Preoperative chemotherapy for prostatic stromal invasive urothelial bladder cancer: comparison of oncological outcomes of male patients with cT4a disease undergoing radical cystectomy with or without preoperative chemotherapy

Background: The value of preoperative chemotherapy to prostatic stromal invasive urothelial bladder cancer remains uncertain. This study presented the pathological response and oncological outcomes of male patients with cT4a urothelial bladder cancer managed with preoperative chemotherapy followed by radical cystectomy. Materials and methods: Data were collected retrospectively from male patients with cT4a urothelial bladder cancer, who underwent radical cystectomy with or without preoperative chemotherapy. Patient characteristics and pathological response were compared. The Kaplan-Meier method and multivariable Cox regression were used to analyze recurrence-free survival and overall survival. Results: From 1989 to 2016, 90 male patients with primary cT4a urothelial bladder cancer underwent radical cystectomy at the institution, 55 (61%) did not have preoperative chemotherapy and 35 (39%) had preoperative chemotherapy. The preoperative chemotherapy group had more lymphovascular invasion on primary transurethral resection of bladder tumor (31.4% vs 18.2%, p = .2) and more clinically positive nodal disease (31.4% vs 10.9%, p = .09). At radical cystectomy, the preoperative chemotherapy group had more tumor down staging (60% vs 29.1%, p = .005), less lymphovascular invasion (40% vs 54.5%, p = .05) and less positive nodal disease (25.7% vs 45.5%, p = .006). Hydronephrosis, lymphovascular invasion and age >70 were associated with worse recurrence-free survival and overall survival (p < .05). Tumor down-staging was associated with improved recurrence-free survival and overall survival (p = .003, p = .03, respectively). Preoperative chemotherapy alone was not associated with improved oncologic outcomes. Conclusions: Preoperative chemotherapy is associated with cT4a bladder cancer down-staging, decreased lymphovascular invasion and decreased positive nodal disease. Preoperative chemotherapy provides survival benefit to those who achieved pathological response.

Staging of bladder cancer

Urothelial carcinoma of the urinary bladder is a heterogeneous disease with multiple possible treatment modalities and a wide spectrum of clinical outcome. Treatment decisions and prognostic expectations hinge on accurate and precise staging, and the recently published American Joint Committee on Cancer (AJCC) Staging Manual, 8th edition, should be the basis for staging of urinary bladder tumours. It is unfortunate that the International Union Against Cancer (UICC) 8th edition failed to incorporate new data which is considered in the AJCC 8th edition. Thus, the AJCC 8th edition is the focus of this review. Several critical changes and clarifications are made by the AJCC 8th edition relative to the 7th edition. Although the most obvious changes in the 8th edition are in the N (i.e. perivesical lymph node involvement now classified as N1) and M (i.e. M1 is subdivided into M1a and M1b) categories, several points are clarified in the T category (e.g. substaging of pT1 should be attempted). Further optimisation, however, is required. No particular method of substaging pT1 is formally recommended. In this review, these modifications are discussed, as well as points, which require further study and optimisation.

Challenges in Pathologic Staging of Bladder Cancer: Proposals for Fresh Approaches of Assessing Pathologic Stage in Light of Recent Studies and Observations Pertaining to Bladder Histoanatomic Variances

The paradigm of pathologic stage (pT) categorization in bladder cancer remains the depth of invasion into the different histologic layers of the bladder wall. However, the approaches to assigning pT stage category toward an enhanced outcome stratification have been marked by challenges and innovations, due in part to our growing appreciation of the surprisingly perplexing bladder histoanatomy. Upstaging of pT1 tumors after radical cystectomy is substantial and underscores the potential value of pT1 substaging in transurethral resection (TUR) specimens. The 2017 American Joint Committee on Cancer tumor-node-metastasis system recommends pT1 substaging but recognizes the need to optimize the approach. Over the years, the cut-off for microinvasion has been significantly lowered to 0.5 mm and is now a promising scheme for pT1 (micrometric) substaging. Unlike the micrometric approach, histoanatomic substaging using muscularis mucosae (MM) and vascular plexus as landmarks is less feasible in TUR specimens and inconsistent in stratifying the outcome of pT1 tumors. The lamina propria possesses inherent variations in depth, MM, and vascular plexus dispositions that should be factored in future pT1 substaging proposals. Histoanatomic variations among the bladder regions also occur, and studies suggest that trigone and bladder neck cancers may have more adverse outcomes. The muscularis propria (MP), besides being the essential histologic landmark for assigning pT2 stage category, is also considered a surrogate for the adequacy of TUR, furthering the importance of identifying its presence in TUR specimens. MP, however, may be mimicked by hyperplastic or isolated MP-like MM muscle bundles in the lamina propria with overstaging implications, and caution should be exercised in distinguishing these 2 muscle types morphologically and immunohistochemically. Presence of additional superficial MP unique from the detrusor muscle proper may also complicate staging at the trigone and ureter insertion sites. With regard to the depth of MP invasion, large and multicenter studies have reaffirmed the prognostic significance of pT2a/b subcategories. It is revealed that there are at least 3 ways used to demarcate the irregular MP to perivesical soft tissue junction, and use of a common criterion indicates improvement in pT2b/pT3a staging reproducibility. Although studies have shown significantly poorer outcome in pT3b compared with pT3a tumors, this designation has a substantial reliance on the prosector's gross assessment of perivesical soft tissue invasion which if performed incorrectly may lead to staging inaccuracy of pT3 tumors. The 8th edition of the American Joint Committee on Cancer has updated the staging schema for bladder cancers with concomitant prostatic stromal invasion and cancers within bladder diverticula. Because of 2 possible pT designations, prostatic stromal invasion in TUR specimens should not be automatically staged as either pT4a or pT2 (urethral). Recent data support that bladder cancer invading into the seminal vesicle has comparable outcome to pT4b tumors. Interestingly, several studies in pT4a tumors, which are staged based on sex-specific organs, have shown poorer outcome in females than males after radical cystectomy, and while there are possibly several reasons, they may also include anatomic factors. Despite the progress has been made, work remains to be done to inform future bladder cancer pT category definitions and their reproducibility in application and prognostication.

Comparative analysis of the effect of prostatic invasion patterns on cancer-specific mortality after radical cystectomy in pT4a urothelial carcinoma of the bladder

PURPOSE

To evaluate the prognostic relevance of different prostatic invasion patterns in pT4a urothelial carcinoma of the bladder (UCB) after radical cystectomy.

MATERIALS AND METHODS

Our study comprised a total of 358 men with pT4a UCB. Patients were divided in 2 groups-group A with stromal infiltration of the prostate via the prostatic urethra with additional muscle-invasive UCB (n = 121, 33.8%) and group B with continuous infiltration of the prostate through the entire bladder wall (n = 237, 66.2%). The effect of age, tumor grade, carcinoma in situ, lymphovascular invasion, soft tissue surgical margin, lymph node metastases, administration of adjuvant chemotherapy, and prostatic invasion patterns on cancer-specific mortality (CSM) was evaluated using competing-risk regression analysis. Decision curve analysis was used to evaluate the net benefit of including the variable invasion pattern within our model.

RESULTS

The estimated 5-year CSM-rates for group A and B were 50.1% and 66.0%, respectively. In multivariable competing-risk analysis, lymph node metastases (hazard ratio [HR] = 1.73, P<0.001), lymphovascular invasion (HR = 1.62, P = 0.0023), soft tissue surgical margin (HR = 1.49, P = 0.026), absence of adjuvant chemotherapy (HR = 2.11, P<0.001), and tumor infiltration of the prostate by continuous infiltration of the entire bladder wall (HR = 1.37, P = 0.044) were significantly associated with a higher risk for CSM. Decision curve analysis showed a net benefit of our model including the variable invasion pattern.

CONCLUSIONS

Continuous infiltration of the prostate through the entire bladder wall showed an adverse effect on CSM. Besides including these patients into clinical trials for an adjuvant therapy, we recommend including prostatic invasion patterns in predictive models in pT4a UCB in men.

Usefulness of transurethral biopsy for staging the prostatic urethra before radical cystectomy

PURPOSE

We determined the likelihood that transurethral resection biopsy of the prostatic urethra adjacent to the verumontanum would detect prostatic involvement of urothelial carcinoma in patients with bladder carcinoma.

MATERIALS AND METHODS

We compared precystectomy transurethral resection biopsy specimens of the prostatic urethra with those of the matched radical cystoprostatectomy in 272 patients with urothelial carcinoma of the bladder. All prostates were evaluated by whole mount step sections.

RESULTS

Prostatic involvement by urothelial carcinoma was detected by transurethral resection biopsy or radical cystoprostatectomy in 101 patients (37.1%). Transurethral resection biopsy detected urothelial carcinoma in 72 cases with 71.3% sensitivity and 100% specificity. The overall accuracy of transurethral resection biopsy to detect urothelial carcinoma of the prostate was 89% (positive and negative predictive values 100% and 86%, respectively). Invasive prostatic urothelial carcinoma arising from the prostatic urethra was detected by transurethral resection biopsy in 21 of 26 patients (81%) while prostatic carcinoma in situ was detected in 39 of 52 (75%). Transurethral resection biopsy detected prostatic invasive urothelial carcinoma resulting from transmural invasion of a bladder tumor in 4 of 15 patients.

CONCLUSIONS

Prostatic involvement by urothelial carcinoma of the bladder was found in 37.1% of patients. Transurethral resection biopsy missed most tumors resulting from transmural invasion of the bladder primary lesion. Carcinoma in situ and invasive urothelial carcinoma arising from the prostatic urethra were detected in most cases. Transurethral resection biopsy of the prostatic urethra can complement staging and support clinical decision making with respect to neoadjuvant chemotherapy and planning for an orthotopic neobladder.

The conundrum of prostatic urethral involvement

The presence and depth of urothelial cancer involvement in the prostatic urethra can significantly affect the management of a patient with non-muscle invasive bladder cancer. This article presents an overview of the incidence, diagnosis, management, and follow-up of urothelial cancer.

[Prognostic influence of prostate gland invasion by bladder tumour and/or prostate cancer in cystoprostatectomy specimen: a review]

INTRODUCTION

Cystoprostatectomy (CPT) is the gold standard surgical treatment for muscle invasive bladder cancer (MIBC). In certain cases, MIBC can invade the prostate gland and/or a prostate cancer (PCa) can be discovered fortuitously on the pathologic specimen. The aim of the current study was to report the prognostic influence of PCa in patients who underwent a CPT for MIBC.

MATERIALS AND METHODS

A systematic review of the scientific literature was achieved in the Pubmed database, using the following keywords: prostatic neoplasm; urinary bladder neoplasm; cystectomy; surgery; recurrence; prognosis; survival. Clinical cases and series of less than five cases were deliberately excluded herein.

RESULTS

Overall, ten studies published between 2004 and 2011 and involving 2196 patients were selected. Only retrospective studies of low level of evidence (NP 4) were available. The incidence of neoplastic invasion of the prostate gland by MIBC ranged from 25 to 48%. Preoperative predictors were multiple BC, recurrent, location in the trigone and existence of CIS. Overall survival at 3 years was significantly affected by the invasion of the prostate gland (pT4a) in these patients. The incidence of PCa discovered incidentally pathologic specimen CPT ranged from 14 to 49%. Only age was found as a positive predictor. The diagnosis of PCa did not influence survival of patients with MIBC and no specific PCa adjuvant treatment was systematically advocated.

CONCLUSION

Fortuitous diagnosis of PCa and/or neoplastic invasion of the prostatic gland by BC on CPT specimen is not uncommon but this is variable across studies, depending on the quality of the pathological analysis. The invasion of the prostate gland by MIBC is a serious situation (pT4a) and linked with a poor prognosis. In case of concomitant PCa and MIBC, the prognosis is much more related to the natural history of the bladder tumour.

[Prostatic involvement by urothelial carcinoma in patients with bladder cancer and their implications in the clinical practice]

OBJECTIVES

Urothelial carcinoma (UC) is a multifocal disease that may develop in any location of the urinary tract, including the prostate. We analyze the types of prostate involvement due to UC, their diagnosis, risk factors and the clinical implications of this entity.

MATERIAL AND METHODS

Analysis of original, review articles and publications related to prostate involvement due to UC. The study included works published in the period of 1985-2011, most of which were obtained from the search in PubMed.

RESULTS

Prostate involvement due to UC has been observed frequently in both non-muscle invasive bladder cancer (NMIBC) series and prolonged follow-up (39%) as in radical cystectomy series (15-48%). Prostatic involvement may occur in the mucosa and ducts (superficial involvement) or prostate stroma (invasive involvement), a fact that has prognostic and therapeutic implications. Stromal involvement may have both a bladder and intraurethral origin. Carcinoma in situ, multifocality, bladder neck/trigone cancer, and previous history of tumor recurrence are the factors that have been m ore consistently associated to prostate involvement due to UC. The incidence of prostatic involvement by UC in patients with NMIBC increases over time when risk factors exist. In these cases, a prostatic urethral biopsy should be performed during the follow-up. Conservative treatment with transurethral resection and BCG is possible in case of superficial involvement of the prostatic urethra, assuming its risk of progression. Patients subjects to cystectomy and with prostate involvement due to UC have a greater risk of urethral recurrence. The elevated incidence of prostatic adenocarcinoma and prostatic involvement by UC in cystectomy specimens makes it necessary to be very selective when indicating prostate-sparing cystectomy. Chemotherapy may be an option in an attempt to improve survival of patients with prostatic stromal involvement.

CONCLUSIONS

Prostatic involvement by UC is not uncommon and it has important implications in the management of patients with NMIBC and in those who have an indication for or have undergone radical cystectomy.

Depth and origin of prostatic involvement by urothelial carcinoma: prognostic significance and staging interpretation

OBJECTIVE

To investigate the prognostic significance of prostatic involvement by bladder urothelial carcinoma using the new 2009 TNM staging system.

METHODS

From 1993 to 2008, 77 consecutive men who were clinically and/or pathologically diagnosed with bladder cancer underwent radical cystectomy. Patients were classified into several groups, according to the presence, extent and invading pathway of prostatic involvement by urothelial carcinoma, whether there was stromal or non-stromal involvement, and whether there was contiguous or non-contiguous involvement. Cause-specific survivals were calculated in each group and they were compared.

RESULTS

Prostatic involvement was observed in 23 (30%) patients: 10 had non-contiguous non-stromal involvement, 5 had non-contiguous stromal involvement and 8 had contiguous stromal involvement. Patients with stromal involvement (both contiguous and non-contiguous) showed significantly shorter cause-specific survival compared with those without prostatic stromal involvement (P= 0.002). The survival of patients with contiguous prostatic stromal involvement was similar to that of patients with non-contiguous prostatic stromal involvement (P= 0.79). Multivariate analysis showed that prostatic stromal involvement (both contiguous and non-contiguous) (hazard ratio, 8.4; P< 0.001), lymph node involvement (hazard ratio, 4.4; P= 0.016) and perivesical fat involvement (hazard ratio, 3.8; P= 0.029) were predictive of cause-specific survival.

CONCLUSIONS

The depth of prostatic involvement has a significant impact on survival for patients with bladder urothelial carcinoma; however, whether its origin is contiguous or non-contiguous does not appear to be important.