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Fujiwara M, Tanaka H, Kobayashi M, Nakamura Y, Fan B, Ishikawa Y, Fukuda S, Toda K, Yoshida S, Yokoyama M, Yoshimura R, Fujii Y. Neoadjuvant Chemoradiotherapy Followed by Radical Cystectomy for Muscle-Invasive Bladder Cancer: Analysis of Efficacy and Safety in 119 Patients. Clin Genitourin Cancer 2024; 22:193-200.e1. [PMID: 38000954 DOI: 10.1016/j.clgc.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 10/22/2023] [Accepted: 10/29/2023] [Indexed: 11/26/2023]
Abstract
INTRODUCTION Cisplatin-based systemic chemotherapy is recommended as neoadjuvant treatment for muscle-invasive bladder cancer (MIBC) before radical cystectomy (RC). However, clinical challenges include the possibility of primary chemoresistance and limited feasibility in patients with renal impairment. This study investigated the efficacy and safety profiles of neoadjuvant chemoradiotherapy (NCRT) followed by RC. MATERIALS AND METHODS We retrospectively analyzed 119 patients with nonmetastatic MIBC, who were pathologically diagnosed with urothelial carcinoma and underwent NCRT before RC. The pathological response to NCRT was evaluated using RC specimens. Recurrence-free survival (RFS) and cancer-specific survival (CSS) were compared according to pathological responses to NCRT. RESULTS Of the 119 patients, 111 (93%) underwent RC; ypT0 and downstaging to ≤ypT1 were observed in 42 (38%) and 76 (68%) patients, respectively. In the multivariable analysis, smaller tumor size was independently associated with ypT0. During a median follow-up of 5.2 years, 28 (25%) patients developed recurrence and 22 (20%) died of bladder cancer after RC. The 5-year RFS and CSS rates were 75% and 80%, respectively. The 5-year RFS rates in patients with ypT0, ypTa/is/1, and ≥ypT2 were 87%, 87%, and 46%, respectively. Similarly, patients with ypT0 and ypTa/is/1 had more favorable CSS (90% and 87% at 5 years, respectively) than those with ≥ypT2 (60%, P = .001). None of the patients experienced ≥grade 4 adverse events related to NCRT or ≥grade 4 complications of RC. CONCLUSIONS This study demonstrated sufficient efficacy and safety profile of NCRT followed by RC. Chemoradiotherapy may be a helpful alternative for neoadjuvant treatment before RC.
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Affiliation(s)
- Motohiro Fujiwara
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hajime Tanaka
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Masaki Kobayashi
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuki Nakamura
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Bo Fan
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yudai Ishikawa
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shohei Fukuda
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazuma Toda
- Department of Radiation Oncology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Soichiro Yoshida
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Minato Yokoyama
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ryoichi Yoshimura
- Department of Radiation Oncology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yasuhisa Fujii
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
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Koga F. Selective multimodal bladder-sparing therapy for muscle-invasive bladder cancer: the present and the future. Expert Rev Anticancer Ther 2023; 23:1127-1139. [PMID: 37753554 DOI: 10.1080/14737140.2023.2257389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/06/2023] [Indexed: 09/28/2023]
Abstract
INTRODUCTION Despite the lack of level 1 evidence, selective bladder-sparing therapy using trimodal therapy is currently recommended by guidelines as a standard of care in patients with non-metastatic, muscle-invasive bladder cancer who are eligible for the treatment. AREAS COVERED This article reviews major studies of selective, bladder-sparing therapy utilizing multiple modalities for muscle-invasive bladder cancer and those comparing the oncological outcomes between bladder-sparing therapy and radical cystectomy. Also discussed are predictive biomarkers potentially capable of guiding treatment decisions by patients with muscle-invasive bladder cancer and a novel strategy for boosting the antitumor immune response in bladder-sparing therapy. PubMed databases were searched for records of 30 June 2023 or earlier. EXPERT OPINION Selective, bladder-sparing therapy appears to be underutilized at present. To promote its use, measures should be taken to facilitate the referral of eligible patients to specialist centers and broaden the number of facilities providing the therapy. Recent studies have suggested a prognostic benefit of radiotherapy for the primary lesion in patients with metastatic bladder cancer. Given that irradiation can induce the abscopal effect, particularly in combination with immune checkpoint inhibitors, demand for bladder-sparing therapies may increase in the context of treatments for metastases.
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Affiliation(s)
- Fumitaka Koga
- Department of Urology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Bunkyo-ku, Tokyo, Japan
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3
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Approaches to Clinical Complete Response after Neoadjuvant Chemotherapy in Muscle-Invasive Bladder Cancer: Possibilities and Limitations. Cancers (Basel) 2023; 15:cancers15041323. [PMID: 36831665 PMCID: PMC9953905 DOI: 10.3390/cancers15041323] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/14/2023] [Accepted: 02/18/2023] [Indexed: 02/22/2023] Open
Abstract
In the surgical oncology field, the change from a past radical surgery to an organ preserving surgery is a big trend. In muscle-invasive bladder cancer treatment, neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC) is the standard of care for muscle-invasive bladder cancer (MIBC) patients eligible for cisplatin. There is a growing interest in bladder preserving strategies after NAC because good oncologic outcome has been reported for pathologic complete response (pCR) patients after NAC, and many studies have continued to discuss whether bladder preservation treatment is possible for these patients. However, in actual clinical practice, decision-making should be determined according to clinical staging and there is a gap that cannot be ignored between clinical complete response (cCR) and pCR. Currently, there is a lack in a uniform approach to post-NAC restaging of MIBC and a standardized cCR definition. In this review, we clarify the gap between cCR and pCR at the current situation and focus on emerging strategies in bladder preservation in selected patients with MIBC who achieve cCR following NAC.
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Ito Y, Yamamoto T, Miyai K, Take J, Scherthan H, Rommel A, Eder S, Steinestel K, Rump A, Port M, Shinomiya N, Kinoshita M. Ascorbic acid-2 glucoside mitigates intestinal damage during pelvic radiotherapy in a rat bladder tumor model. Int J Radiat Biol 2021; 98:942-957. [PMID: 34871138 DOI: 10.1080/09553002.2021.2009145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Ascorbic acid is a strong antioxidant and has potent radioprotective effects on radiation injuries. Ascorbic acid 2-glucoside (AA2G) is a stabilized derivative of ascorbic acid and rapidly hydrolyzed into ascorbic acid and glucose. Since there is the possibility that AA2G treatment interferes with the antitumor activity of radiotherapy, we investigated the effect of AA2G treatment during radiotherapy on acute radiation enteritis and antitumor activity of radiotherapy in rats. MATERIALS AND METHODS AY-27 rat bladder tumor cells were used to induce bladder tumors in rats. Two weeks after inoculation rats received fractionated pelvic radiotherapy in eight fractions for 4 weeks totaling 40 Gy. During radiotherapy, one group of rats received per os AA2G (ascorbic acid: 250 mg/kg/day) and its bolus engulfment (ascorbic acid: 250 mg/kg) 8 h before each X-irradiation fraction. Seven days after the last X-irradiation, we studied histology, DNA double strand break (DSB) damage (by 53BP1 foci staining), and the M1/M2 macrophage response by immunohistochemistry of paraffin-fixed bladder and intestinal tissues. RESULTS AA2G treatment reduced the intestinal damage (shortening of villi) but did not reduce antitumor effectiveness of radiotherapy against bladder tumors. Like the controls, AA2G-treated rats showed no residual tumor lesions in the bladder after X-irradiation. Both AA2G-treated and control groups showed similar persistent DSB damage (53BP1 foci) both in bladders and ilea seven days after radiotherapy. Radiotherapy tended to reduce CD163+ M2 macrophages, which are considered as an anti-inflammatory subtype favoring tissue repair, in the bladders. X-irradiation also reduced the occurrence of M2 macrophages in the ilea. AA2G treatment significantly increased CD163+/CD68+ macrophage ratio in the ilea of rats after pelvic irradiation in comparison to the sham irradiated control rats. AA2G treatment increased, albeit not significantly, the CD163+/CD68+ macrophage ratio in the irradiated bladders relative to the control irradiated rats. On the other hand, bladders and ilea of the irradiated rats with and without AA2G treatment showed similar frequencies of CD68+ macrophages. CONCLUSIONS AA2G treatment mitigated radiation-induced intestinal damage without reducing antitumor activity after fractionated pelvic radiotherapy against bladder tumors in rats. The beneficial effect of AA2G treatment seems to promote a restoration of the M2 answer as well as tissue remodeling and wound healing. Similar residual DNA damage in bladders and ilea seven days post-irradiation is consistent with tumor control in both groups.
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Affiliation(s)
- Yasutoshi Ito
- Military Medicine Research Unit, Test and Evaluation Command, Ground Self-Defense Force, Setagaya, Japan
| | - Tetsuo Yamamoto
- Military Medicine Research Unit, Test and Evaluation Command, Ground Self-Defense Force, Setagaya, Japan.,NBC Counter Medical Unit, Ground Self-Defense Force, Setagaya, Japan
| | - Kosuke Miyai
- Military Medicine Research Unit, Test and Evaluation Command, Ground Self-Defense Force, Setagaya, Japan.,Department of Pathology, Self-Defense Forces Central Hospital, Setagaya, Japan
| | - Junya Take
- Department of Pediatrics, National Defense Medical College, Tokorozawa, Japan
| | | | - Anna Rommel
- Bundeswehr Institute of Radiobiology, Munich, Germany
| | - Stefan Eder
- Bundeswehr Institute of Radiobiology, Munich, Germany
| | | | - Alexis Rump
- Bundeswehr Institute of Radiobiology, Munich, Germany
| | - Matthias Port
- Bundeswehr Institute of Radiobiology, Munich, Germany
| | | | - Manabu Kinoshita
- Department of Immunology and Microbiology, National Defense Medical College, Tokorozawa, Japan
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Sargos P, Supiot S, Créhange G, Fromont-Hankard G, Barret E, Beauval JB, Brureau L, Dariane C, Fiard G, Gauthé M, Mathieu R, Roubaud G, Ruffion A, Renard-Penna R, Neuzillet Y, Rouprêt M, Ploussard G. Oncologic Impact and Safety of Pre-Operative Radiotherapy in Localized Prostate and Bladder Cancer: A Comprehensive Review from the Cancerology Committee of the Association Française d'Urologie. Cancers (Basel) 2021; 13:6070. [PMID: 34885179 PMCID: PMC8656987 DOI: 10.3390/cancers13236070] [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: 11/02/2021] [Revised: 11/26/2021] [Accepted: 11/28/2021] [Indexed: 11/23/2022] Open
Abstract
Preoperative radiotherapy (RT) is commonly used for the treatment of various malignancies, including sarcomas, rectal, and gynaecological cancers, but it is preferentially used as a competitive treatment to radical surgery in uro-oncology or as a salvage procedure in cases of local recurrence. Nevertheless, preoperative RT represents an attractive strategy to prevent from intraoperative tumor seeding in the operative field, to sterilize microscopic extension outside the organ, and to enhance the pathological and/or imaging tumor response rate. Several clinical works support this research field in uro-oncology. In this review article, we summarized the oncologic impact and safety of preoperative RT in localized prostate and muscle-invasive bladder cancer. Preliminary studies suggest that both modalities can be complementary as initial primary tumor treatments and that a pre-operative radiotherapy strategy could be beneficial in a well-defined population of patients who are at a very high-risk of local relapse. Future prospective trials are warranted to evaluate the oncologic benefit of such a combination of local treatments in addition to new life-prolonging systemic therapies, such as immunotherapy, and new generation hormone therapies. Moreover, the safety and the feasibility of salvage surgical procedures due to non-response or local recurrence after pelvic RT remain poorly evaluated in that context.
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Affiliation(s)
- Paul Sargos
- Department of Radiotherapy, Institut Bergonié, 33000 Bordeaux, France;
| | - Stéphane Supiot
- Department of Radiotherapy, Insitut de Cancérologie de l’Ouest, 44800 St-Herblain, France;
| | - Gilles Créhange
- Department of Radiotherapy, Institut Curie, 75005 Paris, France;
| | | | - Eric Barret
- Department of Urology, Institut Mutualiste Montsouris, 75014 Paris, France;
| | | | - Laurent Brureau
- Department of Urology, CHU de Pointe-à-Pitre, University of Antilles, University of Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)—UMR_S 1085, 97110 Pointe-à-Pitre, France;
| | - Charles Dariane
- Department of Urology, Hôpital Européen Georges-Pompidou, APHP, Paris—Paris University—U1151 Inserm-INEM, Necker, 75015 Paris, France;
| | - Gaëlle Fiard
- Department of Urology, Grenoble Alpes University Hospital, Université Grenoble Alpes, CNRS, Grenoble INP, TIMC-IMAG, 38000 Grenoble, France;
| | - Mathieu Gauthé
- Unité de Recherche Clinique en Économie de la Santé, CRESS METHODS INSERM UMR 1153, 75000 Paris, France;
| | - Romain Mathieu
- Department of Urology, CHU Rennes, 35033 Rennes, France;
| | - Guilhem Roubaud
- Department of Medical Oncology, Institut Bergonié, 33000 Bordeaux, France;
| | - Alain Ruffion
- Service d’Urologie Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 69002 Lyon, France;
- Equipe 2, Centre d’Innovation en Cancérologie de Lyon (EA 3738 CICLY), Faculté de Médecine Lyon Sud, Université Lyon 1, 69002 Lyon, France
| | - Raphaële Renard-Penna
- Department of Radiology, Sorbonne University, AP-HP, Pitie-Salpetriere Hospital, 75013 Paris, France;
| | - Yann Neuzillet
- Department of Urology, Hôpital Foch, 92151 Suresnes, France;
| | - Morgan Rouprêt
- Department of Urology, Sorbonne University, GRC 5 Predictive Onco-Uro, AP-HP, Pitie-Salpetriere Hospital, 75013 Paris, France;
| | - Guillaume Ploussard
- Department of Urology, La Croix du Sud Hôpital, 31130 Quint Fonsegrives, France;
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6
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Yamada S, Abe T, Sazawa A, Katano H, Suzuki H, Takeuchi I, Ishizaki J, Minami K, Morita K, Tsuchiya K, Takada N, Maru S, Ishikawa S, Sato S, Kawazu T, Yamashita T, Ono T, Mochizuki T, Akino T, Sasaki Y, Shinno Y, Furumido J, Miyata H, Kikuchi H, Matsumoto R, Osawa T, Shinohara N. Comparative study of postoperative complications after radical cystectomy during the past two decades in Japan: Radical cystectomy remains associated with significant postoperative morbidities. Urol Oncol 2021; 40:11.e17-11.e25. [PMID: 34716081 DOI: 10.1016/j.urolonc.2021.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 08/18/2021] [Accepted: 09/07/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES During the past 2 decades, in order to improve perioperative and oncological outcomes, a minimally invasive approach, neoadjuvant chemotherapy (NAC), and an enhanced postoperative recovery program after surgery have been introduced into routine clinical practice of radical cystectomy (RC). Our aim was to examine the differences in clinical practice and postoperative complications after RC by comparing our previous and current cohorts. MATERIALS AND METHODS A retrospective multi-institutional study. We collected all complications within 90 days after surgery between 2011 and 2017 (current cohort), and categorized them according to a standardized methodology. Then, we compared the outcomes with those in our previous study (previous cohort, 1997-2010). A multivariate logistic regression model was utilized to determine predictors of complications in the current cohort. RESULTS A total of 838 patients were newly collected (current cohort), and 919 from the previous cohort were included in the subsequent analyses. In the current cohort, the rate of performing NAC was significantly higher (13% vs. 4%, respectively, P < 0.0001), and 26% (222/838) underwent laparoscopic RC (LRC, without robotic assistance: n = 210, with robotic assistance: n = 12). There was no significant difference in the overall complication [69% (580/838) vs. 68% (629/919), respectively, P = 0.7284] or major complication (Grades 3-5) [25% (211/838) vs. 22% (201/919), respectively, P = 0.1022] rates between the 2 cohorts. In both cohorts, the most frequent categories were infectious, gastrointestinal, wound-related, and genitourinary. In the current cohort, the performance status (odds ratio, OR = 2.11, P = 0.0013) and operative time (OR = 1.003, P = 0.0016) remained significant predictors of major complications. NAC was not associated with any or major complications. CONCLUSIONS Surgical complications related to RC still remain significant problems, despite the recent improvements in surgical techniques and perioperative care. NAC did not increase the complications.
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Affiliation(s)
- Shuhei Yamada
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takashige Abe
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
| | - Ataru Sazawa
- Hokkaido Urothelial Cancer Research Group, Sapporo, Japan
| | | | | | | | - Junji Ishizaki
- Hokkaido Urothelial Cancer Research Group, Sapporo, Japan
| | - Keita Minami
- Hokkaido Urothelial Cancer Research Group, Sapporo, Japan
| | - Ken Morita
- Hokkaido Urothelial Cancer Research Group, Sapporo, Japan
| | | | | | - Shintaro Maru
- Hokkaido Urothelial Cancer Research Group, Sapporo, Japan
| | | | - Soshu Sato
- Hokkaido Urothelial Cancer Research Group, Sapporo, Japan
| | | | | | - Takenori Ono
- Hokkaido Urothelial Cancer Research Group, Sapporo, Japan
| | | | | | | | | | - Jun Furumido
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Haruka Miyata
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiroshi Kikuchi
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Ryuji Matsumoto
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takahiro Osawa
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Nobuo Shinohara
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Tholomier C, Souhami L, Kassouf W. Bladder-sparing protocols in the treatment of muscle-invasive bladder cancer. Transl Androl Urol 2020; 9:2920-2937. [PMID: 33457265 PMCID: PMC7807363 DOI: 10.21037/tau.2020.02.10] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 11/29/2019] [Indexed: 01/06/2023] Open
Abstract
Bladder-sparing protocols (BSP) have been gaining widespread popularity as an attractive alternative to radical cystectomy (RC) for muscle-invasive bladder cancer. Unimodal therapies are inferior to multimodal regimens. The most promising regimen is trimodal therapy (TMT), which is a combination of maximal transurethral resection of bladder tumor (TURBT), radiotherapy, and chemotherapy. In appropriately selected patients (low volume unifocal T2 disease, complete TURBT, no hydronephrosis and no carcinoma-in-situ), comparable oncological outcomes to RC have been reported in large retrospective studies, with a potential improvement in overall quality of life (QOL). TMT also offers the possibility for definitive therapy for patients who are not surgically fit to undergo RC. Routine biopsy of previous tumor resection is recommended to assess response. Prompt salvage RC is required in non-responders and for recurrent muscle-invasive disease, while non-muscle-invasive recurrence can be managed conservatively with TURBT +/- intravesical BCG. Long-term follow-up consisting of routine cystoscopy, urine cytology, and cross-section imaging is required. Further studies are warranted to better define the role of neoadjuvant or adjuvant chemotherapy in the setting of TMT. Finally, future research on predictive markers of response to TMT and on the integration of immunotherapy in bladder sparing protocols is ongoing and is highly promising.
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Affiliation(s)
- Côme Tholomier
- Department of Surgery, Division of Urology, McGill University, McGill University Health Centre, Montréal, Québec, Canada
| | - Luis Souhami
- Department of Radiation Oncology, McGill University, McGill University Health Centre, Montréal, Québec, Canada
| | - Wassim Kassouf
- Department of Surgery, Division of Urology, McGill University, McGill University Health Centre, Montréal, Québec, Canada
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8
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Fukushima H, Kijima T, Fukuda S, Moriyama S, Uehara S, Yasuda Y, Tanaka H, Yoshida S, Yokoyama M, Matsuoka Y, Saito K, Matsubara N, Numao N, Sakai Y, Yuasa T, Masuda H, Yonese J, Kageyama Y, Fujii Y. Impact of radiotherapy to the primary tumor on the efficacy of pembrolizumab for patients with advanced urothelial cancer: A preliminary study. Cancer Med 2020; 9:8355-8363. [PMID: 32886446 PMCID: PMC7666746 DOI: 10.1002/cam4.3445] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 07/14/2020] [Accepted: 08/19/2020] [Indexed: 01/15/2023] Open
Abstract
Radiotherapy plus immune checkpoint inhibitors can potentially induce synergistic antitumor immune responses. However, little clinical evidence is established regarding their combination therapy. Here, we aimed to assess whether radiotherapy to the primary tumor impacts on the efficacy of pembrolizumab in advanced urothelial cancer. We retrospectively reviewed 98 advanced urothelial cancer patients receiving pembrolizumab in a second- or later-line setting using our multicenter cohort. Patients were categorized according to a history of radiotherapy to the primary tumor: patients previously exposed to radiotherapy to the primary tumor (Radiotherapy group, 17 patients [17%]) and those not (Nonradiotherapy group, 81 patients [83%]). The associations of radiotherapy to the primary tumor with objective response and survival were evaluated. The Radiotherapy group showed a significantly higher objective response ratio than did the Non-radiotherapy group (65% vs 19%; P < .001). The Radiotherapy group had a higher progression-free survival rate compared with the Nonradiotherapy group (52% vs 28% at 12 months; P = .078), but statistical significance was not reached. The Radiotherapy group had a significantly higher overall survival rate compared with the Non-radiotherapy group (77% vs 50% at 12 months; P = .025). From multivariate analysis, radiotherapy to the primary tumor was an independent predictor for longer overall survival (hazard ratio, 0.31; P = .032) along with Eastern Cooperative Oncology Group performance status ≤1 and the absence of visceral metastasis. Therefore, radiotherapy to the primary tumor may enhance the efficacy of pembrolizumab for patients with advanced urothelial cancer.
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MESH Headings
- Aged
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antineoplastic Agents, Immunological/adverse effects
- Antineoplastic Agents, Immunological/therapeutic use
- Carcinoma, Transitional Cell/immunology
- Carcinoma, Transitional Cell/mortality
- Carcinoma, Transitional Cell/pathology
- Carcinoma, Transitional Cell/therapy
- Chemoradiotherapy/adverse effects
- Chemoradiotherapy/mortality
- Female
- Humans
- Male
- Middle Aged
- Progression-Free Survival
- Retrospective Studies
- Risk Assessment
- Risk Factors
- Time Factors
- Tokyo
- Tumor Microenvironment
- Urinary Bladder Neoplasms/immunology
- Urinary Bladder Neoplasms/mortality
- Urinary Bladder Neoplasms/pathology
- Urinary Bladder Neoplasms/therapy
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Affiliation(s)
| | - Toshiki Kijima
- Department of UrologyTokyo Medical and Dental UniversityTokyoJapan
| | - Shohei Fukuda
- Department of UrologyTokyo Medical and Dental UniversityTokyoJapan
| | - Shingo Moriyama
- Department of UrologyTokyo Medical and Dental UniversityTokyoJapan
| | - Sho Uehara
- Department of UrologyTokyo Medical and Dental UniversityTokyoJapan
| | - Yosuke Yasuda
- Department of UrologyTokyo Medical and Dental UniversityTokyoJapan
| | - Hajime Tanaka
- Department of UrologyTokyo Medical and Dental UniversityTokyoJapan
| | - Soichiro Yoshida
- Department of UrologyTokyo Medical and Dental UniversityTokyoJapan
| | - Minato Yokoyama
- Department of UrologyTokyo Medical and Dental UniversityTokyoJapan
| | - Yoh Matsuoka
- Department of UrologyTokyo Medical and Dental UniversityTokyoJapan
| | - Kazutaka Saito
- Department of UrologyTokyo Medical and Dental UniversityTokyoJapan
| | - Nobuaki Matsubara
- Department of Breast and Medical OncologyNational Cancer Center Hospital EastKashiwaJapan
| | - Noboru Numao
- Department of UrologyCancer Institute HospitalJapanese Foundation for Cancer ResearchTokyoJapan
| | | | - Takeshi Yuasa
- Department of UrologyCancer Institute HospitalJapanese Foundation for Cancer ResearchTokyoJapan
| | - Hitoshi Masuda
- Department of UrologyNational Cancer Center Hospital EastKashiwaJapan
| | - Junji Yonese
- Department of UrologyCancer Institute HospitalJapanese Foundation for Cancer ResearchTokyoJapan
| | | | - Yasuhisa Fujii
- Department of UrologyTokyo Medical and Dental UniversityTokyoJapan
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9
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Dinh TKT, Mitin T, Bagshaw HP, Hoffman KE, Hwang C, Jeffrey Karnes R, Kishan AU, Liauw SL, Lloyd S, Potters L, Showalter TN, Taira AV, Vapiwala N, Zaorsky NG, D'Amico AV, Nguyen PL, Davis BJ. Executive Summary of the American Radium Society Appropriate Use Criteria for Radiation Treatment of Node-Negative Muscle Invasive Bladder Cancer. Int J Radiat Oncol Biol Phys 2020; 109:953-963. [PMID: 33127490 DOI: 10.1016/j.ijrobp.2020.10.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/19/2020] [Accepted: 10/22/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Definitive radiation therapy (RT), with or without concurrent chemotherapy, is an alternative to radical cystectomy for patients with localized, muscle-invasive bladder cancer (MIBC) who are either not surgical candidates or prefer organ preservation. We aim to synthesize an evidence-based guideline regarding the appropriate use of RT. METHODS AND MATERIALS We performed a Preferred Reporting Items for Systematic Reviews and Meta-analyses literature review using the PubMed and Embase databases. Based on the literature review, critical management topics were identified and reformulated into consensus questions. An expert panel was assembled to address key areas of both consensus and controversy using the modified Delphi framework. RESULTS A total of 761 articles were screened, of which 61 were published between 1975 and 2019 and included for full review. There were 7 well-designed studies, 20 good quality studies, 28 quality studies with design limitations, and 6 references not suited as primary evidence. Adjuvant radiation therapy after cystectomy was not included owing to lack of high-quality data or clinical use. An expert panel consisting of 14 radiation oncologists, 1 medical oncologist, and 1 urologist was assembled. We identified 4 clinical variants of MIBC: surgically fit patients who wish to pursue organ preservation, patients surgically unfit for cystectomy, patients medically unfit for cisplatin-based chemotherapy, and borderline cystectomy candidates based on age with unilateral hydronephrosis and normal renal function. We identified key areas of controversy, including use of definitive radiation therapy for patients with negative prognostic factors, appropriate radiation therapy dose, fractionation, fields and technique when used, and chemotherapy sequencing and choice of agent. CONCLUSIONS There is limited level-one evidence to guide appropriate treatment of MIBC. Studies vary significantly with regards to patient selection, chemotherapy use, and radiation therapy technique. A consensus guideline on the appropriateness of RT for MIBC may aid practicing oncologists in bridging the gap between data and clinical practice.
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Affiliation(s)
- Tru-Khang T Dinh
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Timur Mitin
- Department of Radiation Medicine, Oregon Health Sciences University, Portland, Oregon.
| | - Hilary P Bagshaw
- Department of Radiation Oncology, Stanford University Clinics, Palo Alto, California
| | - Karen E Hoffman
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Clara Hwang
- Department of Hematology/Oncology, Henry Ford Health System, Detroit, Michigan
| | | | - Amar U Kishan
- Department of Radiation Oncology, University of California at Los Angeles Medical Center, Los Angeles, California
| | - Stanley L Liauw
- Department of Radiation Oncology, University of Chicago, Chicago, Illinois
| | - Shane Lloyd
- Department of Radiation Oncology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Louis Potters
- Department of Radiation Oncology, Northwell Health, New Hyde Park, New York
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia
| | - Al V Taira
- Sutter Health Radiation Oncology, San Mateo, California
| | - Neha Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State University Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Anthony V D'Amico
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana Farber Cancer, Institute, Boston, Massachusetts
| | - Paul L Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana Farber Cancer, Institute, Boston, Massachusetts
| | - Brian J Davis
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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10
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Incidence and outcome of salvage cystectomy after bladder sparing therapy for muscle invasive bladder cancer: a systematic review and meta-analysis. World J Urol 2020; 39:1757-1768. [PMID: 32995918 PMCID: PMC8217031 DOI: 10.1007/s00345-020-03436-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 08/31/2020] [Indexed: 02/07/2023] Open
Abstract
Objective We conducted a systematic review and meta-analysis to assess the available literature regarding the surgical and oncologic outcomes of patients undergoing salvage radical cystectomy (SV-RC) for recurrence or failure of bladder sparing therapy (BST) for muscle-invasive bladder cancer (MIBC). Methods We searched MEDLINE (PubMed), EMBASE and Google Scholar databases in May 2020. We included all studies of patients with ≥ cT2N0/xM0 bladder cancer that were eligible for all treatment modalities at the time of treatment decision who underwent BST including radiotherapy (RTX). A meta-analysis was conducted to calculate the pooled rate of several variables associated with an increased need for SV-RC. Study quality and risk of bias were assessed using MINORS criteria. Results 73 studies comprising 9110 patients were eligible for the meta-analysis. Weighted mean follow-up time was 61.1 months (range 12–144). The pooled rate of non-response to BST and local recurrence after BST, the two primary reasons for SV-RC, was 15.5% and 28.7%, respectively. The pooled rate of SV-RC was 19.2% for studies with a follow-up longer than 5 years. Only three studies provided a thorough report of complication rates after SV-RC. The overall complication rate ranged between 67 and 72% with a 30-day mortality rate of 0–8.8%. The pooled rates of 5 and 10-year disease-free survival after SV-RC were 54.3% and 45.6%, respectively. Conclusion Approximately one-fifth of patients treated with BST with a curative intent eventually require SV-RC. This procedure carries a proportionally high rate of complications and is usually accompanied by an incontinent urinary diversion. Electronic supplementary material The online version of this article (10.1007/s00345-020-03436-0) contains supplementary material, which is available to authorized users.
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11
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Ghandour R, Singla N, Lotan Y. Treatment Options and Outcomes in Nonmetastatic Muscle Invasive Bladder Cancer. Trends Cancer 2019; 5:426-439. [PMID: 31311657 DOI: 10.1016/j.trecan.2019.05.011] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/23/2019] [Accepted: 05/30/2019] [Indexed: 12/26/2022]
Abstract
Muscle-invasive bladder cancer (MIBC) represents 25% of newly diagnosed bladder cancer. MIBC is aggressive and requires timely management. The current standard of care is neoadjuvant chemotherapy followed by radical cystectomy, an approach that could result in significant morbidities. Modifications in the chemotherapy regimens, as well as in perioperative care and surgical approach, have resulted in better overall toxicity profile and faster recovery. However, bladder-preservation in carefully selected patients can lead to acceptable oncological outcomes and better quality of life. Optimization of bladder-preservation protocols and proper identification of patients who tolerate and respond to various treatment modalities will significantly impact patient survival in the coming future.
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Affiliation(s)
- Rashed Ghandour
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX 75390-9110, USA
| | - Nirmish Singla
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX 75390-9110, USA
| | - Yair Lotan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX 75390-9110, USA.
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12
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El-Achkar A, Souhami L, Kassouf W. Bladder Preservation Therapy: Review of Literature and Future Directions of Trimodal Therapy. Curr Urol Rep 2018; 19:108. [PMID: 30392150 DOI: 10.1007/s11934-018-0859-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF THE REVIEW This review targets the latest literature on bladder preservation therapy with emphasis on trimodal therapy (TMT), highlighting its role in the management of muscle invasive bladder cancer (MIBC) and outlining future directions in bladder preservation research. RECENT FINDINGS TMT is the most promising bladder preservation treatment modality. Comparable results to contemporary radical cystectomy series are seen in properly selected patients. A multidisciplinary team approach is critical in the management of these patients. Future research is directed at the integration of immunotherapy into the treatment protocol. TMT, involving maximal transurethral resection followed by chemoradiation, is an attractive alternative to radical cystectomy with urinary diversion in carefully selected patients with muscle invasive disease. In the absence of randomized trial (RCT), comparison between TMT and cystectomy, based on retrospective data from large centers, suggests comparable oncological outcomes, with a favorable impact on quality of life.
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Affiliation(s)
- Adnan El-Achkar
- Experimental surgery, McGill University Health Center, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Luis Souhami
- Department of Radiation Oncology, McGill University Health Center, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Wassim Kassouf
- Department of Surgery, McGill University Health Center, McGill University, 1001 Decarie Blvd, D02.7210, Montreal, QC, H4A 3J1, Canada.
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13
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Koga F, Takemura K, Fukushima H. Biomarkers for Predicting Clinical Outcomes of Chemoradiation-Based Bladder Preservation Therapy for Muscle-Invasive Bladder Cancer. Int J Mol Sci 2018; 19:ijms19092777. [PMID: 30223570 PMCID: PMC6165010 DOI: 10.3390/ijms19092777] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 09/13/2018] [Accepted: 09/14/2018] [Indexed: 02/06/2023] Open
Abstract
Chemoradiation-based bladder preservation therapy (BPT) is currently a curative option for non-metastatic muscle-invasive bladder cancer (MIBC) patients at favorable risk or an alternative to radical cystectomy (RC) for those who are unfit for RC. In BPT, only patients who achieve complete response (CR) after chemoradiation have a favorable prognosis and quality of life with a preserved functional bladder. Thus, predicting CR and favorable prognosis is important for optimal patient selection for BPT. We reviewed biomarkers for predicting the clinical outcomes of chemoradiation-based BPT. The biomarkers studied were categorized into those related to apoptosis, cell proliferation, receptor tyrosine kinases, DNA damage response genes, hypoxia, molecular subtype, and others. Among these biomarkers, the Ki-67 labeling index (Ki-67 LI) and meiotic recombination 11 may be used for selecting BPT or RC. Ki-67 LI and erythroblastic leukemia viral oncogene homolog 2 (erbB2) may be used for predicting both the chemoradiation response and the prognosis of patients on BPT. Concurrent use of trastuzumab and a combination of carbogen and nicotinamide can overcome chemoradiation resistance conferred by erbB2 overexpression and tumor hypoxia. Further studies are needed to confirm the practical utility of these biomarkers for progress on biomarker-directed personalized management of MIBC patients.
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Affiliation(s)
- Fumitaka Koga
- Department of Urology, Tokyo Metropolitan Cancer and Infectious diseases Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan.
| | - Kosuke Takemura
- Department of Urology, Tokyo Metropolitan Cancer and Infectious diseases Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan.
| | - Hiroshi Fukushima
- Department of Urology, Tokyo Metropolitan Cancer and Infectious diseases Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan.
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14
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Abe T, Takada N, Kikuchi H, Matsumoto R, Osawa T, Murai S, Miyajima N, Maruyama S, Shinohara N. Perioperative morbidity and mortality of octogenarians treated by radical cystectomy-a multi-institutional retrospective study in Japan. Jpn J Clin Oncol 2017; 47:755-761. [PMID: 28453639 PMCID: PMC5896694 DOI: 10.1093/jjco/hyx062] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 04/20/2017] [Indexed: 11/12/2022] Open
Abstract
Objective To determine the characteristics of 90-day morbidity and mortality after radical cystectomy in Japanese octogenarians. Methods A retrospective multi-institutional study. We reviewed the records of 834 patients treated by open radical cystectomy between 1997 and 2010. All complications within 90 days after surgery were sorted into the 11 categories proposed by the Memorial Sloan-Kettering Cancer Center and graded according to the modified Clavien-Dindo system. We compared the characteristics of complications between ≥80-year (n = 86) and <80-year (n = 748) groups. Multivariate regression models were used to determine the predictors of complications. Results American Society of Anesthesiologists score III–IV was more frequent (14% vs. 6%, respectively, P < 0.0001), and ureterocutaneostomy was more frequently performed (30% vs. 21%, respectively, P = 0.0148) in the ≥80-year group compared with <80-year group. There were no significant differences in the rates of any complication, major (Grade 3–5) complication, or 90-day mortality between the two groups (≥80-year group: 70%, 21%, 3.5%, respectively, <80-year group: 68%, 22%, 2%, respectively). The ≥80-year group had fewer genitourinary complications (7% vs. 16%, respectively, P = 0.0131). Multivariate regression analyses revealed that bowel-using urinary diversion (P = 0.0031) and the operative time (P = 0.0269) were significant predictors of any grade of complications, and a male sex (P = 0.0167), annual cystectomy volume (P = 0.0284) and prior cardiovascular comorbidity (P = 0.0034) were significant predictors of major complications. Conclusions In our experience, radical cystectomy in Japanese octogenarians caused similar perioperative comorbidities. Old age as a single criterion should not be used to abandon radical cystectomy; careful preoperative assessment is mandatory.
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Affiliation(s)
- Takashige Abe
- For reprints and all correspondence: Takashige Abe, Department of Urology, Hokkaido University Graduate School of Medicine, North-15, West-7, North Ward, Sapporo 060-8638, Japan. E-mail:
| | - Norikata Takada
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiroshi Kikuchi
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Ryuji Matsumoto
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takahiro Osawa
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Sachiyo Murai
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Naoto Miyajima
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Satoru Maruyama
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Nobuo Shinohara
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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15
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Cahn DB, Ristau BT, Ghiraldi EM, Churilla TM, Geynisman DM, Horwitz EM, Uzzo RG, Smaldone MC. Bladder Preservation Therapy: A Review of the Literature and Future Directions. Urology 2016; 96:54-61. [PMID: 27257135 DOI: 10.1016/j.urology.2016.05.041] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 05/14/2016] [Accepted: 05/23/2016] [Indexed: 11/16/2022]
Abstract
Trimodal bladder preservation therapy (ie, transurethral resection followed by chemoradiotherapy) may be an acceptable treatment alternative to radical cystectomy with urinary diversion in the carefully selected patient with muscle invasive bladder cancer. Although no head-to-head randomized controlled trials have been performed, large retrospective cohort reviews and observational data analyses suggest comparable oncologic outcomes in select patients with the additional benefit of maximizing quality of life and maintaining the patient's native bladder. In this review, we discuss the evolution and clinical outcomes of bladder preservation therapy, highlighting its role in the contemporary management of muscle invasive bladder cancer.
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Affiliation(s)
- David B Cahn
- Department of Urology, Einstein Healthcare Network, Philadelphia, PA.
| | - Benjamin T Ristau
- Department of Surgical Oncology, Division of Urologic Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA
| | - Eric M Ghiraldi
- Department of Urology, Einstein Healthcare Network, Philadelphia, PA
| | - Thomas M Churilla
- Department of Radiation Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA
| | - Daniel M Geynisman
- Department of Hematology/Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA
| | - Eric M Horwitz
- Department of Radiation Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA
| | - Robert G Uzzo
- Department of Urology, Einstein Healthcare Network, Philadelphia, PA; Department of Surgical Oncology, Division of Urologic Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA
| | - Marc C Smaldone
- Department of Surgical Oncology, Division of Urologic Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA
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16
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Osawa T, Lee CT, Abe T, Takada N, Hafez KS, Montgomery JS, Weizer AZ, Hollenbeck BK, Skolarus TA, Murai S, Shinohara N, Morgan TM. A Multi-Center International Study Assessing the Impact of Differences in Baseline Characteristics and Perioperative Care Following Radical Cystectomy. Bladder Cancer 2016; 2:251-261. [PMID: 27376144 PMCID: PMC4927825 DOI: 10.3233/blc-150043] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background: To identify potential avenues for quality improvement, we compared the variations in clinical practice and their association with perioperative morbidity and mortality following radical cystectomy (RC) for bladder cancer in the United States (US) and Japan. Methods: We reviewed our retrospectively collected database of 2240 patients who underwent RC for bladder cancer at the University of Michigan (n = 1427) and in 21 Japanese institutions (n = 813) between 1997 and 2014. We performed a systematic comparison of clinical and perioperative factors and assessed predictors of perioperative morbidity and mortality. Death within 90 days of surgery was the primary outcome. Results: There were apparent differences between the two study populations. Notably, US patients had a significantly greater BMI and higher ASA score. In Japanese institutions, median postoperative hospital stay was significantly higher (40 days vs. 7 days, p < 0.001) and 90-day readmission rates were significantly lower (0.6% vs. 26.8% , p < 0.001). There was a total of 1372/2240 (61.2%) patients with complications within 90 days and 66/2240 (2.9%) patient deaths. Significant predictors of 90-day mortality were older age (OR 1.04, CI 1.01–1.07), higher body mass index (OR 1.07, CI 1.02–1.12), node-positive disease (OR 3.14, CI 1.78–5.47), increased blood loss (OR 1.02, CI 1.01–1.03), and major (Clavien-grade 3 or greater) complication (OR 3.29, CI 1.88–5.71). Conclusion: Despite major differences in baseline characteristics and care of cystectomy patients between the two study populations, peri-operative mortality rates proved to be comparable. This data supports an exploration of non-traditional factors that may influence mortality after cystectomy.
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Affiliation(s)
- Takahiro Osawa
- Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA; Department of Urology, Hokkaido University, Sapporo, Japan
| | - Cheryl T Lee
- Department of Urology, University of Michigan Health System , Ann Arbor, MI, USA
| | - Takashige Abe
- Department of Urology, Hokkaido University , Sapporo, Japan
| | | | - Khaled S Hafez
- Department of Urology, University of Michigan Health System , Ann Arbor, MI, USA
| | - Jeffrey S Montgomery
- Department of Urology, University of Michigan Health System , Ann Arbor, MI, USA
| | - Alon Z Weizer
- Department of Urology, University of Michigan Health System , Ann Arbor, MI, USA
| | - Brent K Hollenbeck
- Department of Urology, University of Michigan Health System , Ann Arbor, MI, USA
| | - Ted A Skolarus
- Department of Urology, University of Michigan Health System , Ann Arbor, MI, USA
| | - Sachiyo Murai
- Department of Urology, Hokkaido University , Sapporo, Japan
| | | | - Todd M Morgan
- Department of Urology, University of Michigan Health System , Ann Arbor, MI, USA
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17
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Trimodal therapy for invasive bladder cancer: is it really equal to radical cystectomy? Curr Opin Urol 2016; 25:476-82. [PMID: 26125510 DOI: 10.1097/mou.0000000000000203] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE OF REVIEW Trimodal therapy (TMT) is considered the most effective bladder-sparing approach for muscle-invasive urothelial carcinoma of the bladder (MIBC) and an alternative to radical cystectomy. The purpose of this article was to review and summarize the current knowledge on the equivalence of TMT and radical cystectomy based on the recent literature. RECENT FINDINGS TMT consists of a maximal transuretral resection of the bladder, followed by a concurrent radiotherapy and chemotherapy, limiting salvage radical cystectomy to nonresponder tumors or muscle-invasive recurrence. In large population studies, less than 6% of the patients with nonmetastatic MIBC receive a chemoradiation therapy and this rate is stable. A growing body of evidence exists that TMT provides good oncologic outcomes with low morbidity when compared with radical cystectomy. TMT requires, however, a close follow-up because of the high risk of local recurrence and salvage radical cystectomy in up to 30% of the patients. Salvage radical cystectomy can be performed with adequate results but does not offer the same opportunity of reconstruction and functional outcomes than primary radical cystectomy. SUMMARY Although radical cystectomy is still the treatment of reference for most of the patients with localized MIBC, TMT represents a reasonable alternative in highly selected patients. Any firm conclusion on the equivalence or superiority of one treatment to the other is still limited by the lack of randomized controlled trials and the heterogeneity of the available literature. Future studies and multidisciplinary approach are mandatory to optimize the patient selection and regimen of TMT.
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18
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Yamamoto T, Takahashi S, Ichihara K, Hiyama Y, Uehara T, Hashimoto J, Hirobe M, Masumori N. How do we understand the disagreement in the frequency of surgical site infection between the CDC and Clavien-Dindo classifications? J Infect Chemother 2014; 21:130-3. [PMID: 25434696 DOI: 10.1016/j.jiac.2014.10.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 10/12/2014] [Accepted: 10/25/2014] [Indexed: 10/24/2022]
Abstract
To clarify the discrepancy in the incidence and severity of surgical site infections (SSI) for radical cystectomy between reports based on the CDC guideline and those using the Clavien-Dindo classification we evaluated 449 consecutive patients who underwent radical cystectomy for bladder cancer between 1990 and 2012. Of the 115 (25.6%) patients with SSI defined by the CDC guideline, 89 could be analyzed. We compared the SSI rates and severity defined by the CDC guideline and Clavien-Dindo classifications. There were 58 patients with superficial SSI, 16 with deep SSI, and 15 with organ/space SSI according to the CDC guideline. All patients with organ/space SSI were judged as "not having SSI" by the Clavien-Dindo classification. They were classified as having "intestinal prolapse", "intestinal fistula", "abdominal abscess" and "pelvic abscess." There was a significant association between the treatment duration and depth of SSI based on the CDC guideline by Spearman's rank-correlation coefficient (p < 0.001, r = 0.614) and with the grade of complications (p < 0.001, r = 0.632) in the Clavien-Dindo classification. Multivariate analysis showed that patients with grade III SSI in the Clavien-Dindo classification needed a significantly longer treatment duration. It is necessary to be aware that a discrepancy can occur automatically due to the different natures of the definitions. Using the CDC guideline, we can effectively estimate the future treatment period when SSI occurs. With the Clavien-Dindo classification, grade III SSI requires a longer treatment duration.
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Affiliation(s)
- Takanobu Yamamoto
- Department of Urology, Sapporo Medical University School of Medicine, Japan.
| | - Satoshi Takahashi
- Department of Urology, Sapporo Medical University School of Medicine, Japan.
| | - Koji Ichihara
- Department of Urology, Sapporo Medical University School of Medicine, Japan
| | - Yoshiki Hiyama
- Department of Urology, Sapporo Medical University School of Medicine, Japan
| | - Teruhisa Uehara
- Department of Urology, Sapporo Medical University School of Medicine, Japan
| | - Jiro Hashimoto
- Department of Urology, Sapporo Medical University School of Medicine, Japan
| | - Megumi Hirobe
- Department of Urology, Sapporo Medical University School of Medicine, Japan
| | - Naoya Masumori
- Department of Urology, Sapporo Medical University School of Medicine, Japan
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19
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Ploussard G, Daneshmand S, Efstathiou JA, Herr HW, James ND, Rödel CM, Shariat SF, Shipley WU, Sternberg CN, Thalmann GN, Kassouf W. Critical analysis of bladder sparing with trimodal therapy in muscle-invasive bladder cancer: a systematic review. Eur Urol 2014; 66:120-37. [PMID: 24613684 DOI: 10.1016/j.eururo.2014.02.038] [Citation(s) in RCA: 227] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 02/14/2014] [Indexed: 12/17/2022]
Abstract
CONTEXT Aims of bladder preservation in muscle-invasive bladder cancer (MIBC) are to offer a quality-of-life advantage and avoid potential morbidity or mortality of radical cystectomy (RC) without compromising oncologic outcomes. Because of the lack of a completed randomised controlled trial, oncologic equivalence of bladder preservation modality treatments compared with RC remains unknown. OBJECTIVE This systematic review sought to assess the modern bladder-preservation treatment modalities, focusing on trimodal therapy (TMT) in MIBC. EVIDENCE ACQUISITION A systematic literature search in the PubMed and Cochrane databases was performed from 1980 to July 2013. EVIDENCE SYNTHESIS Optimal bladder-preservation treatment includes a safe transurethral resection of the bladder tumour as complete as possible followed by radiation therapy (RT) with concurrent radiosensitising chemotherapy. A standard radiation schedule includes external-beam RT to the bladder and limited pelvic lymph nodes to an initial dose of 40 Gy, with a boost to the whole bladder to 54 Gy and a further tumour boost to a total dose of 64-65 Gy. Radiosensitising chemotherapy with phase 3 trial evidence in support exists for cisplatin and mitomycin C plus 5-fluorouracil. A cystoscopic assessment with systematic rebiopsy should be performed at TMT completion or early after TMT induction. Thus, nonresponders are identified early to promptly offer salvage RC. The 5-yr cancer-specific survival and overall survival rates range from 50% to 82% and from 36% to 74%, respectively, with salvage cystectomy rates of 25-30%. There are no definitive data to support the benefit of using of neoadjuvant or adjuvant chemotherapy. Critical to good outcomes is proper patient selection. The best cancers eligible for bladder preservation are those with low-volume T2 disease without hydronephrosis or extensive carcinoma in situ. CONCLUSIONS A growing body of accumulated data suggests that bladder preservation with TMT leads to acceptable outcomes and therefore may be considered a reasonable treatment option in well-selected patients. PATIENT SUMMARY Treatment based on a combination of resection, chemotherapy, and radiotherapy as bladder-sparing strategies may be considered as a reasonable treatment option in properly selected patients.
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Affiliation(s)
- Guillaume Ploussard
- Department of Surgery, Division of Urology, McGill University, Montreal, Quebec, Canada; Department of Urology, Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Siamak Daneshmand
- University of Southern California Institute of Urology, University of Southern California/Norris Comprehensive Cancer Center, Los Angeles, CA, USA
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Harry W Herr
- Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Nicholas D James
- University of Birmingham, School of Cancer Sciences, Edgbaston, Birmingham, UK
| | - Claus M Rödel
- Department of Radiotherapy and Oncology, University of Frankfurt, Frankfurt, Germany
| | | | - William U Shipley
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Cora N Sternberg
- Department of Medical Oncology, San Camillo Forlanini Hospital, Rome, Italy
| | | | - Wassim Kassouf
- Department of Surgery, Division of Urology, McGill University, Montreal, Quebec, Canada.
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20
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Abe T, Takada N, Shinohara N, Matsumoto R, Murai S, Sazawa A, Maruyama S, Tsuchiya K, Kanzaki S, Nonomura K. Comparison of 90-day complications between ileal conduit and neobladder reconstruction after radical cystectomy: A retrospective multi-institutional study in Japan. Int J Urol 2013; 21:554-9. [DOI: 10.1111/iju.12357] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 10/28/2013] [Indexed: 02/06/2023]
Affiliation(s)
- Takashige Abe
- Department of Urology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Norikata Takada
- Department of Urology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Nobuo Shinohara
- Department of Urology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Ryuji Matsumoto
- Department of Urology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Sachiyo Murai
- Department of Urology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Ataru Sazawa
- Hokkaido Urothelial Cancer Research Group; Sapporo Japan
| | - Satoru Maruyama
- Department of Urology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Kunihiko Tsuchiya
- Department of Urology; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Shino Kanzaki
- Hokkaido Urothelial Cancer Research Group; Sapporo Japan
| | - Katsuya Nonomura
- Department of Urology; Hokkaido University Graduate School of Medicine; Sapporo Japan
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21
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Takada N, Abe T, Shinohara N, Sazawa A, Maruyama S, Shinno Y, Sato S, Mitsuhashi K, Sato T, Sugishita K, Kamota S, Yamashita T, Ishizaki J, Hioka T, Mouri G, Ono T, Miyajima N, Sakuta T, Mochizuki T, Aoyagi T, Katano H, Akino T, Hirakawa K, Minami K, Kumagai A, Seki T, Togashi M, Nonomura K. Peri-operative morbidity and mortality related to radical cystectomy: a multi-institutional retrospective study in Japan. BJU Int 2012; 110:E756-64. [PMID: 23107013 DOI: 10.1111/j.1464-410x.2012.11609.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2012] [Indexed: 12/20/2022]
Abstract
UNLABELLED What's known on the subject? and What does the study add? Radical cystectomy remains associated with comparatively high perioperative morbidity and mortality, despite improvements in surgical techniques and perioperative care. At present, most studies on the complications associated with open radical cystectomy were derived from Western academic high-volume centres, and data from Japan and other Asian countries were very limited. Using the modified Clavien grading system and 11 category grouping reported from MSKCC, we observed that 68% of patients experienced at least one complication within 90 days of surgery, and 17% of patients experienced major complications (90-day mortality rate = 2%), which were compatible with reports from Western high-volume centres. As far as we know, our report is the largest one regarding perioperative morbidity and mortality in Asian patients who underwent radical cystectomy. OBJECTIVE To determine the type, incidence and severity of 90-day morbidity after radical cystectomy in our institution and our affiliated hospitals in accordance with a standard reporting methodology. At present, most studies on complications associated with open radical cystectomy are derived from Western academic high-volume centres and data from Japan and other Asian countries remain very limited. PATIENTS AND METHODS The study comprised a retrospective multi-institutional study. The records were reviewed of 928 patients who underwent open radical cystectomy between 1997 and 2010. All complications within 90 days of surgery were categorized into 11 specific categories and graded in accordance with the modified Clavien system. Multivariate regression models were used to determine predictors of complications. RESULTS At least one complication was observed in 635 (68%) patients and a major (grade 3-5) complication was observed in 156 (17%) patients. The most common complication categories were infectious (30%), gastrointestinal (26%), wound-related (21%) and genitourinary (15%). The 30-day mortality rate was 0.8% and the 90-day mortality rate was 2%. A multivariate regression model showed that previous cardiovascular comorbidity and type of urinary diversion (i.e. ileal conduit or neobladder) were significant factors for any and major complications. CONCLUSIONS Surgical complication-related radical cystectomy is significant and both previous cardiovascular comorbidity and the type of urinary diversion were found to be significant factors for any and major complications. The 90-day mortality rate was 2%, which is compatible with reports from Western high-volume centres.
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Affiliation(s)
- Norikata Takada
- Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Koga F, Kihara K. Selective bladder preservation with curative intent for muscle-invasive bladder cancer: a contemporary review. Int J Urol 2012; 19:388-401. [PMID: 22409269 DOI: 10.1111/j.1442-2042.2012.02974.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Radical cystectomy plus urinary diversion, the reference standard treatment for muscle-invasive bladder cancer, associates with high complication rates and compromises quality of life as a result of long-term effects on urinary, gastrointestinal and sexual function, and changes in body image. As a society ages, the number of elderly patients unfit for radical cystectomy as a result of comorbidity will increase, and thus the demand for bladder-sparing approaches for muscle-invasive bladder cancer will also inevitably increase. Trimodality bladder-sparing approaches consisting of transurethral resection, chemotherapy and radiotherapy (Σ 55-65 Gy) yield overall survival rates comparable with those of radical cystectomy series (50-70% at 5 years), while preserving the native bladder in 40-60% of muscle-invasive bladder cancer patients, contributing to an improvement in quality of life for such patients. Limitations of the trimodality therapy include (i) muscle-invasive bladder cancer recurrence in the preserved bladder, which most often arises in the original muscle-invasive bladder cancer site; (ii) potential lack of curative intervention for regional lymph nodes; and (iii) increased morbidity in the event of salvage radical cystectomy for remaining or recurrent disease as a result of high-dose pelvic irradiation. Consolidative partial cystectomy with pelvic lymph node dissection followed by induction chemoradiotherapy at lower dose (e.g. 40 Gy) is a rational strategy for overcoming such limitations by strengthening locoregional control and reducing radiation dosage. Molecular profiling of the tumor and functional imaging might play important roles in optimal patient selection for bladder preservation. Refinement of radiation techniques, intensified concurrent or adjuvant chemotherapy, and novel sensitizers, including molecular targeting agent, are also expected to improve outcomes and consequently provide more muscle-invasive bladder cancer patients with favorable quality of life.
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Affiliation(s)
- Fumitaka Koga
- Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan.
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