Edmund Chiong, MD, presents the take home messages on bladder cancer from the AUA annual meeting in San Diego.
Presented by Edmund Chiong, MD
National University Health System, Singapore
• Radiation therapy for uterine cancer increased risk of bladder cancer and death by 1.7-fold and 2.3-fold, respectively.
• Heavy smokers, especially males, are more likely to have higher grade bladder cancer, more advanced-stage disease, and increased risk of muscle invasion at initial presentation.
• In patients with suspected nonmuscle-invase bladder cancer, fluorescence (blue light) cystoscopy showed a significantly improved detection rate and lower recurrence rate up to 4 years compared to white light cystoscopy. In a separate analysis, fluorescence cystoscopy added to white light cystoscopy significantly increased tumor detection rate and reduced the recurrence rate at 12 months.
• Narrow band imagaing cystoscopy plus bipolar plasma vaporization significantly improved diagnostic accuracy, decreased the rate of repeat transurethral resection (TUR) residual tumor, and reduced 3-year recurrence rates when compared to white light cystoscopy and monopolar TUR.
• Repeat TUR prior to initiation of intravesical bacillus Calmette-Guérin significantly decreased recurrence rates at 3, 6, and 12 months versus no repeat TUR.
• The European Organization for Research and Treatment of Cancer (EORTC) risk tables and the Spanish Urological Club for Oncological Treatment (CUETO) scoring system tended to overestimate the risk of disease recurrence and progression in patients with nonmuscle-invasive disease, and there is a need to improve current predictive tools.
• En bloc resection of bladder tumors using a Thulium laser and HybridKnife appears to offer low morbidity and may allow for more complete tumor resection.
• Molecular imaging by intravesical fluorescent labeled anti-CD47 combined with white light cystoscopy and photodynamic diagnosis may be a novel method to improve diagnosis and help image-guided surgery for bladder cancer.
• The role of FDG PET-CT in detecting positive lymph nodes before radical cystectomy is controversial. No benefit over conventional CT was seen, but some abstracts found it may be superior for detecting recurrence after surgery and may detect nodal metastases between 5 and 10 mm.
• Optical coherence tomography as an adjunct to white light cystoscopy was able to differentiate malignant from benign lesions and helped differentiate Ta, T1, and muscle-invasive stages.
• As a novel biomarker, a methylation of 18 tumor suppressor genes in bladder tumor and urine may allow histopathology and outcome stratification and offer noninvasive utility for diagnosis and prognosis.
• No significant differences in side effects were seen when comparisons were made according to BCG dose (full or one-third) or duration of maintenance (1 or 3 years).
• Use of intravesical gemcitabine (Gemzar) alone or in combination with mitomycin C (MMC [Mutamycin]) or electromotive MMC was able to salvage some BCG failures.
• Early data suggest intravesical nanoparticle albumin-bound paclitaxel (Taxol) may be used in BCG-refractory nonmuscle-invasive disease.
• Radiofrequency hypothermia with intravesical MMC can be used in high- and extremely high-risk nonmuscle-invasive disease patients (69.6% tumor-free rate at 26 months).
• A prospective comparative study suggests similar efficacy between the Tokyo and Connaught strains of BCG, which is applicable in view of the shortage of BCG.
• Smoking is associated with worse prognosis for muscle-invasive disease after radical cystectomy, and its effects are abrogated by more than 10 years of smoking cessation.
• Complete debulking TUR prior to neoadjuvant chemotherapy is strongly associated (twofold increase) with pT0 disease at radical cystectomy.
• Extranodal extension and lymph node density are strong predictors of outcome in node-positive disease after cystectomy.
• Comorbidity status incorporating Charlson comorbidity index, ASA score, Elixhauser index, and ECOG status improves prediction of 5-year all-cause mortality in cystectomy patients.
• Cell-cycle and proliferation-related markers in TUR specimens could guide clinical decision making regarding neoadjuvant chemotherapy and cystectomy in advanced bladder cancer.
• Epidermal growth factor receptor and its mediators’ expression and cellular localization in bladder specimens may have a role in assessing chemosensitivity and disease recurrence in muscle-invasive bladder cancer.
• An enhanced recovery after surgery protocol focused on avoiding bowel preparation and nasogastric tubes, early feeding, non-narcotic pain management, use of an opioid antagonist, and early ambulation. It showed enhanced recovery of bowel function and shortened hospital stays for cystectomy without significant increase in early complications or hospital re-admission rates.
• A peripherally acting opioid receptor antagonist, alvimopan, significantly accelerated GI recovery, shortened length of stay, and improved early in-hospital post-surgical outcomes in radical cystectomy patients.
• Sarcopenia, as measured by psoas muscle area on preoperative CT, is an easily obtained, objective measure of frailty and is associated with longer length of stay and greater 90-day complication rates in patients undergoing cystectomy.
• In patients undergoing open cystectomy with diversion, restrictive intraoperative fluid management (low-volume crystalloid infusion plus norepinephrine) reduces the incidence of intraoperative blood loss, need for transfusion, length of stay, and 90-day complications compared to standard intraoperative hydration.
• The optimal management of T1 micropapillary bladder cancer is still controversial. While one series showed a difference between cystectomy and conservative management, another did not. Micropapillary urothelial carcinoma is usually associated with locally advanced disease at cystectomy.
• Neoadjuvant chemotherapy may benefit those with micropapillary bladder cancer who are downstaged. P0 status at cystectomy portends a good prognosis.
• Extensive micropapillary architecture (>10%) in the TUR specimen is associated with more advanced disease and worse disease-specific survival than focal disease.
• Only a minority of patients received all evaluations required for an initial diagnosis of bladder cancer, and lower adherence to such guidelines could affect patients’ survival.
• About half of patients undergoing radical cystectomy for cT2 and cT3 disease did not have an adequate pelvic node dissection, and predictors for inadequate therapy include median income, distance from hospital, and geographic location.
• About half of patients <65 years old did not undergo radical cystectomy for cT2 or cT3 disease. Predictors for non-therapy include sex, race, insurance status, distance from the hospital, and geographical location.
• An overall increase in use of systemic therapy has been seen over the last decade. Use of neoadjuvant chemotherapy for ≥T2 disease also has been increasing over time, but there is significant variation based on access to care.
• Researchers created an orthotopic bladder cancer xenograft murine model using a novel technique of inoculating cancer cells in the bladder wall by ultrasound guidance using high-precision percutaneous injections.
• High-grade urothelial carcinoma (UC) exosomes from cell lines and urine appear to promote tumor progression. Researchers also identified a new tumor-associated protein that is contained in UC exosomes, which is associated with tumor migration.UT