The 3 cases were:
1. 67 year old medically fit male patient who presented with hematuria. Cysto and TURBT, demonstrates muscle-invasive bladder cancer (MIBC), new diagnosis. CT scan shows diffusely irregular bladder thickening and asymmetry in the posterior wall. No known family history. PS 0. Adequate organ function.
2. 65 year old man with prior HG pTa bladder cancer treated with BCG (induction + maintenance) who presents 4 years later with CT Urogram demonstrating right hydronephrosis, lobulated right bladder mass and pelvic adenopathy 2.5 cm (node-positive). TURBT shows HG MIBC with squamous differentiation. Right-sided stent placed, creatinine improves significantly. Gem/Cis 4 cycles completed, good response – hydro resolves, node < 1cm.
3. 84 year old elderly cachectic male presents with 2 months gross hematuria. CT Urogram with 6 cm bladder mass. TURBT with MIBC, new diagnosis. Creatinine 1.2, ECOG worsens to 1, lives with daughter now. Frail.
Steinberg was tasked with providing the surgeon’s perspective, specifically highlighting nuances in the surgical management of these 3 patients. He went through each patient and made some important comments, which are reviewed below.
Patient #1
First, he strongly recommended some additional work-up:
- Additional imaging of upper tracts and chest – never trust outside work-up. Often times they are sent with non-contrast axial imaging or with no delayed image. Complete staging required before making any decisions.
- Get an experienced GU pathologist to review pathology – often times, they may note additional findings (depth of invasion, variant histology, etc) that may change management
- LVI (lymphovascular invasion) – associated with worse prognosis, not often noted by community urologists. Associated with pN+ and pT3+ disease
- Hydronephrosis – the one axial image provided had some right-sided bladder disease. Patient should have evaluation for hydronephrosis. Why?
- Hydronephrosis is associated with node-positive disease (OR 1.94) and cT3+ disease (OR 2.01)
1. Neoadjuvant cisplatin-based chemotherapy
2. Radical cystectomy and lymph node dissection
3. Consideration of trimodal therapy – as an option, but not SOC
With regards to radical cystectomy (RC), he made some good points that need to be considered.
First, this is a radical surgery – so that means removal of the prostate/seminal vesicles and vasectomy for male patients; and for female patients, this is functionally an anterior exenteration (uterus, cervix, vagina, ovaries removed). Occasionally, a vagina can be spared (especially if consider continent neobladder) – if no hydronephrosis, no posterior tumors or bladder neck disease, and if the plane between bladder and vagina is obliterated.
He also noted that lymph node dissection is a critical and required step. Even in some phase III trials, a proportion of patients undergoing at RC did not receive LND. This is unacceptable. However, the extent of dissection is not clear – standard (up to bifurcation of the common iliac vessels), extended (up to bifurcation of aorta or common iliacs), and super-extended (up to take-off of IMA from aorta). There are some ongoing clinical trials that are close to reporting - SWOG 1011 and German Association clinical trial. LEA, a prior randomized trial, failed to show any statistically significant benefit to extended node dissection.
He then went on to discuss patient #2 and some of his thoughts.
1. Repeating TURBT – he strongly recommends repeating TURBT in patients referred from outside. Many urologists, especially for larger tumors or tough location tumors, do a substandard resection. Repeat TURBT is important for staging. He will often use blue light cystoscopy in these procedures to ensure adequate resection.
2. In this patient, options are as follows:
- Observation
- Immunotherapy
- Radiation
- Consolidative cystectomy and LN dissection – this is the preferred option as it has potential therapeutic benefit, better stages the patient, provides tissue for analysis
Lastly, with regards to patient #3, he notes that frailty is an issue in this population. He noted that, as far as his residents have heard him say: “if a patient comes in in a wheelchair or oxygen, but not both, they are candidates for radical cystectomy.” He has had good experience operating on elderly patients – as surgeries are relatively short with minimal blood loss. However, not all patients are candidates.
This patient has 4 options:
1. NAC and RC
2. RC alone
3. Trimodal therapy (maximal TUR, chemo, rad)
4. Palliative TURBT or radiation
He briefly reviewed the literature comparing RC to trimodal therapy but also deferred to Anthony L. Zietman, MD on this topic.
Presented by: Gary Steinberg, MD University of Chicago Pritzker School of Medicine
Read the Corresponding Case-based Discussions:
Jenny Aragon-Ching, Challenges of Perioperative Systemic Therapy of Localized Urothelial Cancer
Anthony Zietman, Bladder-Sparing Strategies in Bladder Cancer
Written by: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, Twitter: @tchandra_uromd at the 2018 ASCO Annual Meeting - June 1-5, 2018 – Chicago, IL USA