FOLLOW-UP AFTER CYSTECTOMY FOR CARCINOMA OF THE BLADDER

Muscle invasive bladder cancer: from diagnosis to survivorship

Bladder cancer is the fifth most commonly diagnosed cancer and the most expensive adult cancer in average healthcare costs incurred per patient in the USA. However, little is known about factors influencing patients' treatment decisions, quality of life, and responses to treatment impairments. The main focus of this paper is to better understand the impact of muscle invasive bladder cancer on patient quality of life and its added implications for primary caregivers and healthcare providers. In this paper, we discuss treatment options, side effects, and challenges that patients and family caregivers face in different phases along the disease trajectory and further identify crucial areas of needed research.

Surveillance guidelines based on recurrence patterns after radical cystectomy for bladder cancer: the Canadian Bladder Cancer Network experience

Study Type - Prognosis (cohort) Level of Evidence 2a. What's known on the subject? and What does the study add? Radical cystectomy with pelvic lymph node dissection is recognized as the standard of care for carcinoma invading bladder muscle and for refractory non-muscle-invasive bladder cancer. Owing to high recurrence and progression rates, a two-pronged strict surveillance regimen, consisting of both functional and oncological follow-up, has been advocated. It is also well recognized that more aggressive tumours with extravesical disease and node-positive disease recur more frequently and have worse outcomes. This study adds to the scant body of literature available regarding surveillance strategies after radical cystectomy for bladder cancer. In the absence of any solid evidence supporting the role of strict surveillance regimens, this extensive examination of recurrence patterns in a large multi-institutional project lends further support to the continued use of risk-stratified follow-up and emphasizes the need for earlier strict surveillance in patients with extravesical and node-positive disease.

OBJECTIVES

• To review our data on recurrence patterns after radical cystectomy (RC) for bladder cancer (BC). • To establish appropriate surveillance protocols.

PATIENTS AND METHODS

• We collected and pooled data from a database of 2287 patients who had undergone RC for BC between 1998 and 2008 in eight different Canadian academic centres. • Of the 2287 patients, 1890 had complete recurrence information and form the basis of the present study.

RESULTS

• A total of 825 patients (43.6%) developed recurrence. • According to location, 48.6% of recurrent tumours were distant, 25.2% pelvic, 14.5% retroperitoneal and 11.8% to multiple regions such as pelvic and retroperitoneal or pelvic and distant. • The median (range) time to recurrence for the entire population was 10.1 (1-192) months with 90 and 97% of all recurrences within 2 and 5 years of RC, respectively. • According to stage, pTxN+ tumours were more likely to recur than ≥pT3N0 tumours and ≤pT2N0 tumours (5-yr RFS 25% vs. 44% vs. 66% respectively, P < 0.001). Similarly, pTxN+ tumours had a shorter median time to recurrence (9 months, range 1-72 months) than ≥pT3N0 tumours (10 months, range 1-70 months) or ≤pT2N0 tumours (14 months, range 1-192 months, P < 0.001).

CONCLUSIONS

• Differences in recurrence patterns after RC suggest the need for varied follow-up protocols for each group. • We propose a stage-based protocol for surveillance of patients with BC treated with RC that captures most recurrences while limiting over-investigation.

Multifactorial, site-specific recurrence model after radical cystectomy for urothelial carcinoma

BACKGROUND

A scoring algorithm of site-specific disease recurrence after cystectomy for urothelial carcinoma was designed.

METHODS

Identified were 1388 patients who underwent radical cystectomy for nonmetastatic urothelial carcinoma between 1980 and 1998. Clinical, surgical, and pathologic features were evaluated for associations with 4 locations of site-specific disease recurrence: upper urinary tract, abdomen/pelvis, thoracic region, and bone. Recurrence-free survival rates were estimated using the Kaplan-Meier method. Cox proportional hazards models were fit to test associations with disease recurrence.

RESULTS

A total of 493 (35.5%) patients experienced at least 1 recurrence. There were 67, 388, 143, and 145 patients with recurrences to the upper tract, abdomen/pelvis, thoracic region, and bone at a median of 3.1 years, 1.1 years, 1.3 years, and 1.0 years, respectively. Pathologic T4 stage (hazard ratio [HR], 2.84; P=.006), positive ureteral margins (HR, 5.71; P<.001), and multifocality (HR, 2.07; P=.009) were found to be independent predictors of upper tract recurrence. Pathologic T3 (HR, 2.30; P<.001) and T4 stage (HR, 3.55; P<.001), lymph node invasion (HR, 1.97; P<.001), extent of lymphadenectomy (pNx [HR, 1.66; P=.002] and <10 lymph nodes [HR, 1.52; P<.001]), multifocality (HR, 1.80; P<.001), and prostatic involvement (HR, 1.45; P=.019) were found to be independent predictors of abdominal/pelvic recurrence. Features independently associated with thoracic recurrence included pathologic T3 (HR, 2.61; P<.001) and T4 (HR, 3.39; P<.001), lymph node invasion (HR, 2.64; P<.001), extent of lymphadenectomy (pNx [HR, 1.89; P=.019] and <10 lymph nodes [HR, 1.58; P<.030]), and multifocality (HR, 1.79; P<.001). Pathologic T3 (HR, 3.45; P<.001) and T4 stage (HR, 3.87; P<.001), lymph node invasion (HR, 1.79; P=.006), occupational exposure to radiation (HR, 2.97; P=.003), and a positive urethral margin (HR, 2.28; P=.039) were found to be independent predictors of osseous recurrence. Macroscopic hematuria (HR, 0.52; P=.009) and obesity (HR, 0.59; P=.027) were found to be protective and negatively associated with upper tract and osseous recurrence, respectively. Scoring algorithms to predict the likelihood of disease recurrence to these sites were developed using regression coefficients from the multivariable models.

CONCLUSIONS

Scoring algorithms based on independent predictors of site-specific recurrence were presented. These models may be used to tailor postoperative surveillance to the individual patient based upon clinicopathologic features at the time of cystectomy.

Oncological followup after radical cystectomy for bladder cancer-is there any benefit?

PURPOSE

Tumor recurrence after radical cystectomy for bladder cancer can be detected in an asymptomatic patient by regular followup or in a symptomatic patient by symptom guided examination. To our knowledge it is still unknown whether detecting tumor recurrence at an asymptomatic stage offers a better survival rate.

MATERIALS AND METHODS

A total of 1,270 radical cystectomies for bladder cancer were performed at a single institution between January 1, 1986 and December 2006. All patients had regular followup examinations with chest x-ray and abdominal ultrasound every 3 months, computerized tomography of the abdomen every 6 months, and bone scan and excretory urography every 12 months. Additional examinations were required for symptomatic disease. We analyzed the first site and date of tumor recurrence. Survival was compared using the log rank test.

RESULTS

The 20-year recurrence rate was 48.6% in the complete series. Tumor recurrence developed in 444 patients, including 154 asymptomatic and 290 symptomatic patients, with a mean time after radical cystectomy of 20 and 17.5 months, respectively. The most frequent symptoms were pain, ileus, acute urinary retention, hydronephrosis with flank pain, hematuria, neurological symptoms and a palpable mass. Of the 444 patients 182 (41%) had local recurrence and 324 (73%) had distant failure at the time of first recurrence. The overall survival rate 1, 2 and 5 years after first recurrence was 22.5%, 10.1% and 5.5% in asymptomatic patients, and 18.9%, 8.2% and 2.9% in symptomatic patients, respectively (log rank not significant).

CONCLUSIONS

This study fails to demonstrate a survival benefit for detecting tumor recurrence early at an asymptomatic stage by regular followup examinations. These data show that symptom guided followup examinations may provide similar results at lower cost.

Risk of Cancer of the Prostate and of the Kidney Parenchyma following Bladder Cancer

Aims and Background

A registry-based cohort study of male patients with bladder cancer was conducted to determine the relative risk of second primary cancer of the prostate and kidney, the uni-/multivariate differences in relative risk according to patient characteristics, the cumulative risk by duration of the follow-up, and the prevalence:incidence ratio of prostate and kidney cancer cases detected in the first 6 months after the diagnosis of bladder cancer.

Methods

The complete case records of all male patients (n = 2025) diagnosed with bladder cancer between 1986 and 2002 were extracted from the database of the Romagna Cancer Registry: 1539 patients were eligible for analysis of the incidence of following prostate and kidney cancers, of the relative risk and the standardized incidence ratio specific for the time interval of follow-up.

Results

A total of 108 prostate cancer cases and 23 kidney cancer cases were observed during the follow-up. The relative risk of second primary cancer of the prostate and kidney was respectively 3.52 (95% CI, 2.89-4.25) and 3.90 (95% CI, 2.475.85). The absolute excess risk was 11.8 × 1000 for prostate cancer and 2.5 × 1000 for kidney cancer. The number of prevalent cases of prostate and kidney cancer detected was approximately 10 times greater than the expected number based on incidence rates from the general population. During the follow-up, incidence of prostate cancer stabilized at a level that was 3- to 4-fold greater than that expected. Despite fluctuations, a decrease was also observed for incidence of kidney cancer.

Conclusions

In summary, our study showed the relatively constant high incidence of prostate and kidney cancers in bladder cancer patients over time. The possibility of subsequent cancer implies that an appropriate long surveillance is required. The pertinence depends on the duration of the follow- up as well as the degree of surveillance.

Urinary Diversion

A consensus conference convened by the World Health Organization (WHO) and the Société Internationale d'Urologie (SIU) met to critically review reports of urinary diversion. The world literature on urinary diversion was identified through a Medline search. Evidence-based recommendations for urinary diversion were prepared with reference to a 4-point scale. Many level 3 and 4 citations, but very few level 2 and no level 1, were noted. This outcome supported the clinical practice pattern. Findings of >300 reviewed citations are summarized. Published reports on urinary diversion rely heavily on expert opinion and single-institution retrospective case series: (1) The frequency distribution of urinary diversions performed by the authors of this report in >7000 patients with cystectomy reflects the current status of urinary diversion after cystectomy for bladder cancer: neobladder, 47%; conduit, 33%; anal diversion, 10%; continent cutaneous diversion, 8%; incontinent cutaneous diversion, 2%; and others, 0.1%. (2) No randomized controlled studies have investigated quality of life (QOL) after radical cystectomy. Such studies are desirable but are probably difficult to conduct. Published evidence does not support an advantage of one type of reconstruction over the others with regard to QOL. An important proposed reason for this is that patients are subjected preoperatively to method-to-patient matching, and thus are prepared for disadvantages associated with different methods. (3) Simple end-to-side, freely refluxing ureterointestinal anastomosis to an afferent limb of a low-pressure orthotopic reconstruction, in combination with regular voiding and close follow-up, is the procedure that results in the lowest overall complication rate. The potential benefit of "conventional" antireflux procedures in combination with orthotopic reconstruction seems outweighed by the higher complication and reoperation rates. The need to prevent reflux in a continent cutaneous reservoir is not significantly debated, and this should be done. (4) Most reconstructive surgeons have abandoned the continent Kock ileal reservoir largely because of the significant complication rate associated with the intussuscepted nipple valve.

Tumores de vejiga pT0 tras cistectomía radical: análisis de nuestra serie

OBJECTIVES

To evaluate the data of progression and survival in 43 patients who underwent cystectomy with stage pT0 according to classification TNM-2002.

MATERIALS AND METHODS

between 1988 and 2003 in our center had realized 420 cystectomies, 43 patients (10.2%) had not tumor in the cystectomy specimen.

RESULTS

In these 43 cases the initial clinical stage (in the transuretral resection of bladder) was T1 in 10 cases (23,3 %), T2 in 31 cases (72%) and T3 in 2 cases. As far as the degree 24 patients presented G2 (55.8%) and 19 (44.2%) were G3. Median time from the transuretral resection to the cistectomy was of 44 days at a median follow-up of 89.3 months. Progression-free survival in the 43 patients was of 180,6 months, but during the follow-up it appeared progression in 7 patients, with disease free survival at 36 months (3-126), since the date of the cistectomia. During the follow up, 5 patients died. When we analyzed the cancer-specific survival according to tumor stage, for the T2 with an average cancer-specific survival is of 180 months, decreasing to 35 months considerably for T3. Similar it happens with the degree of differentiation, significantly diminishing as it advances the degree, with an average of cancer-specific survival for the G3 at 122.6 months. In the same way it happens with pathological positive lymph nodes in the radical cistectomy, with a cancer-specific survival of 188 months when it is N0 and of 54 months if the adenopathy was positive (N+).

CONCLUSION

In our experiencie urothelial carcinoma pT0 present a prolonged free period of disease (medium of 180 months). The associated factors of risk to a smaller free period of disease are high degree of differentiation (G3, 116 months), the infiltration of deep layers in the transuretral resection (T3, 32 months) and the ganglionary affectation (pN+ 45 months).

CT urography of urinary diversions with enhanced CT digital radiography: preliminary experience

OBJECTIVE

The purpose of this study was to determine if 3D-rendered CT urography (CTU) depicts both normal and abnormal findings in patients with urinary diversions and if the addition of contrast-enhanced CT digital radiography (CTDR) improves opacification of the urinary collecting system.

MATERIALS AND METHODS

Thirty CTU and contrast-enhanced CTDR examinations were performed in 24 patients who underwent cystectomy for bladder cancer. Indications for evaluation included hematuria, tumor surveillance, or suspected diversion malfunction. All examinations were evaluated without knowledge of the stage or grade of a patient's tumor and were compared with the clinical records. Opacification of the urinary collecting system was evaluated with 3D CTU alone, contrast-enhanced CTDR alone, and combined CTU and CTDR.

RESULTS

Nine abnormalities were identified including distal ureteral strictures (n = 4), vascular compression of the mid left ureter (n = 1), scarring of the mid right pole infundibulum (n = 1), bilateral hydronephrosis and hydroureter (n = 1), urinary reservoir calculus (n = 1), and tumor recurrence invading the afferent limb of the neobladder (n = 1). Eight of the nine detected abnormalities were surgically or pathologically confirmed. All abnormalities were identified on all three imaging techniques but were best seen on 3D CTU and enhanced CTDR images. Incomplete opacification of the urinary collecting system occurred in 17 patients with CTU alone, 12 patients with contrast-enhanced CTDR alone, and nine patients with combined CTU and contrast-enhanced CTDR. Compared with CTU alone, the combined technique of 3D CTU and contrast-enhanced CTDR improved opacification by a statistically significant difference (p = 0.037).

CONCLUSION

CTU with 3D rendering can accurately depict both normal and abnormal postoperative findings in patients with urinary diversions. Adding enhanced CTDR can improve visualization of the urinary collecting system.

Imaging of the Various Continent Urinary Diversions After Cystectomy

Continent urinary diversions have recently become the preferred procedures rather than performing an ileal conduit. Intravenous urography, pouchography, and computed tomography scans are frequently used for postoperative evaluation of patients with bladder carcinoma. During postoperative follow-up imaging studies, the radiologist must keep these 4 facets in mind as his primary focus: 1) the detection of newly developed urothelial tumors, 2) the detection of metastasis, 3) the detection of postoperative complications, and 4) the monitoring of upper urinary tract distention. Various surgical techniques that are used in continent diversions alter the normal anatomy and make the imaging interpretation difficult. An accurate interpretation can be made only if radiologists become familiar with the various surgical procedures and the appearances of various postoperative anatomic changes.

Follow-up strategies and management of recurrence in urologic oncology bladder cancer:

A surveillance program following cystectomy should consider a patient's individual risk for the development of local and distant recurrences and any specific needs related to the urinary tract reconstruction performed (Table 1). Well-documented recurrence patterns following cystectomy are available from many large surgical series and provide the background information needed for tailoring follow-up based on pathologic criteria. Economic issues also must be considered, given that the health care-related expenses of treating and following patients with bladder cancer is twice as much as that expended for the treatment of prostate cancer. Because of the ever-increasing fiscal constraints placed on clinicians, risk-adjusted follow-up strategies are reasonable, but will require prospective evaluation to validate their appropriateness.

Follow-up surveillance strategies for genitourinary malignancies

BACKGROUND

Genitourinary cancers account for more than 20% of all malignancies in the United States. These cancers do not usually yield rapid mortality, thereby necessitating longer-term surveillance strategies.

METHODS

A review and analysis of relevant studies were performed. Follow-up strategies are proposed to reflect effective methods to detect recurrent prostate, bladder, renal, and testicular cancers. Cost analysis was performed using Medicare reimbursement rates.

RESULTS

For genitourinary tumors, follow-up tests can be planned rationally based on detection rates and patterns. Tumor grade and stage drive follow-up strategies, along with therapeutic implications of detecting a recurrence. Symptomatic recurrences often obviate the need for radiographic tests and can minimize costs. Stage- specific plans for these four urologic malignancies are outlined specifically.

CONCLUSIONS

Not all surveillance approaches have been critically tested for follow-up of genitourinary tumors, but ample data are available to propose sound medical and economic strategies.

Stage specific follow-up strategy after cystectomy for carcinoma of the bladder

BACKGROUND

Follow-up strategies after cystectomy for carcinoma of the bladder should be determined according to the risk of recurrence, which is stage dependent. We aimed to develop follow-up protocol for monitoring patients with carcinoma of the bladder for tumor recurrence and diverted urinary tract complications after radical cystectomy.

METHODS

The records of 351 patients with carcinoma of the bladder who underwent cystectomy between 1979 and 1999 were reviewed for dates and presenting symptoms of local and distant recurrences. The results of imaging studies and blood tests were also reviewed. Based on the division of patients into pathological stages of pT1 and lower, pT2, and pT3 and higher groups, we proposed a new follow-up schedule for carcinoma of the bladder.

RESULTS

The risk of metastasis was related to the pathological stage of the primary tumor. Recurrence developed in 10 of 124 patients (8%) with pT1 or lower, 17 of 101 patients (17%) with pT2, and 55 of 101 patients (54%) with pT3 or higher disease at a median of 11 (range 6-186), 10 (1-40) and 7 (1-76) months, respectively. Recurrences in patients with pT3 or higher were found earlier and more frequently than those with pT2 or lower. Of 82 patients with metastases, 54 initially were symptomatic, and three of pT1 or lower, six of pT2, and 19 of pT3 or higher were asymptomatic. Based on these results we proposed a stage specific follow-up protocol.

CONCLUSIONS

A stage-driven follow-up strategy for monitoring patients after radical cystectomy can reduce medical expenses while efficiently detecting recurrences and complications.

Bladder cancer

Bladder cancer is the second most frequent tumour of the urogenital tract. Tobacco smoke has been shown to increase the risk of bladder cancer two- to fivefold as well as the exposure to metabolites of aniline dyes and other aromatic amines. Seventy-five per cent of bladder cancers are superficial at initial presentation, limited to the mucosa, submucosa, or lamina propria. Recurrence rates after initial treatment are 50-80%, with progression to muscle-invading tumour in 10-25%. In muscle-invading bladder cancers, there is a 50% risk of distant metastases. Surgery is the mainstay of standard treatment both in the form of transurethral endoscopic resection, mainly for superficial disease, and in the form of open ablative surgery with urinary diversion for muscle invasive disease. Endovesical administration of BCG has been employed after endoscopic resection as the most effective agent for both prophylaxis of disease recurrence and progression from superficial to invasive disease. The accepted treatment for muscle infiltrative disease is radical cystectomy. Response rates to combination chemotherapy regimens of up to 70% in patients with advanced metastatic disease have led to an investigation of its use for locally invasive disease in combination with conventional modalities of treatment.

Radiology of urinary diversions

Radiologic evaluation of urinary diversion has three objectives: to monitor upper tract distention, to detect new urothelial tumors and to detect metastasis. The type of imaging procedure and the frequency of imaging is dictated by the urologist preference. As many surgical procedures are available for noncontinent and continent diversion, interpretation of radiographic studies requires a detailed knowledge of the type of surgical procedure that has been performed.

[Follow up of patients with bladder cancer treated with radical cystectomy]

Radical cystectomy provides excellent local control of the disease in cancer patients, although specific 5-year mortality is about 50%. Additionally, nearly half the patients show complications after surgery usually due to urinary by-pass. Patients should undergo periodical monitoring for life. For rescue treatment to be as effective as possible, follow-up schemes should allow for early detection of relapsing-recurrent tumours, metastasis and complications. Knowledge of the "natural evolution" in these patients allows to optimise the frequency of visits and complementary examinations based on each patient's risk at specific time-points. Cost-efficacy relationship will also be optimised. We analyze here the current literature and our own experience of what we know as "natural evolution" of these patients and propose a follow-up scheme for patients with cancer of the bladder treated with radical cystectomy and urinary by-pass.

A stage specific approach to tumor surveillance after radical cystectomy for transitional cell carcinoma of the bladder

PURPOSE

Surveillance protocols after radical surgery for genitourinary tumors typically do not consider that the risk of recurrence is stage dependent. We describe the development of a stage specific protocol for monitoring patients with transitional cell carcinoma for tumor recurrence and conduit complications after radical cystectomy.

MATERIALS AND METHODS

The records of 382 patients with transitional cell carcinoma who underwent cystectomy in 1986 to 1994 were reviewed for the dates and presenting symptoms of local and distant recurrences, and the results of radiological imaging studies and liver function tests. Based on the division of patients into pathological stages of pT1, pT2 and pT3 groups, we developed a new transitional cell carcinoma surveillance protocol.

RESULTS

Of 97 patients with transitional cell carcinoma metastases 72 (74%) were asymptomatic, including 43 with metastases detected by routine chest x-rays (30) or blood tests (13). Surveillance computerized tomography identified isolated asymptomatic intra-abdominal metastases in 10 patients (10%), of whom 90% had pT3 disease. Based on these results we recommend a stage specific surveillance protocol for pT1--annual history, physical examination, chest x-ray and laboratory studies, pT2-same studies at 6, 12, 18, 24, 30, 36, 48 and 60 months after cystectomy, and pT3-same studies at 3, 6, 12, 18, 24, 30, 36, 48 and 60 months plus computerized tomography at 6, 12 and 24 months after cystectomy. A radiographic study of the upper tract should be performed in all patients every 1 to 2 years to evaluate for recurrences and complications of the ileoureteral anastomosis.

CONCLUSIONS

A stage driven surveillance strategy for monitoring patients after radical cystectomy can reduce costly imaging studies while efficiently detecting recurrences and complications.