Pathology‐based risk stratification of muscle‐invasive bladder cancer patients undergoing cystectomy for persistent disease after induction chemoradiotherapy in bladder‐sparing approaches

Koga, Fumitaka; Fujii, Yasuhisa; Masuda, Hitoshi; Numao, Noboru; Yokoyama, Minato; Ishioka, Junichiro; Saito, Kazutaka; Kawakami, Satoru; Kihara, Kazunori

doi:10.1111/j.1464-410x.2011.10874.x

Cited by 14 publications

(12 citation statements)

References 30 publications

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“…38 Among patients who had undergone salvage cystectomy for clinical residual disease after induction CRT, CSS was favorable in cases of organ-confined disease (ՅpT2pN0; 5-year CSS rate, 85%), but quite poor when extravesical disease was present (ՆpT3 or pN+, 20%). 46 …”

Section: Prognostic Factors In Patients Treated With Trimodality Therapymentioning

confidence: 99%

Selective bladder preservation with curative intent for muscle‐invasive bladder cancer: A contemporary review

Koga

Kihara

2012

Int J of Urology

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Abbreviations & Acronyms BIS = bladder-intact survival CIS = carcinoma in situ CR = complete response CRT = chemoradiotherapy CSS = cancer-specific survival FU = fluorouracil GasLESS = gasless laparoendoscopic single-port surgery GC = gemcitabine, cisplatin HD = hemodialysis IAC = intra-arterial chemotherapy IMRT = intensity-modulated radiation therapy LCRT = low-dose chemoradiotherapy MCV = methotrexate, cisplatin and vinblastine MIBC = muscle-invasive bladder cancer MRI = magnetic resonance imaging MVAC = methotrexate, vinblastine, adriamycin and cisplatin NA = not available NFkB = nuclear factor kB NMIBC = non-muscle-invasive bladder cancer OS = overall survival PC = partial cystectomy PLND = pelvic lymph node dissection QoL = quality of life RC = radical cystectomy RTOC = Radiation Therapy Oncology Group SPARE = Selective bladder Preservation Against Radical Excision TMDU = Tokyo Medical and Dental University TURBT = transurethral resection of bladder tumors 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 (S55-65 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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Section: Prognostic Factors In Patients Treated With Trimodality Therapymentioning

confidence: 99%

Selective bladder preservation with curative intent for muscle‐invasive bladder cancer: A contemporary review

Koga

Kihara

2012

Int J of Urology

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“…High-grade and muscle-invasive bladder cancers treated with RC have varied prognoses [6,7]. In recent years, several "variant" morphologies have been described, and most were recognized in the 2004 World Health Organization Classification [8].…”

Section: Discussionmentioning

confidence: 99%

“…It has been shown that variant pathologic tumors are aggressive, a fact that has significant prognostic implications. In view of this factor, early recognition may require novel therapeutic interventions, such as the administration of a therapy distinctive from that used for conventional invasive UC [6]. …”

Section: Discussionmentioning

confidence: 99%

“…Divergent histopathology has different clinical course and survival outcomes, as shown in several case series [4, 5, 6]. There is a dearth of data on the subject, and reported series have variable incidence; however, one factor common to all series is that variant histology increases the likelihood of locally advanced disease and metastasis.…”

Section: Introductionmentioning

confidence: 99%

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Impact of Histopathological Variant on the Outcome of Patients Treated by Radical Cystectomy

Nadeem

Ather

2014

Korean J Urol

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PurposeIt is well established that muscle-invasive urothelial carcinoma (UC) has a marked propensity for divergent differentiation, a fact that has significant diagnostic, prognostic, and therapeutic implications. This work is designed to assess the impact of different histopathologic variants of bladder cancer on morbidity and mortality in patients undergoing radical cystectomy (RC) as compared to the impact in patients with conventional UC.Materials and MethodsWe reviewed records of 201 patients treated with RC and pelvic lymph node dissections. Demographics as well as clinico-pathologic parameters, including histopathological variant, tumor stage, and nodal status, were reviewed. Multivariate analyses were used to evaluate these parameters for overall survival (OS). Kaplan-Meier curves for overall and cancer-specific survival were plotted.ResultsThe majority of patients were male (84%), and the mean age was 61±13.1 years (range, 27-87 years). The mean follow-up was 67 months (range, 6-132 months). A histological variant of UC tumor was found in 19 patients (11%). The OS was 55%, and the cancer-specific survival was 35%. The histopathologic variance showed significant impact on morbidity and mortality (p=0.02 and p=0.05, respectively). Patients with divergent histopathology of bladder tumor have poorer survival than do those with UC in a multivariate analysis.ConclusionsThe pathologic stages at RC and lymph node involvement are predictors for OS. Because of its aggressive nature, histopathologic variance is an independent risk factor determining the outcome in terms of both morbidity and mortality.

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“…propose that patients proven to be non‐CR after induction CRT in bladder‐sparing approaches be grouped into different risk groups for death based on conventional pathology of cystectomy specimens . In patients who underwent radical surgery, pT3–4a (HR 8.3 vs pT0–2, P < 0.001) and pN+ (HR 3.0 vs pN0, P = 0.037) were found to be independent risk variables among other factors including pT stage, lymph node yield at surgery, pN stage and lymphovascular invasion . Patients proven to be non‐CR were grouped by the risk factors into low‐ (pT0–2pN0, 5‐year CSS rate 85%) and high‐risk (pT3–4a or pN+, 5‐year CSS rate 20%) groups …”

Section: Principles Of Bladder Preservationmentioning

confidence: 99%

Can bladder preservation therapy come to the center stage?

et al. 2017

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Decision-making in urological cancer care requires a multidisciplinary approach for refinement, but its impact on urothelial carcinoma of the bladder has not been fully addressed for the past three decades, except for the latest immunological checkpoint inhibitor approved by the U.S. Food and Drug Administration for metastatic muscle-invasive bladder cancer that is resistant to platinum-based chemotherapy. For the time being, radical cystectomy is the gold standard of curative therapy for muscleinvasive bladder cancer. Trimodal therapy that combines chemotherapy for the purpose of radiation sensitization, external beam radiotherapy and transurethral resection of bladder tumor has emerged as a potential alternative treatment option that preserves the bladder. In lack of randomized studies for bladder preservation therapy compared with surgery, the principles of management of urothelial carcinoma of the bladder have evolved in recent times, with an emphasis on bladder preservation. A number of bladder preservation techniques are available to the surgeon; however, appropriately selected patients with muscle-invasive bladder cancer should be offered the opportunity to discuss various treatment options, including organ-sparing trimodal therapy. The aim of the present study was to compare the primary outcomes of the available treatment methods and identify the sources of variance among studies. A review of various bladder preservation techniques in vogue for the management of urothelial carcinoma of the bladder is discussed.

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Pathology‐based risk stratification of muscle‐invasive bladder cancer patients undergoing cystectomy for persistent disease after induction chemoradiotherapy in bladder‐sparing approaches

Cited by 14 publications

References 30 publications

Selective bladder preservation with curative intent for muscle‐invasive bladder cancer: A contemporary review

Selective bladder preservation with curative intent for muscle‐invasive bladder cancer: A contemporary review

Impact of Histopathological Variant on the Outcome of Patients Treated by Radical Cystectomy

Can bladder preservation therapy come to the center stage?

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