Early Versus Deferred Cystectomy for Initial High-Risk pT1G3 Urothelial Carcinoma of the Bladder: Do Risk Factors Define Feasibility of Bladder-Sparing Approach?

Denzinger, Stefan; Fritsche, Hans‐Martin; Otto, Wolfgang; Blana, Andreas; Wieland, W.F.; Burger, Maximilian

doi:10.1016/j.eururo.2007.06.030

Cited by 187 publications

(109 citation statements)

References 21 publications

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“…Despite no randomized trials, multiple retrospective studies have shown advantages for disease-specific and overall survivals in patients treated with RC before muscle invasion occurs (13)(14)(15)(16). In these series, reasons to advocate for early RC include residual T1 disease at re-staging resection, extensive multifocal disease, large tumor volume, location making endoscopic management difficult, variant histology, and presence of CIS (2,5,(11)(12)(13)17,18).…”

Section: Discussionmentioning

confidence: 99%

Re-examination of the Natural History of High-grade T1 Bladder Cancer using a Large Contemporary Cohort

Canter¹,

Revenig

Smith

et al. 2014

Int. braz j urol.

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ARTICLE INFO ______________________________________________________________ ______________________Introduction: High-grade T1 (HGT1) bladder cancer represents a clinical challenge in that the urologist must balance the risk of disease progression against the morbidity and potential mortality of early radical cystectomy and urinary diversion. Using two non-muscle invasive bladder cancer (NMIBC) databases, we re-examined the rate of progression of HG T1 bladder cancer in our bladder cancer populations. Materials and Methods:We queried the NMIBC databases that have been established independently at the Atlanta Veterans Affairs Medical Center (AVAMC) and the University of Pennsylvania to identify patients initially diagnosed with HGT1 bladder cancer. Demographic, clinical, and pathologic variables were examined as well as rates of recurrence and progression.Results: A total of 222 patients were identified; 198 (89.1%) and 199 (89.6%) of whom were male and non-African American, respectively. Mean patient age was 66.5 years. 191 (86.0%) of the patients presented with isolated HG T1 disease while 31 (14.0%) patients presented with HGT1 disease and CIS. Induction BCG was utilized in 175 (78.8%) patients. Recurrence occurred in 112 (50.5%) patients with progression occurring in only 19 (8.6%) patients. At a mean follow-up of 51 months, overall survival was 76.6%. Fifty two patients died, of whom only 13 (25%) patient deaths were bladder cancer related. Conclusions: In our large cohort of patients, we found that the risk of progression at approximately four years was only 8.6%. While limited by its retrospective nature, this study could potentially serve as a starting point in re-examining the treatment algorithm for patients with HG T1 bladder cancer.

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Section: Discussionmentioning

confidence: 99%

Re-examination of the Natural History of High-grade T1 Bladder Cancer using a Large Contemporary Cohort

Canter¹,

Revenig

Smith

et al. 2014

Int. braz j urol.

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“…In addition, these patients are more likely to refuse RC compared to MIBC patients. However, in these cases RC should not be delayed, since with increasing time to RC, the survival decreases significantly [17][18][19][20]. What is more, the risk of being upstaged to MIBC increases with time to RC [18].…”

Section: Discussionmentioning

confidence: 99%

Timing of radical cystectomy in Central Europe – multicenter study on factors influencing the time from diagnosis to radical treatment of bladder cancer patients

Poletajew¹,

Braticevici²,

Brisuda³

et al. 2014

CEJU

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Citation: Poletajew S, Braticevici B, Brisuda A, Cauni V, Grygorenko V, Lesnyak M-Z, et al. Timing of radical cystectomy in Central Europe -multicenter study on factors influencing the time from diagnosis to radical treatment of bladder cancer patients. Cent European J Urol. 2015; 68: 9-14. Introduction Time that passes between an unfavourable diagnosis to a radical cystectomy (RC) affects oncological outcomes in patients with bladder cancer. Unsatisfactory survival of patients after RC in Central Europe can potentially result from this factor. Material and methods The aim of this study was to assess the time interval between transurethral resection of the bladder tumor (TURBT) and RC in Central Europe and to identify clinical factors of possible delays. 941 consecutive patients who underwent RC in nine Central European urological centers were enrolled into the study. After the TURBT-RC time was calculated, selected clinical and pathological parameters were tested as potential factors influencing the timing of RC. Results On average, RCs were performed 73.8 days after TURBTs (median -53, range 0-1587). In 238 patients (25.3%) the time exceeded 12 weeks. Patients with muscle-invasive cancer were operated earlier on than patients with nonmuscle-invasive cancer (67.6 vs.105.2 days, RR = 1.41, p = 0.00). In high volume centers (>30 RC per year) longer TURBT-RC intervals were observed (97.6 vs. 66.3 days, RR = 2.49, p = 0.00). Simultaneously, factors such as female sex (RR = 1.21), more advanced age of patient (>65 years, RR = 1.23), presence of concomitant CIS (RR = 2.43), grade of cancer cells (RR = 1.67) and final post-RC stage (RR = 1.51) had no statistically significant effect on the results (p >0.05). Conclusions The mean time interval between the diagnosis and radical treatment of patients with bladder cancer in Central Europe is adequate. However, there are still a relatively high number of patients waiting for radical cystectomy longer than 8 weeks. A lower stage of disease as well as a higher case load within of a hospital may delay the surgery. Article history

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“…Herr et coll showed that of 92 patients with residual T1 cancer in WLre-cTURBT, 75 (82%) progressed to muscle invasion within 5 years compared to 49 of 260 (19%) who had no or non-T1 tumor detected on restaging cTURBT (34). A similar study reported that early cystectomy seems to prolong cancer-specific survival compared to deferred cystectomy in high-risk high-grade T1 patients (35). Considering the high risk of progression and cancer death of high-grade T1 disease, cystectomy would be the best answer for treatment.…”

Section: Discussionmentioning

confidence: 67%

Can re-cTURBT be useful in pT1HG disease as a risk indicator of recurrence and progression? A single centre experience

Giulianelli¹,

Gentile²,

Mirabile³

et al. 2017

Arch Ital Urol Androl

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Introduction: Understaging after initial transurethral resection is common in patients with high-risk non muscle infiltrating bladder cancer (NMIBC) and can delay accurate diagnosis and definitive treatment. The rate of upstaging from T1 to T2 disease after repeated transurethral resection ranges from 0 to 28%, although the rate of upstaging may be even higher up to 49% when muscularis propria is absent in the first specimen. A restaging classic transurethral resection of bladder tumour (re-cTURBT) is the better predictor of early stage progression. According to some reports, the rate of positivity for tumor in re-cTURBT performed within eight weeks after initial cTURBT was as high as 18-77%, and in about 40% of the patients a change in tumor stage was reported. We aimed to investigate, in high risk group, the presence of residual tumor following white light classical transurethral resection of bladder tumor (WLre-cTURBT) and the different recurrence and progression rate between patients with persistent or negative (pT0) oncological disease after WLre-cTURBT. Materials and methods: A cohort of 285 patients presenting with primitive bladder cancer underwent to WLcTURBT from January 2011 to December 2015; out of them 92 (32.28%) were T1HG. In according to EAU guidelines 2011, after 4-6 weeks all HG bladder cancer patients underwent a WL recTURBT . All patients were submitted to a subsequent followup including cystoscopy every 3 months with multiple biopsies, randomly and in the previous zone of resection; urinary citology on 3 specimens and kidney/bladder ultrasound every 6 months. The average follow-up was 48 months. Results: Following WLre-cTURBT we observed a persistent disease in 18 (15.2%) patients: 14 (77.7%) with a HG-NMIBC and 4 (22.2%) with a high grade (HG) muscle invasive bladder cancer (pT2HG). After follow up of all 92 patients according to the guidelines EAU, we observed recurrence in 36/92 (39.1%) and progression in 14/92 (15.2%). Of 14 NMIBC with persistent disease, 10 patients (71.4%) showed recurrence: 4 patients (40%) were pT1HG with concomitant carcinoma in situ (CIS), 3 patients (30%) multifocal pTaHG, 2 (20%) patients CIS and one patient (10%) a muscle invasive neoplasm (pT2HG). Instead of the group of 48 patients pT0 following WL recTURBT, we observed recurrence in 26 patients (54.1%) and in two patients (4.1%) progressions, who presented after 3 months in association with CIS. The remaining 22 patients (45.9%) with initial pT1HG are still progression free. Multivariate analysis showed that the most important variable of early progression were persistent neoplasm and histopathological findings at WLre-cTURBt (p = 0.01), followed by the Summary No conflict of interest declared. INTRODUCTION Bladder cancer is a common genito-urinary malignancy, with transitional cell carcinoma comprising nearly 90% of all primary bladder tumours. At the first diagnosis 70% to 80% of urothelial tumours are confined to the epithelium, the remainder is characterized by muscle invasion. A significant number of patients with high risk non-muscle invasive bladder tumours (HG-NMIBT) treated with white light classic transurethral resection of bladder tumours (WLcTURBT) and intravesical BCG will progress to invasive disease (1-3). Progression to muscle invasion (pT2) mandates immediate radical cystectomy (4). WLcTURBT is the standard initial therapy for NMIBT, but the high percentage of recurrence after surgery is still an unresolved problem (5). High grade pT1 bladder neoplasm (pT1HG) really represents a therapeutic challenge due to the high risk of progression (about 15-30%) to muscle-invasive disease, usually within 5 years (6). However, no consensus exists regarding the treatment of patients with recurrent bladder tumours that invade the lamina propria (pT1) (7-9). Recent studies suggested that the first cTURBT may be incomplete in a significant number of cases (10). Understaging at the time of the initial transurethral resection is common for patients with high-risk NMIBC and can delay accurate diagnosis and definitive treatment. It is therefore recommended for patients with high-risk disease and in those with large or multiple tumors or when the initial transurethral resection is incomplete, to repeat WLre-cTURBT within 2-6 DOI: 10.4081/aiua.2017.4.272 result of the first cystoscopy (p = 0.002) and presence of CIS (p = 0.02). Discussion: Following WLre-cTURBt in HG-NMIBC patients we identified in 15% of cases a persistent disease with a 4.3% of MIBC. In the high risk persistent bladder neoplasms group we observed recurrent and progression rate higher than in T0 bladder tumours group (Δ = + 17.3% and = Δ + 62.5%, p < 0.05

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Early Versus Deferred Cystectomy for Initial High-Risk pT1G3 Urothelial Carcinoma of the Bladder: Do Risk Factors Define Feasibility of Bladder-Sparing Approach?

Cited by 187 publications

References 21 publications

Re-examination of the Natural History of High-grade T1 Bladder Cancer using a Large Contemporary Cohort

Re-examination of the Natural History of High-grade T1 Bladder Cancer using a Large Contemporary Cohort

Timing of radical cystectomy in Central Europe – multicenter study on factors influencing the time from diagnosis to radical treatment of bladder cancer patients

Can re-cTURBT be useful in pT1HG disease as a risk indicator of recurrence and progression? A single centre experience

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