Urothelial CancerSurvival Outcomes After Immediate Radical Cystectomy Versus Conservative Management with Bacillus Calmette-Guérin Among T1 High-grade Micropapillary Bladder Cancer Patients: Results from a Multicentre Collaboration
Introduction
Approximately 75% of all bladder cancers (BCa) occur as non–muscle-invasive bladder cancer (NMIBC) confined to mucosa and lamina propria [1], which could effectively be treated with transurethral resection of the bladder (TURB) and intravesical bacillus Calmette-Guérin (BCG) immunotherapy in high-risk disease [1]. Management of NMIBC is aimed at preventing recurrence and progression to a muscle-invasive disease requiring radical cystectomy (RC), and several meta-analyses have shown the effectiveness of BCG administered to T1 pure urothelial carcinoma (UC) in reducing both disease recurrence and progression to T2 or higher [2], [3].
However, in approximately 30% of patients [4], BCa may exhibit histological features that differ from those of usual pure UC and correlate with worse prognosis [5], requiring individualised therapy. Among these variant histologies, micropapillary bladder cancer (MPBC) is a highly aggressive carcinoma characterised by the tendency to develop invasive and metastatic diseases [6], [7]. At present, the most effective therapy is still debated [8], [9], especially in an early NMIBC stage, and different approaches are performed. Some authors advocate a conservative management for MPBC confined to lamina propria in an attempt to preserve the bladder without compromising survival outcomes [10], [11], while others, considering its aggressive behaviour, suggest immediate RC even in T1 disease [7], [12], [13]. Currently, due to its rarity and the presence of only small sample size and single-centre studies, literature lacks clear evidence regarding the optimal therapeutic strategy to be performed.
Following these considerations, we retrospectively analysed a large multicentre dataset of 119 patients to assess survival outcomes after immediate RC versus conservative management for T1 high-grade (HG) non–muscle-invasive MPBC.
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Study population
After the approval from each centre’s review board, data of 119 patients with an initial TURB diagnosis of T1 HG MPBC between 2005 and 2019 at 15 European and Asian tertiary referral centres were analysed retrospectively. No neoadjuvant chemotherapy was performed in our T1 cohort [1]. The therapeutic strategy was at the surgeon’s discretion, patient’s preference, and characteristics, such as comorbidities, performance status, and life expectancy. Immediate RC consisted of RC with pelvic lymph
Study population
Descriptive characteristics of the cohort are summarised in Table 1. The majority of patients were men (74.8%), with a median age of 70 yr (IQR 62–76). Pure MPBC, concomitant LVI, and CIS were observed in 41.2%, 25.2%, and 22.7% of patients, respectively. A comprehensive flow chart of different strategies is depicted in Figure 1. Immediate RC and conservative management were performed in 32 (27%) and 87 (73%) patients, respectively. Within a median follow-up time of 35 mo (IQR: 19–64), 21
Discussion
MPBC, first described in 1994 by Amin et al [22], is a rare variant histology of BCa, the prototype of which is represented by the papillary serous carcinoma of the ovary. It exhibits aggressive behaviour, resulting in an increased incidence of lymph node invasion and distant metastasis compared with pure UC [7], [18]. At present, studies with only small sample size and single-centre experience were published, and little is known about the most effective therapy for T1 MPBC. Indeed, even in the
Conclusions
Conservative management with BCG immunotherapy could achieve satisfactory results compared with immediate RC among T1 non–muscle-invasive MPBC patients. However, the risk of disease recurrence and progression among individuals with pure MPBC or LVI suggests preferring conservative management only among T1 MPBC patients with neither pure MPBC nor LVI at initial diagnosis. At present, in the absence of trials evaluating the optimal therapeutic strategy for this rare disease, our study represents
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2023, European Journal of Surgical OncologyCitation Excerpt :These observations indicated that SBC is invariably more aggressive than UBC, regardless of stage and RC status. Additionally, it might be extrapolated from the current data that in presence of SBC, an early RC should be very strongly considered even for non-muscle-invasive disease, as already postulated for other bladder cancer variant histological subtypes [26,27]. Taken together, these observations validated the reduction in CSM associated with RC in SBC, in both OC and NOC stages.
Variant histologies in bladder cancer: Does the centre have an impact in detection accuracy?
2022, Urologic Oncology: Seminars and Original InvestigationsCitation Excerpt :In the PURE-01 trial, 86% of patients with SCC treated with neoadjuvant pembrolizumab had downstaging to pT ≤ 1, which makes these patients potential candidate for neoadjuvant immunotherapy rather than standard chemotherapy [22]. Despite its role in addressing the proper management, only sparse evidence specifically focused on the diagnostic accuracy of TURB in detecting VH compared to RC specimen [7,23–25]. In our study, 45% of VH reported at TURB were not confirmed at RC specimen.
Implications for diagnosis and treatment strategies in non-muscle invasive bladder cancer with variant histology: a systematic review
2023, Minerva Urology and Nephrology
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These authors shared first authorship.