Homburg, Germany--A combined approach of chemotherapy and surgical resection is not only feasible, it may be preferable to chemotherapy alone in some patients with advanced urothelial cancer, German researchers report.
The dual-modality treatment yielded a 3-year tumor-specific survival rate of 92% and an overall survival rate of 85% in a cohort of 14 patients.
"We found that, if we treat patients with distant lymph node metastasis with inductive chemotherapy and see a response, then often these lesions are resectable," said Marcus Hack, MD, a urologic fellow working with Michael Stöckle, MD, at Saarland University Hospital in Homburg. "These patients had a very good prognosis after surgical resection of their metastasis-better than treatment with just chemotherapy."
"It's difficult to say which patients would benefit most from this approach, but I suspect that it may be patients with sole metastasis and small-volume metastasis who would show good response to the inductive chemotherapy," Dr. Hack said.
'New approach in urology' The 14 patients in the study were evenly divided between those with primary bladder tumors and those with upper-urinary-tract tumors. All but two underwent resection of their primary tumor before diagnosis of distant metastasis. The others had concurrent metastasectomy with cystectomy.
The site of metastasis was the distant lymph nodes in 11 patients and the lungs in three others, while one patient also had metastatic disease in an adrenal gland.
Five patients received gemcitabine-based chemotherapy (Gemzar) to optimal response as pre-emptive treatment before metastasectomy. The other nine had received adjuvant chemotherapy for their resected primary tumors, and seven underwent additional chemotherapy after metastasectomy.
Tumor recurrence was observed in three of the 14 patients at mean follow-up of 19 months, starting from the time of diagnosis of metastatic disease. Chemotherapy and surgery were reapplied in one of those patients and were well tolerated.
In all, three patients died during the course of the study. One death was tumor-related, while two died of other causes.
"This is a new approach in urology," Dr. Hack said at the AUA annual meeting. "If you have metastasis, normally you would use palliative chemotherapy and then stop treatment. Now some groups are trying to resect this metastasis in patients who respond to inductive chemotherapy."
One such group is at the University of Texas M.D. Anderson Cancer Center in Houston. Researchers there examined 31 patients with metastatic urothelial cancer who underwent surgery after undergoing chemotherapy. They found that the median survival from time of metastasectomy was 23 months, and the 5-year survival rate was 33%, suggesting that resection may contribute to long-term disease control when integrated with chemotherapy.