Abstract Purpose We present a single institute experience of the four most widely used diversions after cystectomy in 281 patients, with an evaluation of the association between clinical factors, ...complication rates, functional results, and metabolic complications. Materials and methods Between 1990 and 2005, 281 consecutive cystectomies were performed at our institute. Four different diversions were offered: an ileal conduit according to Bricker (IC; 118 patients), an Indiana pouch (IP; 51 patients), and orthotopic diversions after cystectomy/neobladder (N; 62 patients), or sexuality-preserving cystectomy and neobladder (SPCN; 50 patients). Results Forty-four percent developed early complications: IC 48%, IP 43%, N 42%, and SPCN 38%. High ASA score was the only variable significantly associated with early major complications (ASA 1 vs. 3: HR, 0.32; 95%CI, 0.14–0.72). Late complication rate was 51% with fewer complications in the IC group, IC 39%, IP 63%, N 59%, and SPCN 60% (HR, 0.32; 95%CI, 0.14–0.72), which was explained by fewer uncomplicated urinary tract infections (one third of all late complications) in the IC group. There were no differences in experienced late major complications. We found no significant association between tumour stage, ASA, age, preoperative radiotherapy, gender, and diversion-related complication rates. Complete daytime and nighttime continence, respectively, was achieved in 96% and 73% after IP, 90% and 67% after neobladder, and 96% and 67% after SPCN. Metabolic changes were found in 24% of the patients: 21% after IC, 26% after IP, and 28% after orthotopic diversion (neobladder and SPCN combined); low vitamin B12 was measured in 23%, 15%, and 15% respectively. Conclusions Cystectomy with any subsequent diversion remains a procedure with considerable morbidity. High ASA score was associated with more early complications. Orthotopic diversions provide good functional results, but at the cost of more late complications compared with ileal conduits. We found no evidence that age, ASA score, positive lymph nodes, extravesical tumour growth, or previous radiotherapy were contraindications per se for any diversion.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background
Urachal adenocarcinoma (UrAC) is a rare malignancy that can cause peritoneal metastases (PM). Analogous to other enteric malignancies, selected patients with limited PM of UrAC can be ...treated by cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC).
Objective
The aim of this study was to address the value of diagnostic laparoscopy (DLS) and abdominal cytology (ACyt) for the detection and evaluation of the extent of PM in patients with UrAC.
Methods
A consecutive series of cN0M0 patients with UrAC who underwent DLS with or without ACyt at a tertiary referral center between 2000 and 2018 was assessed. Patients were staged with computed tomography (CT) and/or positron emission tomography (PET)/CT or bone scan. DLS was performed to rule out PM and to evaluate the extent and resectability of PM if seen on imaging. Sensitivity and specificity values were calculated for imaging, DLS, ACyt, and the combination of DLS and ACyt.
Results
Thirty-two patients with UrAC underwent DLS. ACyt was obtained in 19 patients. Four patients had suspicion of PM on imaging. In the 28 patients who were PM-negative on imaging, DLS and ACyt revealed PM in 6 (21%) patients, of whom 5 had macroscopically visible PM; 1 patient had positive ACyt without visible PM. Sensitivity of combined DLS/ACyt for the detection of PM was 91%, with a specificity of 100%, whereas sensitivity of imaging was 36%. DLS correctly predicted resectability in all patients.
Conclusion
Combined DLS/ACyt proved an effective tool to detect occult PM and to evaluate the extent of PM to select UrAC patients for possible treatment with CRS/HIPEC.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Objectives
To assess the long‐term outcome and the risk for local recurrence of patients with small cell carcinoma of the bladder (SCCB) treated with neoadjuvant chemotherapy followed by external ...beam radiotherapy (sequential chemoradiation).
Methods
All consecutive patients with primary small cell carcinoma of the bladder (n = 66), treated in our institution between 1993 and 2011 were retrospectively evaluated from an institutional database. Only patients with limited disease (Tx‐4N0‐1M0) small cell carcinoma of the bladder treated with sequential chemoradiation (n = 27) were included in this study. Recurrence rates, overall survival and cancer‐specific survival were analyzed using the Kaplan–Meier method.
Results
Median time to recurrence was 20 months, median overall survival 26 months, 5‐year overall survival 22.2%, median cancer‐specific survival 47 months and 5‐year cancer‐specific survival 39.6%. For complete responders after neoadjuvant chemotherapy (n = 19), median cancer‐specific survival was 52 months with a 5‐year cancer‐specific survival 45.9% versus a median cancer‐specific survival of 22 months and 5‐year cancer‐specific survival 0.0% for incomplete responders (n = 8; P = 0.034). Eight patients (29.6%) underwent transurethral resections (TUR‐BT) for local recurrences in the bladder. At the end of follow up, four patients had undergone cystectomy for recurrence of disease resulting in a bladder‐preservation rate of 85.2%. Median time to local recurrence was 29 months and median time to distant recurrence was 10 months.
Conclusions
Sequential chemoradiation for limited disease small cell carcinoma of the bladder results in a reasonable outcome with a high bladder preservation rate. Response to neoadjuvant chemotherapy represents a significant prognostic factor in this patient population.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
Objective To evaluate the outcome and prognostic factors of patients with node positive bladder cancer (NPBC), who were eligible for surgery and treated with induction chemotherapy. Methods All ...consecutive patients with NPBC, who were treated with at least 2 cycles of induction chemotherapy and initially scheduled for surgery, between 1990 and 2012, were identified from an institutional bladder cancer database. Induction chemotherapy consisted of MVAC (methotrexate, vinblastine, doxorubicin, and cisplatin) or gemcitabine with cisplatin (Gem/Cis) or carboplatin (Gem/Carbo). Results One hundred forty-nine patients with NPBC (mean age, 60 years; range, 31-79) were treated with induction chemotherapy. Median cancer-specific survival (CSS) was 20 months and 5-year CSS 29.2%. In case of complete pathologic response to induction chemotherapy (N = 40; 26.8%), median CSS was 127 months and 5-year CSS 63.5% ( P <.0001). Clinical and pathologic responses to chemotherapy were predictive parameters with respect to CSS and recurrence-free survival. Combined local and nodal responses resulted in a significantly better outcome, compared with isolated nodal or local response ( P <.0001). Conclusion Prognosis for NPBC remains poor despite the use of induction chemotherapy. Nevertheless, in the present series, 1 of 4 patients showed complete pathologic response to induction chemotherapy with subsequently a significant CSS benefit (median CSS 127 months and 5-year CSS 63.5%). Clinical and pathologic responses to chemotherapy are predictive parameters for outcome.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
To evaluate the feasibility and efficacy of a therapeutic algorithm for the management of small cell carcinoma of the bladder derived from the treatment of small cell lung cancer.
During a 10-year ...period, 25 patients (23 men and 2 women; median age 64 years, with 8 32% older than 75 years) with small cell carcinoma of the bladder were defined as having limited disease (LD) or extensive disease (ED) in analogy to the classification of small cell lung cancer. Patients with LD were eligible for chemotherapy and sequential radiotherapy. Patients unfit for chemotherapy were offered complete transurethral resection and radiotherapy or cystectomy for large symptomatic tumors. Patients with ED were offered palliative chemotherapy.
Of the 25 patients, 17 (68%) had LD and 8 (32%) ED. Without regard to stage, the median survival of those receiving chemotherapy was 15 months versus 4 months for those who did not. The median survival for those with LD was 12 months versus 5 months for those with ED. Nine patients (52.9%) with LD could not undergo chemoradiotherapy because of comorbidity and reduced performance (n = 7), progression (n = 1), or drug-related death (n = 1). Five of those patients underwent TUR and radiotherapy and two cystectomy.
The prognosis of small cell carcinoma of the bladder is poor. This treatment algorithm offers bladder sparing for most patients, with few long-term remissions in patients with small, confined tumors. None of the patients died of locoregional tumor progression, supporting that cystectomy is not the treatment of choice for those with LD. With a significant proportion of elderly patients with comorbidities, chemoradiotherapy was not feasible in more than one half of the patients with LD.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Purpose Management of squamous cell carcinoma of the penis changed in recent decades in favor of penile sparing surgery. We assessed whether penile sparing therapies were increasingly applied in our ...penile squamous cell carcinoma cohort with time and whether penile sparing affected 5-year cancer specific survival. Materials and Methods We reviewed the records of 1,000 patients treated between 1956 and 2012, of whom 859 with invasive tumors were eligible for analysis. Tumors were staged according to the 2009 TNM classification. Binary logistic regression was used to assess penile preservation vs amputation with time. Cancer specific survival was analyzed using the Kaplan-Meier method and multivariable Cox proportional hazards model. Competing risk analysis was done for local recurrence. Results With time significantly fewer penile amputations were performed. The 5-year cumulative incidence of local recurrence as the first event after penile preservation was 27% (95% CI 23–32) while after (partial) penectomy it was 3.8% (95% CI 2.3–6.2, Gray test p <0.0001). Patients treated with penile preservation showed no significant difference in survival compared to patients treated with (partial) amputation after adjusting for relevant covariables. Factors associated with cancer specific survival were pathological T stage, pathological N stage and lymphovascular invasion on multivariable analysis. In the penile preservation group local recurrence as a time dependent variable in a Cox model was not associated with cancer specific survival (HR 0.52, 95% CI 0.21–1.24, p = 0.13). Conclusions Significantly more penile preservation therapies were performed in more recent years. Although patients treated with penile preservation experienced more local recurrences, 5-year cancer specific survival was not jeopardized.
Purpose The management of regional nodes of penile squamous cell carcinoma has changed with time due to improved knowledge about diagnosis and treatment. To determine whether changes in the treatment ...of regional nodes have improved survival, we compared contemporary 5-year cancer specific survival of patients with squamous cell carcinoma of the penis with that of patients in previous cohorts. Materials and Methods In an observational cohort study of 1,000 patients treated during 56 years 944 were eligible for analysis. Tumors were staged according to the 2009 TNM classification, and patients were divided into 4 cohorts of 1956 to 1987, 1988 to 1993, 1994 to 2000 and 2001 to 2012, reflecting changes in clinical practice regarding regional nodes. Kaplan-Meier survival curves with the log rank test and Cox proportional hazards modeling were used to examine trends in 5-year cancer specific survival. Results The 5-year cancer specific survival of patients with cN0 disease treated between 2001 and 2012 was 92% compared to 89% (1994 to 2000), 78% (1988 to 1993) and 85% (1956 to 1987). The 5-year cancer specific survival improved significantly since 1994, the year dynamic sentinel node biopsy was introduced, at 91% (1994 to 2012) vs 82% (1956 to 1993) (p = 0.021). This conclusion still holds after adjustment for pathological T stage and grade of differentiation (HR 2.46, p = 0.01). Extranodal extension, number of tumor positive nodes and pelvic involvement in node positive (pN+) cases were associated with worse 5-year cancer specific survival. Conclusions Despite less surgery being performed on regional nodes, 5-year cancer specific survival has improved in patients with cN0 disease. The number of tumor positive nodes, extranodal extension and pelvic involvement were highly associated with worse cancer specific survival in patients with pN+ disease. In this group other treatment strategies are needed as no improvement was observed.
Objective To investigate response rate (RR) of the primary tumor after presurgical sunitinib before planned cytoreductive nephrectomy (CN) in patients with metastatic renal cell carcinoma (mRCC). ...Secondary endpoints were safety and if this strategy can be used to identify patients who progress rapidly and may not benefit from CN. Methods Prospective study to detect a 25% response evaluation criteria in solid tumors RR (RECIST-RR) in the primary tumor (Simon two-stage design). CN was performed after 2 cycles of sunitinib 50 mg/d. Response in the primary tumor and metastatic sites, change of longest diameter of the primary tumor (Δ-LDT), progression-free survival (PFS), and adverse events were assessed. Results Twenty-two patients with primary mRCC were included. The trial did not enter the second stage because only 1 primary tumor responded partially in the first stage (4.5%). Median Δ-LDT was −9.5% (range 2.2 to −36%). A >10% Δ-LDT was significantly associated with a high probability to survive 2 years ( P = .01). At metastatic sites, 7 patients developed a partial response (31.8%), 7 stable disease (31.8%), and 8 progressive disease (36.4%). Subsequently 3 (13.6%) developed a complete response after CN and continued taking sunitinib. Median PFS is 7 months (range 0-41). Median follow-up is 23 months (range 2-41). Median overall survival has not been reached. Conclusions Downsizing of primary tumors after 2 cycles of sunitinib is modest but associated with long-term survival. Patients with progression of metastases after pretreatment have short survival and are unlikely to benefit from CN.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Urachal adenocarcinoma (UrAC) is a rare malignancy arising from persistent urachal remnants, which can cause peritoneal metastases (PM). Currently, patients with this stage UrAC are considered beyond ...cure. Our objective is to report long-term oncological outcome after cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with PM of urachal adenocarcinoma (UrAC).
We identified 55 patients with UrAC treated at our hospital between 1994 and 2017. Patients were staged with CT, bone scintigraphy and/or PET/CT. From 2001 on, cN0M0 patients underwent staging laparoscopy. Ten patients had PM and were treated with CRS/HIPEC; 35 showed no metastases and underwent local treatment; 10 had distant metastases and received palliative chemotherapy.
Disease-specific survival (DSS) rates were estimated using the Kaplan-Meier method and log-rank tests. Postoperative complications represent a secondary outcome.
The median follow-up was 96.8 months. Of the CRS/HIPEC patients, 5 (50%) developed a recurrence; 4 (40%) died of disease. The 2-yr and 5-yr DSS after CRS/HIPEC were 66.7% and 55.6%, respectively. DSS of the CRS/HIPEC patients did not significantly differ from DSS of patients without metastases who only underwent curative local treatment and was superior to patients with distant metastases (P = 0.012). The overall complication rate after CRS/HIPEC was 60%. Major complications (Clavien 3) constituted 20%. The study is limited by its retrospective nature and the small sample size.
CRS/HIPEC demonstrates satisfactory long-term oncological outcome for patients with PM of UrAC. It may be offered as a potentially curative treatment option for this group of patients.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
