Micropapillary urothelial carcinoma of the urinary bladder: Early surgery or neoadjuvant chemotherapy?

2009 ◽  
Vol 27 (15_suppl) ◽  
pp. e16007-e16007
Author(s):  
I. Ghoneim ◽  
A. Stephenson ◽  
M. Gong ◽  
S. Campbell ◽  
A. Fergany
Keyword(s):  
Lymph Node ◽  
Neoadjuvant Chemotherapy ◽  
Urinary Bladder ◽  
Urothelial Carcinoma ◽  
Radical Cystectomy ◽  
Metastatic Lymph Node ◽  
Systemic Disease ◽  
Clinical Stage ◽  
Cancer Specific Survival ◽  
Extended Lymph Node Dissection

e16007 Background: Micropapillary bladder carcinoma is a rare variant of urothelial carcinoma (UC) of the urinary bladder. As a particularly aggressive variant, patients are often urged to undergo up-front radical cystectomy. Though data is scarce on the treatment outcomes of patients with this entity, we present the case for neoadjuvant chemotherapy as opposed to early cystectomy in the setting of clinically localized micropapillary UC. Methods: A review of records of all patients evaluated at our institution for UC was conducted to identify micropapillary UC of the bladder over the period from 2000–2007. A total of 24 cases were found, and were evaluated for preoperative pathology and clinical stage, treatment course, pathological stage and cancer specific survival. Results: Mean patient age was 67.9 years with 19 males and 5 females. Twenty-one (87.5%) patients had clinically organ confined micropapillary UC at the time of diagnosis, three had minimally enlarged lymph nodes on pelvic CAT scans. Half of our patients had BCG refractory high grade non-muscle invasive UC. Twenty-two patients (91.67%) were offered radical cystectomy as first line management. Extended lymph node dissection was performed in eleven patients (45.83%). Final pathologic examination diagnosed metastatic lymph node involvement in 20 patients (83.33%), with 4 patients (20%) having positive LN outside the standard (pelvic) template of dissection. A stage upgrade was noticed in 95.23% of cases. Median cancer specific survival was 13 months. Survival at one year was 44% and 50% at 2years, with only one patient alive at 5 years. Conclusions: Our results suggest that clinically localized micropapillary UC is often metastatic to LN at the time of presentation. This setting of frequent systemic disease should encourage standard neoadjuvant chemotherapy rather than early surgical management for these patients. Extended LN dissection is warranted in these cases due to the high incidence of nodal involvement outside the standard template. No significant financial relationships to disclose.

Surgical Pathology Findings in Patients Who Have Undergone Radical Cystectomy/Cystoprostatectomy With Extended Versus Standard Lymph Node Dissection for Urothelial Carcinoma of the Bladder: A Contemporary Analysis

2020 ◽  
pp. 106689692093707
Author(s):  
Joshua Kagan ◽  
Mehrdad Alemozaffar ◽  
Bradley Carthon ◽  
Adeboye O. Osunkoya
Keyword(s):  
Lymph Node ◽  
Neoadjuvant Chemotherapy ◽  
Lymph Nodes ◽  
Urothelial Carcinoma ◽  
Radical Cystectomy ◽  
Lymph Node Dissection ◽  
Detrusor Muscle ◽  
Node Dissection ◽  
Extended Lymph Node Dissection ◽  
Positive Lymph Nodes

Radical cystectomy/cystoprostatectomy with pelvic lymph node dissection (with or without neoadjuvant chemotherapy) is the gold standard in the management of patients with urothelial carcinoma (UCa) with muscularis propria (detrusor muscle) invasion. However, it remains controversial how extensive the lymph node dissection should be. In this article, we analyzed the clinicopathologic findings in patients who had radical cystectomy/cystoprostatectomy with extended versus standard lymph node dissection. A search was made through our Urologic Pathology files for radical cystectomy/cystoprostatectomy cases with extended and standard lymph node dissection for UCa. A total of 264 cases were included in the study (218 cystoprostatectomy and 46 cystectomy specimens). Mean patients age was 68 years (range = 32-92 years). Patients in all stage categories had more extended lymph node dissection performed compared with standard lymph node dissection: pT0 (20 vs 7), pTis (40 vs 12), pTa (8 vs 4), pT1 (27 vs 5), pT2 (39 vs 8), pT3 (51 vs 17), and pT4 (18 vs 8). In cases with neoadjuvant therapy there was a 19% lymph node positivity rate compared with a 24% positivity rate in those with no presurgical therapy. The only cases categorized as pT2 and below with positive lymph node metastasis were those that had extended lymph node dissection performed. Positive lymph nodes were more frequently detected in cases that had extended lymph node dissection. More than 35% of the positive lymph nodes were in nonregional distribution. Extended lymph node dissection should be considered in patients with UCa even in the low stage or post-neoadjuvant chemotherapy setting.

Risk group stratification in patients with micropapillary bladder cancer treated with radical cystectomy and/or neoadjuvant chemotherapy.

2015 ◽  
Vol 33 (7_suppl) ◽  
pp. 302-302
Author(s):  
Stephen Bentley Williams ◽  
Mario Fernandez ◽  
Daniel Levi Willis ◽  
Rebecca Slack ◽  
Arlene O. Siefker-Radtke ◽  
...  
Keyword(s):  
Risk Factors ◽  
Bladder Cancer ◽  
Neoadjuvant Chemotherapy ◽  
Urothelial Carcinoma ◽  
Radical Cystectomy ◽  
Clinical Stage ◽  
Recursive Partitioning ◽  
Risk Groups ◽  
Preoperative Risk Factors ◽  
Traditional Risk Factors

302 Background: Micropapillary bladder cancer (MPBC) is an aggressive variant of urothelial carcinoma. We have previously published clinical risk stratification groups for patients with conventional urothelial carcinoma and sought to identify if these were valid in patients with this variant histology. Methods: An IRB approved review of 1910 patients in our radical cystectomy database revealed 106 patients with preoperative diagnosis of ≤cT4aN0M0 MPBC between December 1992 and January 2012 who underwent upfront radical cystectomy (RC, n = 74) or neoadjuvant chemotherapy (NAC) followed by RC (n = 32). To determine whether patients with MPBC can be risk stratified using traditional risk factors, a recursive partitioning analysis (RPA) was performed. Results: In multivariate analyses, hydronephrosis (HR=3.1; p=0.01), and extent of MPBC at transurethral resection (TUR) (HR=1.9; p=0.04) were associated with shortened OS. In the reduced model, clinical stage also achieved significance (HR=2.8; p=0.03). Results were similar for DSS: hydronephrosis (HR=2.4, p=0.03), extent of MPBC (HR=2.1, p=0.03) and clinical stage (HR=4.7, p=0.02). Using the RPA analysis, following risk groups were identified according to OS or DSS: 1) cT1 disease with no hydronephrosis; 2) cT2 or higher with no hydronephrosis; or 3) hydronephrosis (with any cT stage). These groups corresponded to a low, intermediate and high-risk groups with 5-year OS and DSS rates of 85% and 91%, 50% and 57% and 16% and 17%, (p<0.001), respectively. We found these risk groups to hold true in those treated with NAC or upfront RC; those who received NAC trended towards better outcomes. Conclusions: In patients with MPBC, preoperative risk factors can help stratify patients into different risk groups similar to what is seen in patients with conventional UC. Presence of hydronephrosis is an especially ominous sign.

scholarly journals Improving the outcome of patients with muscle invasive urothelial carcinoma of the bladder with neoadjuvant gemcitabine/cisplatin chemotherapy: A single institution experience

2014 ◽  
Vol 8 (3-4) ◽  
pp. 287 ◽  
Author(s):  
Faraj El-Gehani ◽  
Scott North ◽  
Sunita Ghosh ◽  
Peter Venner
Keyword(s):  
Neoadjuvant Chemotherapy ◽  
Urothelial Carcinoma ◽  
Clinical Stage ◽  
Retrospective Chart Review ◽  
Cancer Specific Survival ◽  
Risk Of Death ◽  
Lower Stage ◽  
Carcinoma Of The Bladder ◽  
Muscle Invasive ◽  
Gemcitabine And Cisplatin

Introduction: Neoadjuvant cisplatin-based chemotherapy prior to radical cystectomy (RC) for muscle invasive urothelial carcinoma of the bladder improves survival. This study was undertaken to determine the rate of neoadjuvant gemcitabine and cisplatin use prior to RC and to assess its effect on the pathologic response rates and cancer-specific survival (CSS) and overall survival (OS).Methods: This retrospective chart review examined all patients having a RC between January 1, 2007 and June 30, 2011. We collected patient demographics, pre-treatment clinical stage, type of chemotherapy, post-RC pathologic data and survival data.Results: A total of 251 RC were performed of which 160 were for stage cT2-T4 urothelial carcinoma of the bladder. Of the 160 patients, 91 (57%) received neoadjuvant gemcitabine and cisplatin (GC) and 69 (43%) went straight to RC. Patients receiving neoadjuvant GC had a greater chance of achieving a pathologically lower stage compared to the untreated population: pT0 at 21% vs. 3%; non-invasive cancer at 37% vs. 10%; and organ-confined cancer at 60% vs. 33% (p < 0.001). Survival correlated with pathological stage: ≤pT3a patients had a median OS and CSS of 48.8 and 51.2 months compared to an OS and a CSS in ≥pT3b patients of 21.8 and 28.1 months, respectively (p < 0.0001).Conclusions: Neoadjuvant chemotherapy for urothelial carcinoma of the bladder is more frequently administered at our institution compared to the published literature. We have found that neoadjuvant chemotherapy increases the rate of down-staging, which is associated with a reduced the risk of death from urothelial carcinoma of the bladder.

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