Clinical outcome of radical cystectomy for patients with pT4 bladder cancer

Radical cystectomy for locally advanced urothelial carcinoma of the urinary bladder: Health-related quality of life, oncological outcomes and predictors for survival

PURPOSE

While survival outcomes of locally advanced bladder cancer patients undergoing radical cystectomy are known to be poor, less is known regarding patient-reported outcomes and predictive features for survival in this patient subgroup.

METHODS

One hundred and eighteen consecutive patients with pT4a cM0 urothelial carcinoma of the bladder were included. Based on pathological review, patients were stratified into 3 subgroups based on existence of additional lesions and invasion depth of the respective lesions. Cancer-specific survival and overall survival (OS) was determined using Kaplan-Meier-analyses and multivariate Cox regression models (P <0.05). Health-related quality of life was assessed using the validated EORTC-QLQ-C30 questionnaire pre- and postoperatively.

RESULTS

Seventy-two (61.0%) patients were ineligible for neoadjuvant chemotherapy. Median follow-up based on censored patients was 12 months. Twelve month OS rate was 56.1%, 24 months OS rate was 21.1%. A total of 44.4% of the patients stated good general health-related quality of life. In multivariate analysis, we found significantly adverse OS outcomes for female patients (hazard ratio 2.35, 95% confidence interval 1.09-5.08, P = 0.030). Patients with at least 1 additional locally advanced tumor had significantly worse OS outcomes compared to patients who had no additional lesions in multivariate Cox regression analysis (hazard Ratio 3.37, 95% confidence interval 1.29-8.78, P = 0.013).

CONCLUSION

Existence of multiple locally advanced lesions and female gender is an independent predictor of worse survival outcomes in patients with pT4a urothelial carcinoma undergoing radical cystectomy.

Prognosis of patients receiving induction chemotherapy for locally advanced or lymph node metastatic bladder cancer

Background:

Induction chemotherapy is recommended before surgery for unresectable muscle-invasive bladder cancer, locally advanced or lymph node disseminated disease. These patients’ prognoses cannot be extrapolated from data regarding neoadjuvant chemotherapy, which is performed in operable patients.

Objective:

We assessed the prognosis of patients undergoing induction chemotherapy for locally advanced or lymph node metastatic bladder cancer.

Methods:

We analysed patients with cT4NxM0 or cTxN+M0 bladder cancer treated by induction chemotherapy between 2006 and 2016. The tumour extension and node invasion was determined by imaging or histologically after upfront lymph node dissection. Clinical, biological, pathological and patient follow-up data were identified. Kaplan–Meier survival curves were compared by log rank test. Factors associated with the response to induction chemotherapy, operability of patients and survival were determined by multivariable logistic regression.

Results:

Among 70 patients included in the analysis, 51 (73%) showed response to induction chemotherapy. Progression-free and overall survival were improved in responder patients compared with non-responders ( P<0.0001 and P=0.025, respectively) and for patients who underwent surgery compared with non-operated patients (both P<0.001). On multivariable analysis, poor response was associated with chemotherapy other than methotrexate, vinblastine, doxorubicin and cisplatin ( P=0.016), operability with late response ( P=0.0024) and overall survival with surgery after induction chemotherapy ( P=0.0014).

Conclusions:

Surgery after induction chemotherapy with methotrexate, vinblastine, doxorubicin and cisplatin may improve prognosis with locally advanced or lymph node metastatic bladder cancer.

Level of evidence:

4

Role of Radical Cystectomy in Non-Organ Confined Bladder Cancer: A Systematic Review

Background:

Currently, a diagnosis of non-organ confined bladder cancer (NOCBCa) confers a grave prognosis. The mainstay of treatment consists of systemic chemotherapy. However, it must be recognized that NOCBCa is a heterogeneous disease state with important clinical distinctions. While surgical extirpation has traditionally been regarded as overly aggressive for all NOCBCa patients, its utility as part of a multimodal treatment strategy in various clinical scenarios has not been thoroughly investigated.

Objective:

To perform a review of the literature regarding the role of radical cystectomy and pelvic lymph node dissection (RC-LND) in the setting of NOCBCa.

Methods:

Medline, and Pubmed electronic database were queried for English language articles from January 1990 to Nov 2016 on RC-LND for cT4, lymph node positive, and metastatic urothelial cancer. NOCBCa was separated into four distinct clinical scenarios: 1. Locally advanced/unresectable disease (cT4bN0M0); 2. Occult pelvic nodal disease (pN+) (cTxN0M0 and pTxN1-3Mx); 3. Clinical node positive disease (cN+) (cTxN1-3M0); and 4. Distant metastatic disease (TxNxM1). Evidence for the role of RC-LND in each of these clinical scenarios was summarized.

Results:

cT4b may be more effectively treated by presurgical chemotherapy (PSC) than other forms of NOCBCa. Although clinical response predicted improved survival, surgical factors, such as surgical margin status may also play a role in determining outcomes. In well selected patients, 5-year CSS may reach 60% after consolidative RC-LND. Survival in patients found to have pathologic nodal metastases without PSC was dictated not only by the histologically verified metastatic nodal disease burden, but also by the meticulousness of the lymph node dissection. In these patients, adjuvant chemotherapy may improve survival. On the other hand, in patients undergoing RC-LND after PSC, pathologic complete response (pCR) was the strongest predictor of improved CSS. The results of population based studies have suggested a therapeutic role by consolidative RC-LND in both patients with cN+ and metastatic BCa (mBCa). For the cN+ population, 5-year OS was 31% in patients undergoing RC-LND after PSC vs. 14% in those receiving chemotherapy alone. Similarly, consolidative intensive local therapy improved OS by approximately 5 months in patients with mBCa. Metastasectomy has also been shown to be effective in small retrospective series and may especially be useful in patients with solitary pulmonary lesions.

Conclusions:

Extirpative treatment of the primary tumor may be an important step in the management of de novo NOCBCa. The current retrospective and population based studies have demonstrated improved survival outcomes in patients with NOCBCa following RC-LND, especially in those with favorable response to PSC. With the advent of minimally invasive surgery and the enhanced post-surgical recovery protocols, RC-LND has not only been demonstrated to be feasible, but also tolerable in the setting of advanced BCa. Well designed, prospective trials are needed to definitively assess the value of surgical extirpation for NOCBCa patients.

Antioncogenic effects of transient receptor potential vanilloid 1 in the progression of transitional urothelial cancer of human bladder

The progression of normal cells to a tumorigenic and metastatic state involves the accumulation of mutations in multiple key signaling proteins, encoded by oncogenes and tumor suppressor genes. Recently, members of the TRP channel family have been included in the oncogenic and tumor suppressor protein family. TRPM1, TRPM8, and TRPV6 are considered to be tumor suppressors and oncogenes in localized melanoma and prostate cancer, respectively. Herein, we focus our attention on the antioncogenic properties of TRPV1. Changes in TRPV1 expression occur during the development of transitional cell carcinoma (TCC) of human bladder. A progressive decrease in TRPV1 expression as the TCC stage increases triggers the development of a more aggressive gene phenotype and invasiveness. Finally, downregulation of TRPV1 represents a negative prognostic factor in TCC patients. The knowledge of the mechanism controlling TRPV1 expression might improve the diagnosis and new therapeutic strategies in bladder cancer.

Gender-specific differences in cancer-specific survival after radical cystectomy for patients with urothelial carcinoma of the urinary bladder in pathologic tumor stage T4a

BACKGROUND

Bladder cancer (UCB) staged pT4a show heterogeneous outcome after radical cystectomy (RC). No risk model has been established to date. Despite gender-specific differences, no comparative studies exist for this tumor stage.

MATERIALS AND METHODS

Cancer-specific survival (CSS) of 245 UCB patients without neoadjuvant chemotherapy staged pT4a, pN0-2, M0 after RC were analyzed in a retrospective multi-center study. Seventeen patients were excluded from further analysis due to carcinoma in situ (CIS) of the prostatic urethra and/or positive surgical margins. Average follow-up period was 30 months (IQR: 14-45). The influence of different clinical and histopathologic variables on CSS was determined through uni- and multivariate Cox regression analyses. Two risk groups were generated using factors with independent effect in multivariate models. Internal validity of the prediction model was evaluated by bootstrapping.

RESULTS

Eighty-four percent of the patients (n = 192) were male; 72% (n = 165) showed lymphovascular invasion (LVI). The 5-year CSS rate was 31%, and significantly different between male and female (35% vs. 15%, P = 0.003). Multivariate Cox regression modeling, female gender (HR = 1.83, P = 0.008), LVI (HR = 1.92, P = 0.005), and absence of adjuvant chemotherapy (HR = 0.61, P = 0.020) significantly worsened CSS. Two risk groups were generated using these 3 criteria, which differed significantly between each other in CSS (5-year-CSS: 46% vs. 12%, P < 0.001). The c-index value of the risk model was 0.61 (95% CI: 0.53-0.68, P < 0.001).

CONCLUSIONS

Prognosis in UCB staged pT4a is heterogeneous. Female gender and LVI are adverse factors. Adjuvant chemotherapy seems to improve outcome. The present analysis establishes the first risk model for this demanding tumor stage.

Expression of transient receptor potential vanilloid-1 (TRPV1) in urothelial cancers of human bladder: relation to clinicopathological and molecular parameters

AIMS

To evaluate the expression of transient receptor potential vanilloid type-1 channel protein (TRPV1) in normal and neoplastic urothelial tissues and to correlate TRPV1 expression with clinicopathological parameters and disease-specific survival.

METHODS AND RESULTS

TRPV1 expression was analysed in normal and neoplastic urothelial samples at both mRNA and protein levels by quantitative real time polymerase chain reaction (qPCR) and immunohistochemistry, respectively. TRPV1 downregulation was found in urothelial cancer (UC) specimens, which correlated with tumour progression. Moreover, TRPV1 mRNA levels were associated with clinicopathological parameters to assess the role of TRPV1 downregulation as a negative prognostic factor for survival. Kaplan-Meier survival analysis demonstrated a significantly shorter survival in patients showing TRPV1 mRNA downregulation. Multivariate Cox regression analysis indicated further that TRPV1 mRNA expression retained its significance as an independent risk factor.

CONCLUSIONS

The progression of UC of human bladder is associated with a marked decrease in TRPV1 expression, with a progressive loss in high-grade muscle invasive UC. Downregulation of TRPV1 mRNA expression may represent an independent negative prognostic factor for bladder cancer patients.

Characteristics and outcomes of patients with pT4 urothelial carcinoma at radical cystectomy: a retrospective international study of 583 patients

PURPOSE

We describe cancer specific outcomes in patients with pT4 bladder urothelial carcinoma at radical cystectomy in a large international cohort.

MATERIALS AND METHODS

We reviewed the records of 4,257 patients treated with radical cystectomy for bladder urothelial carcinoma at 12 centers. No patient received any preoperative systemic chemotherapy or radiotherapy.

RESULTS

Of the 4,257 patients 583 (14%) had pT4 bladder urothelial carcinoma, of whom 83.7% were male, 85.2% had substage pT4a disease, 24.9% had positive soft tissue surgical margins, 57.8% had lymphovascular invasion and 53.5% had lymph node metastasis. Median followup was 55.0 months. Overall estimated 5-year recurrence-free and cancer specific survival was 29% (95% CI 22-32) and 31% (95% CI 25-36), respectively. On multivariate analysis female gender (p = 0.005 and p = 0.001), positive soft tissue surgical margins (p = 0.014 and p <0.001), lymphovascular invasion (p = 0.016 and p = 0.005), pT4b substage (p = 0.041 and p = 0.002, respectively) and lymph node involvement (each p <0.001) were independently associated with disease recurrence and cancer specific mortality.

CONCLUSIONS

Patients with pT4 bladder urothelial carcinoma have highly variable outcomes. Features associated with metastatic tumor dissemination (ie lymph node invasion and lymphovascular invasion) and local disease burden (ie soft tissue surgical margins and pT4 substage) are associated with poor outcomes in patients with pT4 bladder urothelial carcinoma. Further research is needed to understand why female patients with pT4 bladder urothelial carcinoma have a worse outcome than their male counterparts.