remains an individual therapeutic approach and should be performed in combination with systemic chemotherapy.
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Ellinger J, Hauser S, Kübler H, Müller SC. [When is surgical resection of the primary tumor indicated in metastatic urothelial carcinoma of the bladder and what is the scientific rationale?]. Urologe A 2017; 56:564-569. [PMID: 28314967 DOI: 10.1007/s00120-017-0360-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Cisplatin-based polychemotherapy is still the standard therapy for metastatic urothelial carcinoma, although disease progression is often noted at an early time point even in patients with response. In recent years, cytoreductive surgery has been gaining increasing interest in many tumor entities in the setting of metastatic disease to improve patients outcome, but urothelial carcinoma is not regarded as a candidate for such a multimodal therapy approach. However, several retrospective studies suggest a survival benefit of radical cystectomy and/or metastasectomy for well-selected patients with metastatic urothelial carcinoma. Prognostically relevant parameters for consolidative cystectomy/metastasectomy after chemotherapy seem to be a distinct response to inductive chemotherapy and limited metastatic spread (regional lymph node, single lung metastasis).
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Affiliation(s)
- J Ellinger
- Klinik und Poliklinik für Urologie und Kinderurologie, Universitätsklinikum Bonn, Sigmund-Freud-Straße 25, 53105, Bonn, Deutschland.
| | - S Hauser
- Klinik und Poliklinik für Urologie und Kinderurologie, Universitätsklinikum Bonn, Sigmund-Freud-Straße 25, 53105, Bonn, Deutschland
| | - H Kübler
- Klinik und Poliklinik für Urologie und Kinderurologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - S C Müller
- Klinik und Poliklinik für Urologie und Kinderurologie, Universitätsklinikum Bonn, Sigmund-Freud-Straße 25, 53105, Bonn, Deutschland
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Abufaraj M, Gust K, Moschini M, Foerster B, Soria F, Mathieu R, Shariat SF. Management of muscle invasive, locally advanced and metastatic urothelial carcinoma of the bladder: a literature review with emphasis on the role of surgery. Transl Androl Urol 2016; 5:735-744. [PMID: 27785430 PMCID: PMC5071186 DOI: 10.21037/tau.2016.08.23] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Locally advanced (T3b, T4 and N1-N3) and metastatic urothelial bladder cancer (BCa) is a lethal disease with poor survival outcomes. Combination chemotherapy remains the treatment of choice in patients with metastatic disease and an important part of treatment in addition to radical cystectomy (RC) in patients with locally advanced tumour. Approximately half of patients who underwent RC for muscle invasive BCa relapse after surgery with either local recurrence or distant metastasis. This review focuses on the management of muscle invasive, locally advanced and metastatic BCa with emphasis on the role of surgery; to summarize the current knowledge in order to enhance clinical decision-making and counselling process.
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Affiliation(s)
- Mohammad Abufaraj
- Department of Urology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Kilian Gust
- Department of Urology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria; ; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria
| | - Marco Moschini
- Department of Urology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria; ; Department of Urology, Urological Research Institute, Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy
| | - Beat Foerster
- Department of Urology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria; ; Department of Urology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Francesco Soria
- Department of Urology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria; ; Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Studies of Torino, Turin, Italy
| | - Romain Mathieu
- Department of Urology, Rennes University Hospital, Rennes, France
| | - Shahrokh F Shariat
- Department of Urology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria; ; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria; ; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; ; Department of Urology, Weill Cornell Medical College, New York, NY, USA
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Al-Marrawi MY, Mackley HB, Ali S, Wagner H, Joshi M, Holder S, Kaag M, Mallon C, Talamo G, Drabick JJ. Consolidation With Radiation or Concurrent Chemo-Radiation After Chemotherapy Results in Durable Complete Remissions of Isolated Nodal Recurrences of Urothelial Cancer: A Case Series and Review. Clin Genitourin Cancer 2016; 14:e393-9. [PMID: 26877063 DOI: 10.1016/j.clgc.2016.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 01/13/2016] [Accepted: 01/16/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Mhd Yaser Al-Marrawi
- Division of Hematology and Oncology, Penn State University/Hershey Cancer Institute, Hershey, PA.
| | - Heath B Mackley
- Division of Radiation Oncology, Penn State University/Hershey Cancer Institute, Hershey, PA
| | - Suhail Ali
- Division of Hematology and Oncology, Penn State University/Hershey Cancer Institute, Hershey, PA
| | - Henry Wagner
- Division of Radiation Oncology, Penn State University/Hershey Cancer Institute, Hershey, PA
| | - Monika Joshi
- Division of Hematology and Oncology, Penn State University/Hershey Cancer Institute, Hershey, PA
| | - Sheldon Holder
- Division of Hematology and Oncology, Penn State University/Hershey Cancer Institute, Hershey, PA
| | - Mathew Kaag
- Division of Urological Surgery, Penn State University/Hershey Cancer Institute, Hershey, PA
| | - Carol Mallon
- Division of Hematology and Oncology, Penn State University/Hershey Cancer Institute, Hershey, PA
| | - Giampaolo Talamo
- Division of Hematology and Oncology, Penn State University/Hershey Cancer Institute, Hershey, PA
| | - Joseph J Drabick
- Division of Hematology and Oncology, Penn State University/Hershey Cancer Institute, Hershey, PA
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Does solitary- and organ-confined metastasectomy really improve survival in advanced urologic malignancies? Int Urol Nephrol 2016; 48:671-80. [DOI: 10.1007/s11255-016-1226-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 01/22/2016] [Indexed: 10/22/2022]
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[A CASE OF HEPATIC METASTASECTOMY FOR RENAL PELVIS CARCINOMA]. Nihon Hinyokika Gakkai Zasshi 2015; 106:190-3. [PMID: 26419077 DOI: 10.5980/jpnjurol.106.190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A 68-year-old woman presented with asymptomatic gross hematuria. Computed tomography (CT) scan revealed noninvasive tumor in the right ureteropelvic junction. After diagnosis with right pelvis carcinoma by ureteroscopy, she underwent laparoscopic nephroureterectomy in Aug. 2008. Six months later, hepatic metastasis was detected. Three courses of combination chemotherapy consisting of gemcitabine and cisplatin (GC) were conducted, and then partial response (PR) was achieved. In Aug. 2009, radical metastasectomy for liver metastasis was performed. More than four years and five months after hepatectomy, the patient has achieved a high quality of life.
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Lees AN. Cutaneous metastasis of transitional cell carcinoma of the urinary bladder eight years after the primary: a case report. J Med Case Rep 2015; 9:102. [PMID: 25943325 PMCID: PMC4427993 DOI: 10.1186/s13256-015-0585-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 04/02/2015] [Indexed: 03/23/2024] Open
Abstract
INTRODUCTION Cutaneous metastasis of bladder carcinoma is extremely rare with a limited number of published cases. An awareness of this rare clinical entity and high index of suspicion is needed for diagnosis, as it can occur months or rarely as in this case, even years, after the primary cancer. CASE PRESENTATION An 81-year-old Caucasian man presented with a one-year history of increasing left leg swelling and a two-month history of a macular-nodular rash on the anterior thigh, on a background of a high-grade (WHO Grade 2 of 3) papillary and invasive transitional cell carcinoma of the bladder in 2006. Following investigations, he was diagnosed as having probable locoregional recurrence of previously resected urothelial cancer of the bladder with extensive retrograde lymphatic permeation into the left thigh with cutaneous eruptions of malignancy. He completed a planned course of palliative radiation therapy to the left thigh lesions (30 Gy divided over 10 fractions) as well as the left pelvic node (a total dose of 18 Gy divided over six fractions). The disease ran an aggressive course and our patient died six months after the diagnosis of cutaneous metastases. CONCLUSIONS Metastatic disease should always be considered in the differential diagnosis in patients with a previous history of bladder cancer who present with cutaneous nodules, even many years after the initial diagnosis at the primary site.
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Affiliation(s)
- Andrea Nicole Lees
- Royal Hobart Hospital, 48 Liverpool Street, Hobart, Tasmania, 7000, Australia.
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Necchi A, Giannatempo P, Lo Vullo S, Farè E, Raggi D, Nicolai N, Piva L, Biasoni D, Torelli T, Catanzaro M, Stagni S, Maffezzini M, Mariani L, Salvioni R. Postchemotherapy lymphadenectomy in patients with metastatic urothelial carcinoma: long-term efficacy and implications for trial design. Clin Genitourin Cancer 2014; 13:80-86.e1. [PMID: 25027186 DOI: 10.1016/j.clgc.2014.06.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 05/03/2014] [Accepted: 06/03/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The contribution of postchemotherapy pelvic (PLND) or retroperitoneal lymphadenectomy (RPLND) on survival in patients with advanced and metastatic UC is still unclear. PATIENTS AND METHODS Between September 1986 and May 2012, 157 patients with locally advanced or metastatic UC received first-line chemotherapy consisting of mMVAC (modified methotrexate, vinblastine, doxorubicin, and cisplatin), according to our policy. Patients with subdiaphragmatic nodal disease and/or local recurrence only and who experienced at least stable disease (SD) were selected. Fifty-nine patients were identified, 28 of whom underwent surgery, 31 started consolidation chemotherapy with or without radiotherapy or observation. The prognostic effect of candidate factors on survival was evaluated using Cox proportional hazard regression models. RESULTS A total of 14 PLND and 14 RPLND patients were identified after they had achieved a complete response (CR; n = 7) or a partial response (PR) and SD (n = 21). Median follow-up was 88 months (interquartile range, 24-211 months). Median PFS was 18 (95% confidence interval [CI], 11-not estimated) and 11 (95% CI, 5-19) months, respectively, in favor of the surgical cohort and curves were statistically different (log-rank test, P = .009). In multivariate analysis, postchemotherapy surgery was significantly prognostic for PFS and OS and response to chemotherapy (PR and SD vs. CR) was prognostic for PFS and trended to significance for OS. A model including these 2 factors showed bootstrap-corrected Harrel C statistics for PFS and OS of 0.65 and 0.68, respectively. CONCLUSION In well selected patients with UC like those who achieved a clinical benefit with chemotherapy and had nodal metastatic disease, there was a survival advantage in removal of disease residuals.
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Affiliation(s)
- Andrea Necchi
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Patrizia Giannatempo
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Salvatore Lo Vullo
- Clinical Epidemiology and Trials Organization Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Elena Farè
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Daniele Raggi
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Nicola Nicolai
- Department of Surgery, Urology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Luigi Piva
- Department of Surgery, Urology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Davide Biasoni
- Department of Surgery, Urology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Tullio Torelli
- Department of Surgery, Urology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Mario Catanzaro
- Department of Surgery, Urology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Silvia Stagni
- Department of Surgery, Urology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Massimo Maffezzini
- Department of Surgery, Urology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Luigi Mariani
- Clinical Epidemiology and Trials Organization Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Roberto Salvioni
- Department of Surgery, Urology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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Abe T, Kitamura H, Obara W, Matsumura N, Tsukamoto T, Fujioka T, Hara I, Murai S, Shinohara N, Nonomura K. Outcome of Metastasectomy for Urothelial Carcinoma: A Multi-Institutional Retrospective Study in Japan. J Urol 2014; 191:932-6. [DOI: 10.1016/j.juro.2013.11.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Takashige Abe
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiroshi Kitamura
- Department of Urology, Sapporo Medical University, Sapporo, Japan
| | - Wataru Obara
- Department of Urology, Iwate Medical University, Iwate, Japan
| | | | - Taiji Tsukamoto
- Department of Urology, Sapporo Medical University, Sapporo, Japan
| | - Tomoaki Fujioka
- Department of Urology, Iwate Medical University, Iwate, Japan
| | - Isao Hara
- Department of Urology, Wakayama Medical University, Wakayama, Japan
| | - Sachiyo Murai
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Nobuo Shinohara
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Katsuya Nonomura
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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31
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Neuzillet Y, Larré S, Comperat E, Rouprêt M, Pignot G, Houede N, Quintens H, Wallerand H, Roy C, Soulie M, Pfister C. [Surgical treatment of metastatic urothelial carcinoma of the bladder: Review of the Cancer Committee of the French Association of Urology]. Prog Urol 2013; 23:951-7. [PMID: 24090779 DOI: 10.1016/j.purol.2013.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 02/18/2013] [Accepted: 03/09/2013] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The role of surgery in the treatment of patients with metastatic urothelial bladder cancer is controversial. The aim was to review situations where surgical resection of the bladder tumor and/or metastatic urothelial carcinoma has been reported and analyze its results. MATERIALS AND METHODS A bibliographic research in French and English using the keywords BCG, bladder cancer, metastases, cystectomy, metastasectomy, radiotherapy, curative treatment and palliative treatment was performed, 177 articles have been reviewed, and 18 have been selected. RESULTS Synchronous or metachronous urothelial carcinoma metastases were diagnosed in 4 and 50% of the cases, respectively. The surgical treatment of metastatic urothelial carcinoma of the bladder has been proposed to achieve oncologic resection of all detectable lesions after a first-line chemotherapy or to treat symptoms, which were refractory to other treatment modalities. In achieving complete resection of the primary tumor and metastases after MVAC chemotherapies, the 5years overall survival was 28%. CONCLUSION There was no evidence in favouring surgical treatment of metastatic urothelial carcinoma. Considering the high perioperative mortality rate of cystectomy in imperative indications, particularly in the case of hematuria, all therapeutic alternatives must have been exhausted and urine derived in the simplest way.
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Affiliation(s)
- Y Neuzillet
- Service d'urologie, hôpital Foch, université de Versailles-Saint-Quentin-en-Yvelines (UVSQ), 40, rue Worth, 92150 Suresnes, France.
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Otto T. Surgical resection should be viewed with skepticism in patients with bladder cancer. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:176. [PMID: 23533552 DOI: 10.3238/arztebl.2013.0176a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Racioppi M, D'Agostino D, Totaro A, Pinto F, Sacco E, D'Addessi A, Marangi F, Palermo G, Bassi PF. Value of current chemotherapy and surgery in advanced and metastatic bladder cancer. Urol Int 2012; 88:249-58. [PMID: 22354060 DOI: 10.1159/000335556] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The aim of the present paper was to review findings from the most relevant studies and to evaluate the value of current chemotherapy and surgery in advanced unresectable and metastatic bladder cancer. Studies were identified by searching the MEDLINE® and PubMed® databases up to 2011 using both medical subject heading (Mesh) and a free text strategy with the name of the known individual chemotherapeutic drug and the following key words: 'muscle-invasive bladder cancer', 'chemotherapeutics agents', and 'surgery in advanced bladder cancer'. At the end of our literature research we selected 141 articles complying with the aim of the review. The results showed that it has been many years since the MVAC (methotrexate, vinblastine, adriamycin, cisplatin) regimen was first developed. The use of cisplatin-based combination chemotherapy is associated with significant toxicity and produces long-term survival in only approximately 15-20% of patients. Gemcitabine + cisplatin represents the gold standard in the treatment of metastatic bladder cancer. In conclusion, the optimal approach in the management of advanced urothelial cancer continues to evolve. Further progress relies on the expansion of research into tumor biology and an understanding of the underlying molecular 'fingerprints' that can be used to enhance diagnostic and therapeutic strategies. Cisplatin-based therapy has had the best track record thus far.
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Affiliation(s)
- M Racioppi
- Department of Urology, Catholic University of the Sacred Heart, Rome, Italy
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Bekku K, Saika T, Kobayashi Y, Kioshimoto R, Kanbara T, Nasu Y, Kumon H. Could salvage surgery after chemotherapy have clinical impact on cancer survival of patients with metastatic urothelial carcinoma? Int J Clin Oncol 2011; 18:110-5. [PMID: 22095246 DOI: 10.1007/s10147-011-0350-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Accepted: 11/01/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND The clinical impact of salvage surgery after chemotherapy on cancer survival of patients with metastatic urothelial carcinoma is controversial. We aimed to verify the clinical role of salvage surgery by analyzing the long-term outcome in patients with urothelial carcinoma treated by chemotherapy. METHODS Between 2003 and 2010 at a single institution, 31 of 47 patients (66%) with metastatic urothelial carcinoma showed objective responses (CR in 4, PR in 27) after multiple courses of cisplatin/gemcitabine/paclitaxel-based chemotherapy, and a cohort of patients with partial response (PR) were retrospectively enrolled. Twelve (10 male and 2 female, median age 64.0 years) of 27 patients with PR underwent salvage surgeries after the chemotherapy: metastatectomy of residual lesions (10 retroperitoneal lymph nodes, 2 lung), and 6 radical surgeries for primary lesions as well. Progression-free survival and overall patient survival rates were analyzed retrospectively and compared with those of patients without salvage surgery. RESULTS All 12 patients achieved surgical CR. Pathological findings of metastatic lesions showed viable cancer cells in 3 patients. In univariate analysis, sole salvage surgery affected overall survival in 27 patients with PR to the chemotherapy (P = 0.0037). Progression-free survival and overall survival rates in patients with salvage surgery were better than those in 15 PR patients without the surgery (39.8 vs. 0%, and 71.6 vs. 12.1% at 3 years, P = 0.01032 and 0.01048; log-rank test). CONCLUSIONS Salvage surgery for patients with residual tumor who achieve partial response to chemotherapy could have a possible impact on cancer survival.
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Affiliation(s)
- Kensuke Bekku
- Department of Urology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
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Abstract
Background: There is a significant variation in the treatment strategies adopted for the treatment of locally advanced T3b, T4a, N1-3 and metastatic bladder cancer. There is increasing evidence that we would be able to offer them some benefit in terms of disease-free survival and improving the quality of life. This article is aimed at reviewing the current literature on the treatment strategies in locally advanced and metastatic bladder cancer. Materials and Methods: Extensive literature search was done on Medline/Pubmed from 1980-2007 using the key words - treatment of locally advanced, metastatic bladder cancer. Standard textbooks on urology, urologic oncology and monograms were reviewed. Guidelines such as National Comprehensive Cancer Network guidelines, European Urology Association guidelines and American Urology Association guidelines were also studied. Results and Conclusions: There is a place for radical cystectomy in locally advanced T3b-T4 and N1-3 bladder cancer. Radical cystectomy alone rarely cures this subgroup of patients. There is increasing evidence that meticulous surgical clearance and extended lymphadenectomy has significant impact on disease-free survival. Adjuvant chemotherapy has been found to be effective in terms of recurrence-free survival and better than cystectomy alone. Neoadjuvant chemotherapy followed by radical cystectomy also has beneficial effects in terms of downstaging the disease and improving recurrence-free survival. This perioperative chemotherapy (adjuvant/neoadjuvant) has 5-7% survival benefit and 10% reduction in the death due to cancer disease. Excellent five-year survival rates have been achieved in patients achieving pT0 stage at surgery following chemotherapy (around 80%) and overall 40% five-year survival in node positive patients, which is promising. Though practiced widely, perioperative chemotherapy is not considered as a standard of care as yet. Current ongoing trials are likely to help us in reaching a consensus over this. There is no role of preoperative or postoperative radiotherapy in locally advanced/metastatic bladder cancer except in non TCC bilharzial/squamous cell carcinoma of bladder. Use of nomograms and prognostic factor evaluation may help us in the future in predicting the disease relapse and may help us in tailoring the treatment accordingly. Newer and more effective chemotherapeutic drugs and ongoing trials will have a significant impact on the treatment strategies and outcome of these patients in the future.
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Affiliation(s)
- Makarand V Khochikar
- Department of Uro-Oncology, Siddhi Vinayak Ganapati Cancer Hospital, Miraj, India
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Kitamura H, Taguchi K, Kunishima Y, Yanase M, Takahashi A, Shigyo M, Tanaka T, Mutoh M, Fukuta F, Masumori N, Tsukamoto T. Paclitaxel, ifosfamide, and nedaplatin as second-line treatment for patients with metastatic urothelial carcinoma: a phase II study of the SUOC group. Cancer Sci 2011; 102:1171-5. [PMID: 21323791 PMCID: PMC11159473 DOI: 10.1111/j.1349-7006.2011.01909.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Revised: 01/20/2011] [Accepted: 02/09/2011] [Indexed: 11/28/2022] Open
Abstract
There is no standard second-line chemotherapy treatment for recurrent or metastatic urothelial cancer (MUC). The purpose of this phase II study was to evaluate the efficacy and toxicity of the three-drug combination of paclitaxel, ifosfamide, and nedaplatin (TIN). Patients with MUC were eligible after treatment failure with methotrexate, vinblastine, doxorubicin, and cisplatin, or gemcitabine and cisplatin. Doses for TIN therapy were paclitaxel 175 mg/m2 on day 1, ifosfamide 1500 mg/m2 on days 1-3, and nedaplatin 70 mg/m2 on day 1, every 4 weeks. Tumor response, the primary efficacy parameter, was assessed according to unidimensional measurements (Response Evaluation Criteria in Solid Tumors criteria, version 1.0). Secondary efficacy parameters were overall survival (OS) and progression-free survival (PFS). Toxicity was assessed according to the National Cancer Institute Common Toxicity Criteria, version 3.0. A total of 45 patients (13 females and 32 males) with MUC were evaluable for response and toxicity. The overall response rate was 40.0%. Median PFS time was 4.0 months (95% confidence interval [CI], 4.6-11.6). Median OS time was 8.9 months (95% CI, 10.5-18.9). Grade 3 or 4 hematologic adverse events were neutropenia (95.6%), anemia (15.6%), and thrombocytopenia (17.8%). The most common grade 3 or 4 non-hematologic adverse events were anorexia (4.4%) and elevated aspartate transaminase/alanine transaminase (2.2%). No toxic death was observed. The main limitation of this study is that only 10 patients (22.2%) who were previously treated with gemcitabine and cisplatin were included. In conclusion, TIN as second-line treatment for MUC is an active regimen with a manageable toxicity profile.
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Affiliation(s)
- Hiroshi Kitamura
- Department of Urology, School of Medicine, Sapporo Medical University, Sapporo Sapporo Medical University Urologic Oncology Consortium, Sapporo, Japan.
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Kanzaki R, Higashiyama M, Fujiwara A, Tokunaga T, Maeda J, Okami J, Nishimura K, Kodama K. Outcome of surgical resection of pulmonary metastasis from urinary tract transitional cell carcinoma. Interact Cardiovasc Thorac Surg 2010; 11:60-4. [PMID: 20395251 DOI: 10.1510/icvts.2010.236687] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
There is little information on pulmonary metastasectomy of urinary tract transitional cell carcinoma (TCC). In this study, we examined the long-term outcome and the factors associated with long-term survival after pulmonary metastasectomy of urinary tract TCC based on a 20-year single center experience. Between 1984 and 2005, 18 patients (12 men, six women) underwent pulmonary metastasectomy of the urinary tract TCC in our hospital. The clinicopathological and surgical data of these patients obtained from the medical records were analyzed in this retrospective study. The time interval between lung resection and death, or latest follow-up ranged from two to 200 months (median 52). Survival analysis was conducted by the Kaplan-Meier method and log-rank test. The cumulative three- and five-year survival rates were 59.8% and 46.5%, respectively. The number of resected metastatic tumors (solitary vs. multiple) was associated with long-term survival (P<0.05). The five-year survival rate of patients with solitary metastasis was 85.7% while that of patients with multiple metastases was 20.0%. Pulmonary metastasectomy of urinary tract TCC is associated with a favorable outcome, and solitary metastasis is associated with long-term survival. Aggressive management of solitary pulmonary metastasis from a urinary tract TCC is feasible in selected patients.
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Affiliation(s)
- Ryu Kanzaki
- Department of Thoracic Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi, Higashinari-ku, Osaka 537-8511, Japan.
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Abstract
BACKGROUND Recent publications suggest that a subgroup of patients can benefit from surgical removal of transitional cell carcinoma (TCC) metastases in addition to systemic chemotherapy. We report the combined experience and outcome of patients undergoing resection of TCC metastases at 15 uro-oncologic centers in Germany. MATERIALS AND METHODS Forty-four patients with distant metastatic TCC of the bladder or upper urinary tract underwent resection of all detectable metastases in 15 different German uro-oncological centers between 1991 and 2008 in an attempt to be rendered free of disease. RESULTS The resected metastatic sites consisted of retroperitoneal lymph nodes (56.8%), distant lymph nodes (11.3%), lung (18.2%), bone (4.5%), adrenal gland (2.3%), brain (2.3%), small intestine (2.3%), and skin (2.3%). The treatment sequence included systemic chemotherapy in 35/44 (79.5%) patients before and/or after surgery. Median survival times from initial diagnosis of metastatic TCC and subsequent resection were as follows: overall survival, 35 and 27 months, respectively; cancer-specific survival, 38 and 34 months, respectively; and progression-free survival, 19 and 15 months, respectively. Overall 5-year survival from metastasectomy for the entire cohort was 28%. Seventeen patients were still alive without progression at a median follow-up time of 8 months. Seven patients without disease progression survived for more than 2 years and remain free from tumor progression at a median of 63 months. CONCLUSION The results in this selected cohort confirm that long-term cancer control and possibly cure can be achieved in a subgroup of patients following surgical removal of TCC metastases. However, prospective data to identify patients most likely to benefit from this aggressive therapeutic approach are lacking. Therefore, metastasectomy in patients with disseminated TCC remains investigational and should be offered only to those with limited disease as a combined-modality approach with systemic chemotherapy.
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Uro-Onkologie – Update 2009. Urologe A 2009; 48:1056-8. [DOI: 10.1007/s00120-009-2083-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lehmann J, Suttmann H, Albers P, Volkmer B, Gschwend JE, Fechner G, Spahn M, Heidenreich A, Odenthal A, Seif C, Nürnberg N, Wülfing C, Greb C, Kälble T, Grimm MO, Fieseler CF, Krege S, Retz M, Schulte-Baukloh H, Gerber M, Hack M, Kamradt J, Stöckle M. Surgery for Metastatic Urothelial Carcinoma with Curative Intent: The German Experience (AUO AB 30/05). Eur Urol 2009; 55:1293-9. [DOI: 10.1016/j.eururo.2008.11.039] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2008] [Accepted: 11/21/2008] [Indexed: 11/30/2022]
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Abstract
Although surgery has a limited role in the management of metastatic urothelial carcinoma patients, it can be envisaged in association with chemotherapy. In highly symptomatic patients and for complete response patients, cystectomy can be part of a multimodal approach. Metastasis resection can also be proposed in association with chemotherapy in case of complete response. In case of non responsive metastasis, metastasectomy can also de discussed in order to improve quality of life.
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Affiliation(s)
- T Lebret
- Service d'Urologie, Hôpital Foch, Faculté de médecine Paris-Ile-de-France-Ouest, UVSQ, France.
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Pascual Samaniego M, Ruiz Serrano MA, González Núñez MA, Bravo Fernández I, Ramos Martín JA, García González A. [Cutaneous metastases from transitional cell carcinoma of the bladder producing beta-HCG]. Actas Urol Esp 2009; 33:209-13. [PMID: 19418849 DOI: 10.1016/s0210-4806(09)74126-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In spite of the high incidence of transitional cell carcinoma, cutaneous metastases are infrequent, especially when they are the first sign of metastatic spread, with a low survival rate. Thirty five per cent of transitional cell carcinoma of the bladder have ectopic beta- human chorionic gonadotropin (beta-HCG) production. It has been related with high grade tumors, advanced stage, metastatic disease, radioresistent tumors and low survival rate because of its effect as a growth modulator with a probably antagonist action in the apoptotic cascade. We present a thirty six years old woman affected by a transitional cell carcinoma of the bladder producing beta-HCG that showed two cutaneous metastases as first sign of metastatic disease. The exceptional coincidence of these two circumstances announced a very aggressive tumor behaviour and bad prognostic, with a quickly multiple metastatic dissemination including a pericardic metastases.
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Hess J, vom Dorp F, Becker M, Rübben H, Börgermann C. [Impact of surgery for residual tumors after chemotherapy]. Urologe A 2008; 48:73-8. [PMID: 19066839 DOI: 10.1007/s00120-008-1756-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Metastases are a feature not only of local tumor manifestation but also of systemic disease. Thus, the question arises regarding the extent to which local therapy contributes to a systemic state of disease. With renal cell carcinoma, resection of pulmonary metastases is a common operation. Other sites should be considered individually. Only a well-defined subset of patients with metastasized urothelial carcinoma benefit from the resection of their metastases.
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Affiliation(s)
- J Hess
- Klinik und Poliklinik für Urologie, Hufelandstrasse 55, 45122 Essen
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44
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Presentation and management of a patient with subcutaneous metastatic transitional cell carcinoma of the bladder. ACTA ACUST UNITED AC 2008; 5:691-4. [PMID: 19002126 DOI: 10.1038/ncpuro1253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2008] [Accepted: 10/16/2008] [Indexed: 11/09/2022]
Abstract
BACKGROUND A 60-year-old female with a 6-month history of muscle-invasive transitional cell carcinoma of the bladder presented with an enlarging subcutaneous lesion involving her right flank. She had previously undergone radical cystectomy, bilateral pelvic lymphadenectomy and ileal orthotopic neobladder reconstruction. INVESTIGATIONS Axial fused fluorodeoxyglucose PET-CT of the chest, abdomen and pelvis, fine needle aspiration with direct ultrasound guidance, excisional biopsy and immunohistochemistry. DIAGNOSIS Subcutaneous and liver metastases of transitional cell carcinoma. MANAGEMENT Wide local excision of the subcutaneous lesion followed by combination gemcitabine-cisplatin chemotherapy. Gemcitabine was administered at a dose of 1,000 mg/m(2) on days 1, 8, and 15, and cisplatin was administered at a dose of 75 mg/m(2) on day 1; the schedule was repeated every 28 days for three cycles.
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Abstract
Cutaneous metastases are rare and usually signify a poor prognosis. The manifestation of cutaneous metastases is variable; crucial to their diagnosis is their inclusion in the differential diagnosis. The therapy occurs mostly with palliative intention. The quality of life of the patient should take first priority. A combination chemotherapy is usually carried out because of systemic progress. For local tumor control and wound care, metastasis surgery and radiotherapy are used.
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Affiliation(s)
- C Börgermann
- Klinik und Poliklinik für Urologie, Universitätsklinikum, 45122, Hufelandstrasse 55, Essen, Deutschland.
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Rasco DW, Assikis V, Marshall F. Integrating Metastasectomy in the Management of Advanced Urological Malignancies—Where are we in 2005? J Urol 2006; 176:1921-6. [PMID: 17070212 DOI: 10.1016/j.juro.2006.07.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2005] [Indexed: 10/24/2022]
Abstract
PURPOSE In the past patients with metastatic cancer were considered incurable and they were not candidates for surgical management of metastases. However, experience with testicular cancer has shown that metastasectomy can often be the final, critical step in achieving disease-free status. We summarized the most current data on metastasectomy for advanced urological malignancies. MATERIALS AND METHODS We performed an extensive review of the literature from 1990 to the present using MEDLINE. Only original reports were included with an emphasis on specific malignancies and specific sites of metastasis. RESULTS There is increasing evidence that patients with metastatic renal cell carcinoma and bladder carcinoma can be cured by surgical resection of metastases, usually combined with systemic therapy. The ideal patient has responded to systemic therapy and has few metastatic sites. CONCLUSIONS Metastasectomy should frequently be done in patients with advanced testicular cancer and it should increasingly be considered in patients with metastatic renal cell carcinoma or bladder carcinoma. This technique may be used for cure and palliation. Specific patient factors determine the likelihood and degree of potential benefit.
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Affiliation(s)
- Drew W Rasco
- Medicine Department, Emory University Medical School, Atlanta, Georgia 30322, USA
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Calabrò F, Sternberg CN. State-of-the-art management of metastatic disease at initial presentation or recurrence. World J Urol 2006; 24:543-56. [PMID: 17031652 DOI: 10.1007/s00345-006-0115-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Carcinoma of the bladder is the second most prevalent genitourinay malignancy and the fifth most common solid tumor in the USA. On the basis of favorable response rates and survival data, cisplatin-based regimens can be considered the standard treatment for fit patients with metastatic urothelial cancer. Since cisplatin-containing regimens are contraindicated for patients with impaired renal function, gemcitabine plus either paclitaxel or docetaxel may be an effective and well-tolerated treatment option for these patients. Randomized trials are needed to determine the future role of these combinations in the management of advanced transitional cell carcinoma. The optimal regimens for the medically unfit patients and second-line chemotherapy remain undefined. Postchemotherapy surgical resection of residual cancer may result in a disease-free survival in highly selected patients who would otherwise die of the disease. Progresses in the understanding of the molecular biology of bladder cancer and identification of new targeted therapies will undoubtedly provide new opportunities but whether or not this approach to therapy will lead to better results must still be determined.
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Affiliation(s)
- Fabio Calabrò
- Department of Medical Oncology, San Camillo/Forlanini Hospital, Nuovi Padiglioni, 4th Floor, Circonvallazione Gianicolense 87, Rome 00152, Italy
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48
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Abstract
The prognosis for patients with local recurrence following cystectomy for urothelial bladder cancer is poor. Only a small proportion of patients with good performance status are candidates for any form of therapy at all. Clinical experience shows that local recurrence is often accompanied or followed by systemic tumor spread. Therefore, palliative systemic chemotherapy is the cornerstone of treatment. Local radiotherapy or local tumor resection is reserved for subgroups of patients and to ease local symptoms or complications. Only a few patients are candidates for multimodal therapeutic approaches with curative intent. Despite such efforts, the survival of patients with local recurrence is limited in nearly all cases.
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Affiliation(s)
- J Simon
- Klinik für Urologie und Kinderurologie, Urologische Universitätsklinik Ulm.
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49
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Abstract
Detailed data on treating systemic recurrences of urothelial cancer after radical cystectomy and/or radical upper tract surgery are sparse. This review describes the data available from two large clinical phase III trials, one on systemic chemotherapy for metastatic/inoperable urothelial cancer and the other on adjuvant systemic chemotherapy after radical cystectomy for locally advanced bladder cancer. In addition, an overview of contemporary series on metastasectomy for urothelial cancer with palliative as well as curative intent is presented. The impact of therapeutic options for the treatment of systemic urothelial cancer recurrences such as radiotherapy, surgery or systemic first and second line therapy represented by conventional chemotherapy and contemporary target therapy are discussed.
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Affiliation(s)
- J Lehmann
- Klinik für Urologie und Kinderurologie, Universitätsklinikum des Saarlandes, Homburg/Saar.
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May M, Helke C, Nitzke T, Vogler H, Hoschke B. Survival rates after radical cystectomy according to tumor stage of bladder carcinoma at first presentation. Urol Int 2004; 72:103-11. [PMID: 14963349 DOI: 10.1159/000075962] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2003] [Accepted: 11/11/2003] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The aim of this study was to establish to what extent the survival rates of muscle-invasive bladder carcinoma are influenced by the tumor stage at initial presentation. PATIENTS AND METHODS This study examined the clinical course of 230 patients who underwent radical cystectomy for bladder carcinoma from 1992 to 2002. The patients were divided into three groups according to the histological results of the initial and final transurethral tumor resection (TURB). In group 1 (n = 41) radical cystectomy was carried out for a superficial bladder carcinoma which had a high likelihood of progressing. Group 2 (n = 57) consisted of patients who displayed a superficial tumor stage when they first presented and developed progressive muscle-invasive bladder carcinoma under conservative treatment. Group 3 (n = 132) was made up of patients who were already at the muscle-invasive tumor stage in the course of primary TURB. The histopathological characteristics of all transurethral tumor resections and radical cystectomy were recorded. Progression-free survival and overall survival in the three groups were then compared. RESULTS The average patient age when cystectomy was carried out was 63.9 (35-80) years and the average follow-up period was 38 months. An average of 2.3 (1-16) transurethral tumor resections were carried out before radical cystectomy (median = 1). Progression-free survival and overall survival of all 230 patients was 54 and 50%, respectively, after 5 years. The best result was a 74% progression-free 5-year survival rate with organ-confined lymph node-negative tumors (n = 106) which was statistically significant (p = 0.0004) compared to the progression-free 5-year survival rate of 50% for non-organ-confined, lymph node-negative tumors (n = 64). Lymph node-positive patients achieved a progression-free survival rate of 21% after 5 years regardless of the tumor infiltration. Patients in group 1 achieved a progression-free 5-year survival rate of 77% and an overall survival rate of 63% after 5 years. In group 2 patients achieved a progression-free survival rate of 51% after 5 years and an overall survival rate of 50%. In the case of primary muscle invasion (group 3), progression-free survival and overall survival were 49 and 46%, respectively, after 5 years. There was no significant difference between groups 2 and 3 with regard to their progression-free or overall survival rates (p > 0.35). However, both groups displayed a significantly poorer progression-free and overall survival rate compared with group 1 (p < 0.01). CONCLUSION Our results show that superficial bladder carcinoma with tumor progress to muscle invasion does not have a better prognosis after radical cystectomy than initial muscle-invasive bladder carcinoma. Survival rates in this group can only be improved by singling out patients on the basis of risk factors at an earlier stage and carrying out a cystectomy.
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Affiliation(s)
- Matthias May
- Urology Clinic, Carl-Thiem Hospital, Cottbus, University Teaching Hospital Charité zu Berlin, Thiemstrasse, Cottbus, Germany.
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