EAU-ESMO consensus statements on the management of advanced and variant bladder cancer-an international collaborative multi-stakeholder effort: under the auspices of the EAU and ESMO Guidelines Committees†

BACKGROUND

Although guidelines exist for advanced and variant bladder cancer management, evidence is limited/conflicting in some areas and the optimal approach remains controversial.

OBJECTIVE

To bring together a large multidisciplinary group of experts to develop consensus statements on controversial topics in bladder cancer management.

DESIGN

A steering committee compiled proposed statements regarding advanced and variant bladder cancer management which were assessed by 113 experts in a Delphi survey. Statements not reaching consensus were reviewed; those prioritised were revised by a panel of 45 experts before voting during a consensus conference.

SETTING

Online Delphi survey and consensus conference.

PARTICIPANTS

The European Association of Urology (EAU), the European Society for Medical Oncology (ESMO), experts in bladder cancer management.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Statements were ranked by experts according to their level of agreement: 1-3 (disagree), 4-6 (equivocal), 7-9 (agree). A priori (level 1) consensus was defined as ≥70% agreement and ≤15% disagreement, or vice versa. In the Delphi survey, a second analysis was restricted to stakeholder group(s) considered to have adequate expertise relating to each statement (to achieve level 2 consensus).

RESULTS AND LIMITATIONS

Overall, 116 statements were included in the Delphi survey. Of these, 33 (28%) statements achieved level 1 consensus and 49 (42%) statements achieved level 1 or 2 consensus. At the consensus conference, 22 of 27 (81%) statements achieved consensus. These consensus statements provide further guidance across a broad range of topics, including the management of variant histologies, the role/limitations of prognostic biomarkers in clinical decision making, bladder preservation strategies, modern radiotherapy techniques, the management of oligometastatic disease and the evolving role of checkpoint inhibitor therapy in metastatic disease.

CONCLUSIONS

These consensus statements provide further guidance on controversial topics in advanced and variant bladder cancer management until a time where further evidence is available to guide our approach.

Second primary cancers occurring after I-125 brachytherapy as monotherapy for early prostate cancer

AIMS

Prostate brachytherapy may be associated with a lower risk of radiation-induced second primary cancer (SPC) as a significantly smaller volume of normal tissue is irradiated when compared with external beam techniques. Limited data are available as it has been a routine treatment option for less than 20 years. This study identified cases of SPC in patients who underwent I-125 prostate brachytherapy as monotherapy in a single institution.

MATERIALS AND METHODS

SPC incidence was retrieved by conducting a UK cancer registry search (Northern and Yorkshire Cancer Registry and Information Service) for 1805 consecutive patients with localised prostate cancer who received monotherapy with I-125 brachytherapy from 1995 to 2006 at a single public hospital. Of 1730 UK residents, the completeness of the registry match was 91% (1574 patients). The mean age at treatment (interquartile range) of the cohort was 63 (58-68) years with 1100 patients (70%) over the age of 60 years at treatment. The median (range) follow-up was 8 (6-10) years with 487 patients (31%) having 10 years or more.

RESULTS

In total, 170 patients (10.8%) were diagnosed with second primaries (1 year or more after implant); 20 of these were bladder and 10 rectal cancers. The 10 year cumulative incidences were 14.6, 1 and 0.84% for any second malignancy, bladder and rectal cancer, respectively. Only the standardised incidence rate (SIR) for bladder cancer was higher at 1.54 (95% confidence interval 0.96-2.46) compared with the general population. The SIR for bladder cancer was higher in the first few years after treatment, suggesting that the increased incidence of bladder cancer is due to increased urological surveillance.

CONCLUSIONS

Overall, the incidence of SPC after I-125 is comparable with other published data with no significant excess more than 5 years from treatment. Mortality secondary to SPC of the bladder or rectum is unusual.

Recto-urethral fistula following brachytherapy for localized prostate cancer

OBJECTIVE

The use of prostate brachytherapy (BT) in the management of prostate cancer is increasing. BT is often chosen because of its perceived lower toxicity when compared with other radical therapy options. Rarely however serious complications can occur. One such complication is recto-urethral fistula (RUF). We report the incidence of RUF following BT at our centre and review the potential factors in fistula development.

METHOD

A prospectively collected database was used to identify cases of RUF among 1455 patients treated with prostate BT at a single UK centre with at least 2 years of follow up. This included patients treated with BT monotherapy, as well as those treated with BT combined with external beam radiotherapy and BT used as salvage as all these groups have a higher incidence of RUF. Implant dose and volume characteristics for those patients, their co-morbidities and history of endoscopic procedures were recorded.

RESULTS

Recto-urethral fistula was identified in three (0.2%) patients, occurring at 19-27 months following BT. All these patients had BT monotherapy. All three patients had rectal symptoms after their BT and had been investigated with endoscopy and low rectal biopsy. Subsequent surgical management with faecal and/or urinary diversion was required. On review of patients' BT details, radiation dose and volume parameters were higher on the postprocedure CT calculations than had been suggested by the preimplant plan. No other predisposing risk factors for RUF were identified.

CONCLUSION

The incidence of RUF in our population is low. RUF following BT has been associated with rectal biopsy in previous series and this is confirmed in our report. Gastrointestinal specialists should not perform biopsy of the anterior rectum in patients who have had BT unless there is a very high clinical suspicion of malignancy.

Low-dose prophylactic cranial irradiation in patients with poor prognosis small-cell lung cancer

AIMS

In small-cell lung cancer (SCLC), prophylactic cranial irradiation (PCI) provides a survival advantage in good performance status patients with limited disease. Its role in those with poor performance status limited disease or extensive disease is unclear. A low-dose PCI schedule has been used in these groups, and outcomes have been analysed.

MATERIALS AND METHODS

Retrospective analyses of brain metastasis-free survival and overall survival of patients receiving low-dose PCI over a 2-year period.

RESULTS

Fifty-six patients were treated, with 55 evaluable due to missing notes for one. No major treatment-related toxicity was observed. Median brain metastasis-free survival and overall survival for the group were 44 and 46 weeks, respectively. The median brain metastasis-free survival were 32 and 50 weeks, and median overall survival were 39 and 57 weeks, in those with extensive and limited disease, respectively. A total of 10 patients developed clinical or radiological evidence of brain metastases, four (16%) with limited disease and six (21%) with extensive disease. Thirteen (52%) with limited disease and 10 (36%) with extensive disease survived 1 year.

CONCLUSIONS

Symptomatic brain metastases occurred less frequently than would be expected, with most patients developing widespread metastatic disease. Low-dose PCI may benefit these groups, and the results of an ongoing EORTC randomised-controlled trial in extensive disease should provide more information.

Radiotherapy Treatment Verification in the UK: An Audit of Practice in 2004

AIMS

To audit current practice related to treatment verification undertaken in radiotherapy departments throughout the UK.

MATERIALS AND METHODS

A questionnaire was circulated to the radiotherapy service managers of 62 radiotherapy centres in the UK. This looked in detail at the department demographics, imaging equipment, site-specific verification protocols, and training and competency assessment of staff responsible for verification.

RESULTS

The response rate was 48% (30/62). All departments were using megavoltage imaging equipment in routine clinical practice. Twenty-four out of 29 (83%) departments that had electronic portal imaging capability were using image analysis software for verification. Twenty-nine out of 30 (97%) departments had site-specific written verification protocols. Twenty out of 30 (67%) treatment centres audited set-up errors within their department. Forty-three per cent of centres were using simulator image as the reference image of choice across all sites. Electronic portal imaging, alone or in combination with portal film, was being used for verification in 75% of the centres. Fifty-three per cent of centres used off-line correction strategies for measuring set-up errors across all sites. Radiographer-led interventions were primarily in the pelvis.

CONCLUSION

Presently in the UK, verification strategies vary widely at individual treatment sites and between departments. Dedicated departmental verification teams, with input from radiographers, physicists and clinicians, may assist in the effective implementation of evidence-based verification. The inclusion of comprehensive verification protocols within multicentre radiotherapy trials encourages standardisation across treatment centres.

An assessment of clinically optimal gold marker length and diameter for pelvic radiotherapy verification using an amorphous silicon flat panel electronic portal imaging device

Verification of target organ position is essential for the accurate delivery of conformal radiotherapy. Megavoltage electronic portal imaging with flat panel amorphous silicon detectors delivers high quality images that can be used for verification of bony landmark position. Gold markers implanted into the target organ can be visualized and used as a surrogate of actual organ position. On-line compensation for marker displacement, by adjusting patient position, can reduce geometric errors associated with radiation delivery. This study assesses the optimal marker length and diameter to be used with an amorphous silicon (a-Si) flat panel detector and electronic portal images (EPIs), prior to implementation of a clinical programme of gold marker insertion in prostate cancer patients. Seven marker sizes varying from 3 mm to 8 mm in length and 0.8 mm to 1.1 mm in diameter were investigated in a group of patients undergoing pelvic radiotherapy using an 8 MV Elekta SL20 linear accelerator. Markers were placed on the skin entry and exit sites of the treatment beam and EPIs in both lateral and anterior pelvic views were acquired. Three observers independently assessed visibility success and failure using a subjective scoring system. Markers less than 5 mm in length or 0.9 mm in diameter were poorly visualized (<70% visualization success in lateral EPIs). The marker measuring 0.9 mm x 5 mm appears to be clinically optimal in pelvic radiotherapy patients (80% visualization success in lateral EPIs) and will be used for actual organ implantation.

Controversies in the radiotherapeutic management of poor prognosis locally advanced prostate cancer

The Grand Round was held at the Christie Hospital, Manchester, U.K., on 30 November 2002. It followed a presentation by Dr David Dearnaley from the Royal Marsden Hospital in Sutton on 'Novel approaches and trials in prostate cancer'. Controversies in the management of locally advanced prostate cancer were illustrated by a case presentation and followed by a discussion on the evaluation of disease extent, and the roles of radiotherapy and hormone ablation.

Comparison of vaginal misoprostol and gemeprost as pre-treatment in first trimester pregnancy interruption

OBJECTIVE

To compare the effectiveness of vaginal misoprostol pre-treatment with standard gemeprost pre-treatment in first trimester pregnancy termination.

DESIGN

A prospective randomised study.

POPULATION

One hundred and ninety-nine women scheduled for day case termination of pregnancy during the first trimester.

METHODS

Cervical priming with a vaginally applied 200 microg tablet of misoprostol for at least four hours, compared with a 1.0 mg vaginal suppository of gemeprost for at least three hours before vacuum aspiration.

MAIN OUTCOME MEASURES

The prostaglandin effect on baseline cervical dilatation was the main outcome. Others were occurrence of pre-operative pain and need for analgesia, pre-operative side effects such as nausea, vomiting and diarrhoea, presence of blood in the vagina and blood loss during the operation.

RESULTS

There was no significant difference in the dilatation ability of misoprostol or gemeprost, nor in the pre-operative use of analgesics. The frequency of nausea and diarrhoea was significantly less common in the misoprostol treated women.

CONCLUSIONS

Vaginally applied misoprostol is as effective as gemeprost in cervical priming prior to first trimester vacuum aspiration. Misoprostol was associated with fewer side effects than gemeprost.

High rates of polymorphism and recombination at the Opaque-2 locus in cultivated maize

As a first step in the study of the functional consequences of molecular polymorphism at the Opaque-2 locus in maize, 1933 bp of the gene were sequenced in 21 inbred lines representative of the progenitors of cultivated varieties. High levels of polymorphism were found: 109 sites were variable in non-coding regions and 159 in protein-coding regions. Among the latter, 103 were nonsynonymous, resulting in 94 amino acid replacements in a 422-residue peptide. Moreover, 26 insertion/deletion polymorphisms were found, eight of them in coding regions. The high rate of polymorphism observed could indicate that the effective size of the ancestral population was very large, and/or that the O2 gene evolved under the influence of a high mutation rate or was subjected to some kind of balancing selection. The distribution of polymorphism within the sequence was not uniform. Silent polymorphisms were relatively frequent in exon 1 and rare in intron 5, whereas nonsynonymous polymorphisms were infrequent in the part of the sequence encoding the active domain of the transcription factor. The peptide sequence also showed a relatively higher level of resistance to amino acid replacements in this region. Sites in linkage disequilibrium were arranged mainly in three spatial patterns. This mosaic pattern can be related with an apparently large number of recombination events which might be a characteristic feature of this particular sample and/or imply that the O2 locus is a hot spot for recombination.