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Surgical Management of Urothelial Carcinoma A 21 st Century Approach

Surgical Management of Urothelial Carcinoma A 21 st Century Approach. Douglas S. Scherr, M.D. Clinical Director, Urologic Oncology Weill Medical College of Cornell University. Estimated new cancer cases. 10 leading sites by gender, US, 2000. 38 300. 14 900.

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Surgical Management of Urothelial Carcinoma A 21 st Century Approach

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  1. Surgical Management of Urothelial CarcinomaA 21st Century Approach Douglas S. Scherr, M.D. Clinical Director, Urologic Oncology Weill Medical College of Cornell University

  2. Estimated new cancer cases.10 leading sites by gender, US, 2000 38 300 14 900

  3. Estimated cancer deaths.10 leading sites by gender, US, 2000 8 100 4 100

  4. Epidemiology • 5th most common cancer in men • 12,000 cancer related deaths/year • 70% present as superficial TCC • “Superficial” = Ta, Tis, T1 • Men>Women

  5. Epidemiology • 2.8% lifetime risk in caucasian men0.9% lifetime risk in African American men • 1% risk in caucasian women0.6% African American women • Carcinogens implicated in bladder cancer – could have 40 year latency period

  6. Risk Factors for Transitional Cell Carcinoma • Cigarette smoking: 2-4 fold increase risk 4-Aminobiphenyl O-toluidine • Arylamine exposure 2-Naphthylamine Benzidine 4-Aminobiphenyl • Chemotherapy – cyclophosphamide • Pelvic radiation therapy

  7. Overview • Role of TUR • Neoadjuvant Chemotherapy • Surgical Principles of Importance • Minimally Invasive Techniques -Robotics -Prostate Sparing Techniques • Future Horizons

  8. TUR vs. TUR + BCGT1, GIII • 153 patients (92 TUR+BCG, 61 TUR alone) 23% in BCG arm had co-existing CIS compared with 10% in TUR alone arm (p=0.04) • 5.3 year median follow up • Recurrence rate: a.) BCG: 70% b.) TUR alone: 75% • Time to recurrence: a.) BCG: 38 months b.) TUR alone: 22 months • Progression Rate: a.) BCG: 33% b.) TUR alone: 36% • Cystectomy Requirement: a.) BCG: 29% b.) TUR alone: 31% • Overall Survival: No significant difference Shahin et al. J Urol 169: 96-100, 2003

  9. Overall Survival Time to cystectomy Recurrence Free Survival Progression Free Survival Shahin et al. J Urol 169: 96-100, 2003

  10. Neoadjuvant Chemotherapy Meta-Analysis • Analysis of data from 2688 individual patients from 10 randomized trials • Clinical stage T2-T4a disease • Platinum based chemotherapy with a significant benefit to overall survival • 13% reduction in risk of death • 5% absolute benefit at 5 years • Overall survival increased from 45% to 50% • No evidence for single agent CDDP Lancet 2003; 361: 1927-34

  11. Neoadjuvant Chemotherapy Meta-analysis Lancet 2003; 361: 1927-34

  12. Neoadjuvant Chemotherapy Meta-analysis Lancet 2003; 361: 1927-34

  13. Neoadjuvant Chemotherapy Meta-analysis Lancet 2003; 361: 1927-34

  14. N Engl J Med 349;9 859-66 August 28, 2003

  15. Patient Characteristics N Engl J Med 349;9 859-66 August 28, 2003

  16. MVAC Toxicities  Grade 3 (n = 150) N Engl J Med 349;9 859-66 August 28, 2003

  17. N Engl J Med 349;9 859-66 August 28, 2003

  18. Survival among Patients Randomly Assigned to Receive Methotrexate, Vinblastine, Doxorubicin, and Cisplatin (M-VAC) Followed by Cystectomy or Cystectomy Alone, According to an Intention-to-Treat Analysis Grossman, H. B. et. al. N Engl J Med 2003;349:859-866

  19. Survival According to Treatment Group and Whether Patients Were Pathologically Free of Cancer (pT0) or Had Residual Disease (RD) at the Time of Cystectomy Grossman, H. B. et. al. N Engl J Med 2003;349:859-866

  20. Survival According to Treatment Group and Whether Patients Had Superficial Muscle Involvement (Stage T2 Disease) or More Advanced Disease (Stage T3 or T4a) Grossman, H. B. et. al. N Engl J Med 2003;349:859-866

  21. Conclusions • Median survival of cystectomy alone was 46 mo c/w 77 mo for combination therapy (p=0.06 by two-sided stratified log rank test) • In both groups, improved survival associated with the absence of residual cancer in the cystectomy specimen • Significantly more patients in the combination group had no residual disease than patients in the cystectomy group (38% vs. 15%, p=<0.001) N Engl J Med 349;9 859-66 August 28, 2003

  22. Diagnosis and StagingThe “Re-Staging TURB” • 78% of T1 tumors have residual tumor at the time of re-staging TURB • 25-40% are upstaged to T2 • If no muscle in first biopsy, approximately 50% of pts are upstaged to T2 • If T1 is restaged and remains T1, only 13% are upstaged at time of cystectomy Herr et al. J Urol, 162: 74-76, 1999 Brauer et al. J Urol, 165: 808-10, 2001 Dalbagni et al, Urology, 10: 19-24, 2003 Dutta et al. J Urol, 166: 490-3. 2001

  23. Radical Cystectomy for T1 TCC • USC Experience: 208 pts with T1 disease Recurrence Free Survival Overall Survival 5 Year 10 Year 5 Year 10 Year 80% 75% 74% 51% Stein et al., J Clin Oncol, 19(3): 666-75, 2001

  24. Early Vs. Late Cystectomy • 90 pts who had TUR + BCG ultimately underwent cystectomy • 41/90 had T1 disease • Median Follow up of 96 mos Early cystectomy (<2 years): 92% survival Late cystectomy (>2 years): 56% survival Herr and Sogani, J Urol, 166: 1296-9, 2001

  25. Natural HistoryT1, GIII TCC • Natural history of T1, G3: -69-80% recurrence rate -33-48% progression rate • “Rule of 30%” a.) 30% never recur b.) 30% die of metastatic TCC c.) 30% require deferred cystectomy

  26. Was the Effect all Chemotherapy?Are surgical variables important? • Post cystectomy survival predicted by: a.) age b.) stage c.) node status d.) negative surgical margins e.) >10 nodes removed • Hazard ratio for death: a.) 2.7 for + surgical margin b.) 2.0 for <10 nodes removed Herr et al. JCO, 22(14): 2781, 2004

  27. Extent of Lymphadenectomy • Is there more to the node dissection than staging? • 1936 Colston and Leadbetter performed studies on 98 cadavers “limited metastatic disease was restricted to the pelvic nodes” • 1946 – Dr. Jewett “cardinal site of metastasis” Colston and Leadbetter, J Urol, 36: 669, 1936 Jewett et al. J Urol, 55: 366, 1946

  28. Extent of Lymphadenectomy • Node positive patients can enjoy long term survival • 24% of grossly node positive disease survived 10 years without adjuvant therapy • More nodes removed correlates with improved survival Sanderson et al. Urol Oncol., 22: 205, 2004

  29. Extent of Lymphadenectomy • Likely no staging advantage to extending the node dissection above the aortic bifurcation • 33% of unsuspected nodes found at common iliacs • Practice patterns vary widely: a.) 40% of cystectomies have no LND b.) 12.7% of LND had <4 nodes removed Lymph node density (# pos nodes/total # nodes) Konety et al. J Urol, 170: 1765, 2003

  30. Extent of Pelvic Lymph Node Dissection IMA Genitofemoral nerve Genitofemoral nerve Aortic Nodes Common Iliac Nodes Hypogastric and Obturator Nodes

  31. Survival By Number Of Lymph Nodes Removed Herr et al. JCO, 22(14): 2781, 2004

  32. Postcystectomy survival by node status and number of nodes removed Herr, H. W. et al. J Clin Oncol; 22:2781-2789 2004

  33. Post Cystectomy Survival Herr, H. W. et al. J Clin Oncol; 22:2781-2789 2004

  34. T1 Bladder Cancer“Superficial?” • Balance between over treatment and under diagnosis • Role of cystectomy • Intravesical Therapy

  35. Prostate Sparing Cystectomy • Role for improved continence and potency • Need to rule out prostate cancer or TCC of prostatic urethra • Functional Results are good: a.) 97% complete continence b.) No episodes of retention c.) 82% maintained potency Vallancien et al. J Urol, 168: 2413, 2002

  36. Prostate Sparing Cystectomy • Incidence of Pca is 30-50% with approx. 48% are clinically significant • 60% of CaP involve the apex (79% significant and 42% insignificant) • 48% of prostates had urothelial ca involvement of which 33% had apical involvement • 61% had no prostatic apical involvement of CaP or Urothelial ca.

  37. U S C / N o r r i s B l a d d e r C a n c e r E x p e r i e n c e i n 1 0 5 4 P a t i e n t s P r o b a b i l i t y o f N o t R e c u r r i n g A c c o r d i n g t o P a t h o l o g i c G r o u p 1 . 0 0 0 . 9 0 O r g a n C o n f i n e d ( n = 5 9 4 ) 0 . 8 0 0 . 7 0 E x t r a v e s i c a l ( n = 2 1 4 ) 0 . 6 0 Probability of Not Recurring 0 . 5 0 0 . 4 0 0 . 3 0 L y m p h N o d e ( + ) ( n = 2 4 6 ) 0 . 2 0 P < 0 . 0 0 1 0 . 1 0 0 . 0 0 0 5 1 0 1 5 Y e a r s f r o m C y s t e c t o m y ( 6 / 7 1 - 1 2 / 9 7 )

  38. U S C / N o r r i s B l a d d e r C a n c e r E x p e r i e n c e i n 1 0 5 4 P a t i e n t s P r o b a b i l i t y o f S u r v i v a l A c c o r d i n g t o P a t h o l o g i c G r o u p s 1 . 0 0 0 . 9 0 0 . 8 0 0 . 7 0 O r g a n C o n f i n e d ( n = 5 9 4 ) 0 . 6 0 Probability of Survival 0 . 5 0 0 . 4 0 E x t r a v e s i c a l ( n = 2 1 4 ) 0 . 3 0 0 . 2 0 P < 0 . 0 0 1 L y m p h N o d e ( + ) ( n = 2 4 6 ) 0 . 1 0 0 . 0 0 0 5 1 0 1 5 Y e a r s f r o m C y s t e c t o m y ( 6 / 7 1 - 1 2 / 9 7 )

  39. U S C / N o r r i s B l a d d e r C a n c e r E x p e r i e n c e P a t i e n t s w i t h P o s i t i v e L y m p h N o d e s ( N = 2 4 6 ) : P r o b a b i l i t y o f N o t R e c u r r i n g A c c o r d i n g t o P a t h o l o g i c G r o u p s 1 . 0 0 0 . 9 0 0 . 8 0 0 . 7 0 0 . 6 0 Probability of Not Recurring 0 . 5 0 L N + : O r g a n C o n f i n e d ( n = 7 5 ) 0 . 4 0 0 . 3 0 L N + : E x t r a v e s i c a l ( n = 1 7 1 ) 0 . 2 0 P = 0 . 0 0 4 0 . 1 0 0 . 0 0 0 5 1 0 1 5 Y e a r s f r o m C y s t e c t o m y ( 6 / 7 1 - 1 2 / 9 7 )

  40. U S C / N o r r i s B l a d d e r C a n c e r E x p e r i e n c e P a t i e n t s w i t h P o s i t i v e L y m p h N o d e s ( N = 2 4 6 ) : P r o b a b i l i t y o f S u r v i v a l A c c o r d i n g t o P a t h o l o g i c G r o u p s 1 . 0 0 0 . 9 0 0 . 8 0 0 . 7 0 0 . 6 0 Probability of Survival 0 . 5 0 L N + : O r g a n C o n f i n e d ( n = 7 5 ) 0 . 4 0 0 . 3 0 0 . 2 0 P < 0 . 0 0 1 L N + : E x t r a v e s i c a l ( n = 1 7 1 ) 0 . 1 0 0 . 0 0 0 5 1 0 1 5 Y e a r s f r o m C y s t e c t o m y ( 6 / 7 1 - 1 2 / 9 7 )

  41. U S C / N o r r i s B l a d d e r C a n c e r E x p e r i e n c e P r o b a b i l i t y o f N o t R e c u r r i n g A c c o r d i n g t o # o f L y m p h N o d e s I n v o l v e d 1 . 0 0 0 . 9 0 0 . 8 0 L y m p h N o d e - ( n = 8 0 8 ) 0 . 7 0 0 . 6 0 Probability of Not Recurring 0 . 5 0 1 - 4 L y m p h N o d e s + ( n = 1 6 0 ) 0 . 4 0 0 . 3 0 > 5 L y m p h N o d e s + ( n = 8 6 ) 0 . 2 0 P < 0 . 0 0 1 0 . 1 0 0 . 0 0 0 5 1 0 1 5 Y e a r s f r o m C y s t e c t o m y ( 6 / 7 1 - 1 2 / 9 7 )

  42. U S C / N o r r i s B l a d d e r C a n c e r E x p e r i e n c e P r o b a b i l i t y o f S u r v i v a l A c c o r d i n g t o # o f L y m p h N o d e s I n v o l v e d 1 . 0 0 0 . 9 0 0 . 8 0 0 . 7 0 0 . 6 0 Probability of Survival L y m p h N o d e - ( n = 8 0 8 ) 0 . 5 0 0 . 4 0 1 - 4 L y m p h N o d e s + ( n = 1 6 0 ) 0 . 3 0 0 . 2 0 > 5 L y m p h N o d e s + ( n = 8 6 ) P < 0 . 0 0 1 0 . 1 0 0 . 0 0 0 5 1 0 1 5 Y e a r s f r o m C y s t e c t o m y ( 6 / 7 1 - 1 2 / 9 7 )

  43. U S C / N o r r i s B l a d d e r C a n c e r E x p e r i e n c e I n c i d e n c e o f R e c u r r e n c e F o l l o w i n g S u r g e r y : L y m p h N o d e s P o s i t i v e T C C ( N = 2 4 6 ) 1 . 0 0 0 . 9 0 0 . 8 0 0 . 7 0 0 . 6 0 Incidence of Recurrence D i s t a n t R e c u r r e n c e ( f = 1 1 3 ) 0 . 5 0 0 . 4 0 0 . 3 0 0 . 2 0 L o c a l R e c u r r e n c e ( f = 2 8 ) 0 . 1 0 0 . 0 0 0 5 1 0 1 5 Y e a r s f r o m C y s t e c t o m y ( 6 / 7 1 - 1 2 / 9 7 )

  44. Outcome of Postchemotherapy Surgery After MVAC for Advanced Transitional Cell Carcinoma Dodd et al, JCO, 1999

  45. Role of Robotics In Bladder Cancer • Decrease in hospital stay • Lower morbidity • Can it compete oncologically?

  46. Conclusion • Bladder cancer is a multidisciplinary disease • Surgery plus chemotherapy are the cornerstone of therapy • New advances in biomarkers and better characterization of T1 disease is necessary

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