Multicenter evaluation of the prognostic value of pT0 stage after radical cystectomy due to urothelial carcinoma of the bladder

Outcomes and Prognostic Factors of Patients with Urothelial Carcinoma Undergoing Radical Cystectomy and pT0 in the Final Histology Without Neoadjuvant Chemotherapy

Purpose

Absence of tumor in the final histopathology after radical cystectomy (RC) is a rare but potentially favorable outcome. Therefore, we aimed to analyze outcomes and prognostic factors of patients with urothelial carcinoma (UC) undergoing RC and T0 in the final histology without neoadjuvant chemotherapy at a high-volume academic center.

Patients and Methods

We retrospectively analyzed patients undergoing RC for pure UC between 2004 and 2020. Cancer-specific survival (CSS) and overall survival (OS) were calculated using Kaplan–Meier analysis and group comparison by Log rank test. Potential prognostic factors were analyzed using univariate Cox regression models.

Results

A total of 1051 patients with UC underwent RC. 72 patients (6.7%) showed pT0 in the final histology. Across all T-stages, 5-year CSS was significantly different with 88% for pT0, 80% for pTa/pTis, 78% for pT1, 76% for pT2, 51% for pT3 and 27% for pT4 in our cohort (p=0.001). Neither instillation therapy (HR 0.31, 95% CI 0.07–1.43), number of TURB prior RC (HR 1.47, 95% CI 0.25–6.18), use of photodynamic diagnostics (PDD) (HR 0.64, 95% CI 0.14–3.02), performing a second resection (HR 0.87, 95% CI 0.27–2.86), muscle-invasive disease prior RC at any TURB (HR 0.7, 95% CI 0.2–2.39) or muscle-invasive disease in the TURB prior RC (HR 1.0, 0.31–3.29) were associated with CSS in univariate analysis.

Conclusion

pT0 reveals a survival benefit in patients undergoing RC for UC and therefore presents a distinctive tumor entity. As clinical and cystoscopic characteristics do not improve patient stratification, further research is warranted to define risk groups in this specific tumor entity.

Curative Effect and Survival Assessment Comparing Gemcitabine and Cisplatin Versus Methotrexate, Vinblastine, Doxorubicin and Cisplatin as Neoadjuvant Therapy for Bladder Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

Neoadjuvant chemotherapy has been accepted as an effective curative treatment for muscle-invasive bladder cancer patients and has resulted in better survival outcomes than radical cystectomy or a cisplatin-based regimen. In the present study, we aimed to compare the two most commonly used cisplatin-based neoadjuvant chemotherapies, gemcitabine plus cisplatin and methotrexate plus vinblastine plus doxorubicin plus cisplatin, by summarizing and analyzing clinical data and outcomes of published research.

METHODS

We searched for qualified studies that compared these two types of neoadjuvant chemotherapy, including 4 randomized controlled trials and 14 retrospective studies. Data and information on pathological responses and long-term survival studies were extracted and analyzed separately.

RESULTS

A total of 18 studies with 3116 patients were selected from 1188 studies, which contained data on pathological complete response, pathological partial response, and overall survival. In contrast to the results of previous studies, there was no significant difference in pathological complete response (odds ratio, 0.97; 95% confidence interval, 0.81-1.15), pathological partial response (odds ratio, 0.85; 95% confidence interval, 0.72-1.14), and overall survival (hazard ratio, 0.99; 95% confidence interval, 0.83-1.17) between GC and MVAC in this meta-analysis.

CONCLUSION

No significant differences were observed between GC and MVAC in the muscle-invasive bladder cancer treatment due to the similar curative effect and parallel long survival outcomes due to the similar curative effect and parallel long survival outcomes. The priority selection of GC or MVAC in the clinic should be guided by further investigation, and the clinical standard strategy still counts on the results of more randomized controlled trials in the future.

Molecular Predictors of Complete Response Following Neoadjuvant Chemotherapy in Urothelial Carcinoma of the Bladder and Upper Tracts

Urothelial carcinoma of the bladder (UCB) and upper tracts (UTUC) is often regarded as one entity and is managed generally with similar principles. While neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC) is an established standard of care in UCB, strong evidence for a similar approach is lacking in UTUC. The longest survival is seen in patients with complete response (pT0) on pathological examination of the RC specimen, but impact of delayed RC in nonresponders may be detrimental. The rate of pT0 following NAC in UTUC is considerably lower than that in UCB due to differences in access and instrumentation. Molecular markers have been evaluated to try to predict response to chemotherapy to reduce unnecessary treatment and expedite different treatment for nonresponders. A variety of potential biomarkers have been evaluated to predict response to cisplatin based chemotherapy including DNA repair genes (ATM, RB1, FANCC, ERCC2, BRCA1, and ERCC1), regulators of apoptosis (survivin, Bcl-xL, and emmprin), receptor tyrosine kinases (EGFR and erbB2), genes involved in cellular efflux (MDR1 and CTR1), in addition to molecular subtypes (Basal, luminal, and p53-like). The current state of the literature on the prediction of response to NAC based on the presence of these biomarkers is discussed in this review.

Neoadjuvant Chemotherapy in Patients With Muscle-Invasive Bladder Cancer and Its Impact on Surgical Morbidity and Oncological Outcomes: A Real-World Experience

Objectives: The purpose of this study was to investigate the impact of neoadjuvant chemotherapy (NAC) on perioperative morbidity and on oncological outcomes according to the type of chemotherapy regimen administered to patients with muscle-invasive bladder cancer (MIBC) who subsequently underwent radical cystectomy (RC). Methods: Data were collected retrospectively on 40 patients with bladder urothelial carcinoma who had at least two cycles of NAC, followed by RC, from 2011 to 2015 at our institution. The outcomes evaluated were NAC toxicity, perioperative complications, cancer-specific, and overall survival. Results: Among these cases, 23 patients (57.5%) received methotrexate, vinblastine, doxorubicin and cisplatin (MVAC), 4 patients (10%) received gemcitabine and cisplatin (GC), and 13 patients (32.5%) received other regimes. The early and late postoperative complication rates were 35% and 12.5%. Regarding toxicity, 85% of patients had at least one side effect of NAC, but only 21.7% discontinued therapy in the MVAC group. The pathological complete response (pCR) rates for cisplatin-based regimens (MVAC and GC) and other regimens were 44.4 and 15.4%, respectively, (p = 0.09). The pathological partial response (pPR) rates for cisplatin-based regimens and other regimens were 66.7 and 15.4%, respectively, (p = 0.002). Patients treated with a cisplatin-based chemotherapy regimen had longer overall survival than those treated with other regimen (median 38.1 vs. 18.4 months, p = 0.01). Conclusions: NAC administration was not associated with high toxicity or surgical morbidity. The pathological response rates and survival outcomes in the cisplatin-based regimens were higher than with those with non-cisplatin-based regimens. These data support the use, in patients elective to a neoadjuvant setting prior to RC for MBIC, of a cisplatin-based regimen.

A systematic review and meta-analysis on the oncological long-term outcomes after trimodality therapy and radical cystectomy with or without neoadjuvant chemotherapy for muscle-invasive bladder cancer

OBJECTIVE

This study aimed to comprehensively analyze the oncological long-term outcomes of trimodal therapy (TMT) and radical cystectomy (RC) for the treatment of muscle-invasive bladder cancer (BC) with or without neoadjuvant chemotherapy (NAC).

PATIENTS AND METHODS

A systematic search was conducted according to the PRISMA guidelines for studies reporting on outcomes after TMT and RC. A total of 57 studies including 30,293 patients were included. The 10-year overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) rates for TMT and RC were assessed.

RESULTS

The mean 10-year OS was 30.9% for TMT and 35.1% for RC (P = 0.32). The mean 10-year DSS was 50.9% for TMT and 57.8% for RC (P = 0.26). NAC was administered before therapy to 453 (13.3%) of 3,402 patients treated with TMT and 812 (3.0%) of 27,867 patients treated with RC (P<0.001). Complete response (CR) was achieved in 1,545 (75.3%) of 2,051 evaluable patients treated with TMT. A 5-year OS, DSS, and RFS after CR were 66.9%, 78.3%, and 52.5%, respectively. Downstaging after transurethral bladder tumor resection or NAC to stage ≤pT1 at RC was reported in 2,416 (29.1%) of 8,311 patients. NAC significantly increased the rate of pT0 from 20.2% to 34.3% (P = 0.007) in cT2 and from 3.8% to 23.9% (P<0.001) in cT3-4. A 5-year OS, DSS, and RFS in downstaged patients (≤pT1) at RC were 75.7%, 88.3%, and 75.8%, respectively.

CONCLUSION

In this analysis, the survival outcomes of patients after TMT and RC for MIBC were comparable. Patients who experienced downstaging after NAC and RC exhibited improved survival compared to patients treated with RC only. Best survival outcomes after TMT are associated with CR to this approach.

[Structure of biobanks for urological research]

Biomedical research plays an important role in the development of novel diagnostic procedures, drugs and treatment strategies with regard to cancerous and chronic inflammatory diseases. Biobanks are essential tools in this process. The complex structures and benefits of biobanks are presented in this article.

[Transitional cell carcinoma of the bladder: bladder-sparing therapy]

Transitional cell carcinoma of the bladder can - in the majority of cases - be safely treated by transurethral resection and bladder preservation. In case of more aggressive and genetically instable tumors, the effect of radical cystectomy depends on tumor volume. If complete resection of invasive tumors is also possible, the additional effect of radical cystectomy seems to be marginal. In patients with favorable tumor location and acceptable prostate parameters, prostate-sparing surgery seems to be oncologically safe with good quality of life.

Randomised phase III study of neoadjuvant chemotherapy with methotrexate, doxorubicin, vinblastine and cisplatin followed by radical cystectomy compared with radical cystectomy alone for muscle-invasive bladder cancer: Japan Clinical Oncology Group Study JCOG0209

BACKGROUND

This study aimed to determine the clinical benefit of neoadjuvant methotrexate, doxorubicin, vinblastine, and cisplatin (MVAC) in patients with muscle-invasive bladder cancer (MIBC) treated with radical cystectomy.

PATIENTS AND METHODS

Patients with MIBC (T2-4aN0M0) were randomised to receive two cycles of neoadjuvant MVAC followed by radical cystectomy (NAC arm) or radical cystectomy alone (RC arm). The primary end point was overall survival (OS). Secondary end points were progression-free survival, surgery-related complications, adverse events during chemotherapy, proportion with no residual tumour in the cystectomy specimens, and quality of life. To detect an improvement in 5-year OS from 45% in the RC arm to 57% in the NAC arm with 80% power, 176 events were required per arm.

RESULTS

Patients (N = 130) were randomly assigned to the RC arm (N = 66) and the NAC arm (N = 64). The patient registration was terminated before reaching the initially planned number of patients because of slow accrual. At the second interim analysis just after the early stoppage of patient accrual, the Data and Safety Monitoring Committee recommended early publication of the results because the trial did not have enough power to draw a confirmatory conclusion. OS of the NAC arm was better than that of the RC arm, although the difference was not statistically significant [hazard ratio 0.65, multiplicity adjusted 99.99% confidence interval 0.19-2.18, one-sided P = 0.07]. In the NAC arm and the RC arm, 34% and 9% of the patients had pT0, respectively (P < 0.01). In subgroup analyses, OS in almost all subgroups was in favour of NAC.

CONCLUSIONS

This trial showed a significantly increased pT0 proportion and favourable OS of patients who received neoadjuvant MVAC. NAC with MVAC can still be considered promising as a standard treatment.

UMIN CLINICAL TRIALS REGISTRY IDENTIFIER

C000000093.

Accurate determination of the pathological stage with gross dissection protocol for radical cystectomy

The current protocol for reporting urinary bladder cancer in radical cystectomies may exhibit limitations in the diagnostic accuracy, such as a risk of understaging, especially in cases with prostatic involvement. Difficulty can arise in the verification of stage pT0, and the assessment of surgical margins is suboptimal. We have developed a daily gross dissection protocol practice where radical cystectomies are totally embedded and evaluated histologically in whole-mount sections. We report here on the first 138 consecutive specimens from 2008 to the first quarter of 2012 inclusive. The incidence of the cancer stages was compared with data on 15,586 radical cystectomies from the literature. The differences were analyzed with the one-sample z-test (p < 0.05). The following emerged from and our series and the literature data: pT0 8.7 % and 6.1 %; pTa 0.7 % and 2.9 %; pTis 2.9 % and 6 %; pT1 15.2 % and 15.5 %; pT2 21 % and 23.3 %; pT3 34.8 % and 34.3 %; and pT4 16.7 % and 11 %, respectively. Our findings closely reflected the means of the published statistical data based on a large number of cases. The differences were due to the more detailed processing: the case numbers in groups from pTis to pT2 were comparatively low, while those in groups pT3 and pT4 were higher. The difference in group pT4 was significant (p = 0.0494). With this method, only those samples were regarded as pT0 in which the granulomatous area and the hemosiderin deposition indicative of the earlier intervention were observable and the entire preparation was tumor-free.