RESUMO
OBJECTIVE: To perform a narrative review of the contemporary literature on the diagnosis, prognosis and adjuvant management of muscle-invasive bladder cancer (MIBC) patients with pathological pelvic lymph node involvement (pN+) at radical cystectomy. METHOD: A narrative review of the contemporary literature available on Medline was conducted to report studies evaluating the diagnosis, prognosis and/or adjuvant treatments for MIBC patients with pN+ disease at radical cystectomy. RESULTS: Open or robotic extended pelvic lymph node dissection up to the crossing of the ureter with common iliac vessels can enhance the diagnosis of pN+ MIBC, especially using separate packages for the submission of a maximum number of lymph nodes. The main prognosis factors for pN+ patients are the number of positive and retrieved lymph nodes, lymph node density, extranodal extension as well as lymph node metastasis diameter. Adjuvant chemotherapy is likely to prolong overall survival in pN+ patients treated with radical cystectomy alone while adjuvant immunotherapy using nivolumab has been shown to decrease the risk of recurrence in all pN+ patients, especially those with ypN+ disease after neoadjuvant chemotherapy followed by radical cystectomy. However, few data are currently available on the role of adjuvant radiation therapy, which remains currently experimental for these patients. CONCLUSION: Multiple parameters have been reported to impact the diagnosis and prognosis of patients with pN+ MIBC at radical cystectomy. Adjuvant management is currently based on chemotherapy and immunotherapy with preliminary data on radiation therapy.
Assuntos
Cistectomia , Neoplasias da Bexiga Urinária , Humanos , Neoplasias da Bexiga Urinária/patologia , Bexiga Urinária/patologia , Linfonodos/patologia , Prognóstico , Excisão de Linfonodo , Músculos/patologia , Estudos Retrospectivos , Estadiamento de NeoplasiasRESUMO
OBJECTIVE: The aim of our study was to assess prevalence of geriatric assessment (GA) in patients over 75years with nonmetastatic invasive bladder cancer (MIBC). MATERIAL AND METHODS: We performed a retrospective study between 2000 and 2015. We assessed comobidity by Charlson score and ASA score, geriatric assessement (GA) and treatments. RESULTS: One hundred and twenty one patients were inclued. Median age was 81 (73-95) at diagnosis. Thirty nine patients (32%) were evaluated by GA, G8 screening tool was performed in 16% of patients. Patients without GA were older (82 vs. 81years) and had less comorbidities (Charlson≥2 à 61% vs. 69%). Seventy-four percent of patients received a curarive therapy: 60% were treated by RC, 9% by chemoradiotherapy, 26% received palliative therapy and 15% were only in observation. CONCLUSION: Patients with MIBC over 75years were less evaluated and less treated. Patients in pallative care received mostly observation. Although practices have improved, GA was underused. Care of these patients needs standardization in order to adapt therapeutic to their comorbidities and to treat them with curative intent. LEVEL OF PROOF: 4.
Assuntos
Neoplasias da Bexiga Urinária , Idoso , Idoso de 80 Anos ou mais , Cistectomia , Avaliação Geriátrica , Humanos , Músculos/patologia , Invasividade Neoplásica , Estudos Retrospectivos , Neoplasias da Bexiga Urinária/tratamento farmacológico , Neoplasias da Bexiga Urinária/terapiaRESUMO
INTRODUCTION: Factors predicting response to adjuvant chemotherapy (AC) are required to identify patients who will most benefit from it. The aim of this study was to evaluate the impact of carcinoma in situ (CIS) at radical cystectomy (RC) on recurrence free survival (RFS), cancer specific survival (CSS) and overall survival (OS) of patients treated by AC. MATERIALS AND METHODS: A single-center retrospective study was performed on patients who received AC after RC without pre-RC chemotherapy or trimodal therapy. RESULTS: Among the 150 patients analyzed, 52,7% had CIS on the RC specimens. Baseline characteristics were not significantly different between the CIS negative and positive groups. Most patients received a cisplatin-based AC (74%). The median follow-up of the cohort was 36,4 months. The presence of CIS was not significantly associated to disease-recurrence (OR=0.67; 95%CI=0.35-1.29; P=0.23), cancer related death (OR=0.70; 95%CI=0.36-1.33; P=0.27) or death by any cause (OR=0.80; 95%CI=0.42-1.52; P=0.50). The presence of CIS had no significant impact on RFS (HR=0.86; 95%CI=0.56-1.33; P=0.49), CSS (HR=0.85; 95%CI=0.53-1.36; P=0.50) or OS (HR=0.93; 95%CI=0.60-1.45; P=0.74). CONCLUSION: The presence of CIS on RC specimens did not have an impact on survival of patients treated by AC. CIS could be evaluated as a prognostic factor of response to novel adjuvant regimens such as immunotherapy.
Assuntos
Carcinoma in Situ , Neoplasias da Bexiga Urinária , Carcinoma in Situ/patologia , Quimioterapia Adjuvante , Cistectomia , Humanos , Recidiva Local de Neoplasia , Estadiamento de Neoplasias , Estudos Retrospectivos , Resultado do Tratamento , Neoplasias da Bexiga Urinária/patologiaRESUMO
OBJECTIVE: Achieving negative status of distal ureteral margin at the time of radical cystectomy (RC), and its therapeutic benefit, remains controversial. The aim of this review was to evaluate frequency, reliability and impact of positive distal ureteral margin after radical cystectomy for bladder cancer on upper tract recurrence, cancer specific and overall survival, and to identify best candidates for intraoperative frozen section analyses. MATERIAL AND METHODS: A systemic review was performed following the PRISMA guideline. PubMed/Medline (with following terms; bladder cancer or cystectomy and frozen section or ureteral margin), and Cochrane Library were searched up to April 2020, to identify all papers evaluating distal ureteral margin and discussing clinical interest. Previous reviews and single case reports were excluded. RESULTS: In total, thirty-two relevant studies were identified. Mean rate of positive ureteral frozen section after RC was close to 10% [1.1-25.4%]. Frozen section (FS) achieved a very good specificity [83-100%] and reserved sensibility [45-100%]. In many cases, an initial positive margin on FS can be converted to negative. Positive FS and/or PS (permanent section) were associated with upper urinary tract recurrence (UUTR). Conversion from positive FS to negative PS was associated with low UUTR frequency and better cancer survival in large retrospective studies. The relevant prognostic factor associated with positive FS and/or PS was CIS within the bladder. CONCLUSION: FS should be recommended for patients with CIS within the bladder. Achieving negative FS/PS might be associated with lower rates of UUTR and better survival, for patients with higher life expectancy. Prospective randomized controlled studies need to be performed to provide definitive recommendations in this area.
Assuntos
Cistectomia/métodos , Margens de Excisão , Ureter/cirurgia , Neoplasias da Bexiga Urinária/cirurgia , Humanos , Taxa de Sobrevida , Neoplasias da Bexiga Urinária/mortalidadeRESUMO
OBJECTIVES: To evaluate the efficacy of Continuous Saline Bladder Irrigation (CSBI) after blue light transurethral resection of bladder tumor (TURBT) to prevent recurrence of low- to intermediate-risk Non-Muscle Invasive Bladder Cancer (NMIBC). PATIENTS AND METHODS: We conducted a retrospective study including patients with low- to intermediate-risk NMIBC who underwent TURBT in two urological centers between January 2017 and December 2018. Each TURBT was performed using blue light after intravesical instillation of hexaminolaevulinic acid. The experimental group included patients who received CSBI while the control group included patients without CSBI. When practice, CSBI was started immediately after the surgery and was interrupted 24 hours thereafter. Low-risk NMIBC had a surveillance while intermediate NMIBC had 8 adjuvant endovesical instillations of Mitomycin. The primary endpoint was bladder tumor recurrence free-survival which was defined as the time between the initial TURBT and the date of TURBT for bladder recurrence. RESULTS: A total of 167 patients (median age: 71 years) were included: 20% female, 15% low-risk, 85% intermediate-risk NMIBC. CSBI was performed in 95 cases (57%). No complication related to irrigation was reported. Bladder recurrence was observed in 55 cases (32.9%): 22 (23.1%) in the CSBI group vs. 33 (45.8%) in the control group (P=0.002). Multivariate stepwise logistic regression analysis with backward selection revealed that CSBI (HR 0.47 [0.27-0.81]; P=0.006) and MMC (HR 0.55 [0.31-0.95]; P=0.034) were significantly associated with reduced risk of bladder recurrence. CONCLUSIONS: Continuous saline bladder irrigation reduced the risk of bladder recurrence after blue light TURBT in patients with low- to intermediate-risk NMIBC while being safe. Prospective randomized study is needed to confirm these results. LEVEL OF EVIDENCE: 3.
Assuntos
Cistectomia/métodos , Solução Salina , Irrigação Terapêutica/métodos , Neoplasias da Bexiga Urinária/terapia , Idoso , Terapia Combinada , Intervalo Livre de Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Recidiva Local de Neoplasia/prevenção & controle , Estudos Retrospectivos , Medição de Risco , Neoplasias da Bexiga Urinária/patologiaRESUMO
PURPOSE: To compare quality of life and functional outcomes associated with orthotopic neobladder (ONB) and ileal conduit (IC) after anterior pelvic exenteration for bladder cancer in women, through a multicentric cross-sectional study. METHODS: All women who have undergone an anterior pelvic exenteration associated with ONB or IC for a bladder cancer between January 2004 and December 2014 within the three participating university hospital centers and that were still alive in February 2016 were included. Three distinct auto-administered questionnaires were submitted to the patients: the EORTC QLQ-C30, the EORTC QLQ-BLmi30 and the SF-12. Comparison of response to these questionnaires between women with ONB and those with IC were studied with Mann-Whitney U tests, with a statistically significant P-value set at<0.05. The primary endpoint was the "global health status" sub-score extracted from the EORTC QLQ-C30 questionnaire. The secondary endpoints were the functional sub-scores and symptoms sub-scores obtained with the EORTC QLQ-C30 questionnaire as well as the sub-scores obtained with the EORTC QLQ-BLmi30 and the SF-12 questionnaires. RESULTS: Forty women were included in the study (17 ONB, 23 IC). The primary endpoint was comparable between the ONB and IC women (83.3 vs. 66.7 P=0.22). Similarly, no significant statistical difference could be pointed between the ONB and IC women in terms of secondary endpoints. CONCLUSION: The present study did not report any significance difference in terms of quality of life and functional outcomes between women with ONB and those with IC after pelvic exenteration for bladder cancer. LEVEL OF EVIDENCE: 3.
Assuntos
Qualidade de Vida , Neoplasias da Bexiga Urinária/cirurgia , Derivação Urinária/métodos , Coletores de Urina , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Humanos , Pessoa de Meia-Idade , Inquéritos e QuestionáriosRESUMO
INTRODUCTION: The enhanced recovery program (ERP) is a management mode whose objective is to reduce the risk of complications and allow the patient to recover more quickly all its functional capacities and to reintegrate at most quickly and safely in his usual environment. This intentionally synthetic document aims to disseminate in the urological community the main points of the ERP recommendations for cystectomy. This work, coordinated by AFU, involves several other partners. The full document is available on the "Urofrance" website. Another article will follow on organizational measures. METHOD: The development of the recommendations is based on the method "formalized consensus of experts" proposed by the HAS. The report is based on a systematic review of the literature (January 2006-May 2017), two rounds of iterative quotations and a national proofreading. Levels of proof of conclusions and gradation of recommendations are based on the HAS grid. RESULTS: The bibliographic strategy made it possible to retain 298 articles. Only the recommendations that obtained a strong agreement after the two rounds of iterative listing were retained. The recommendations presented here are in chronological form (before, during, after hospitalization). Twenty-six key points on the technical and organizational measures of ERP have been identified. CONCLUSION: The result of the literature review, supplemented by expert opinion, suggests a significant clinical interest in the application and dissemination of ERP for cystectomy, despite the limited data available for this indication.
Assuntos
Cistectomia/métodos , Recuperação de Função Fisiológica , Neoplasias da Bexiga Urinária/cirurgia , Humanos , Complicações Pós-Operatórias/prevenção & controle , Fatores de TempoRESUMO
INTRODUCTION: Active cancer is a risk factor in the occurrence of venous thromboembolism (VTE). This is the second cause of death for these patients. In onco-urology, some cancers are associated with an increased risk of VTE. The aim of this study was to propose a focus of epidemiology and VTE therapy management. MATERIAL AND METHODS: A systematic analysis of the PubMed® database was performed through the PRISMA methodology using the followings keywords : "neoplasm", "venous thromboembolism", "prophylaxis", "pulmonary embolism", "urology". The original papers were included with a priority on: meta-analyzes, literature reviews, randomized controlled trials and good-level proof cohort studies. Only publications in English or French have been selected. RESULTS: The incidence of VTE was more important in case of renal carcinomas (3.5%/year). When surgery was proposed cystectomy was the riskiest procedure (2.6 to 11.6% VTE). Chemotherapy alone was an important risk factor increasing by a factor of six the occurrence of VTE. Hormonotherapy also increased this risk by induced hypogonadism. The curative treatment for VTE associated with cancers has to be performed through the injection of low molecular weight heparin. The implantation of a prophylactic treatment was not systematic among patients diagnosed with urological cancer. CONCLUSION: The understanding of mechanisms associated with the occurrence of VTE among these patients has enabled to improve patient management, especially those suffering from urological cancer. Undeniably, frequency of VTE is probably underestimated by urologists during clinical practice.
Assuntos
Neoplasias Urológicas/epidemiologia , Neoplasias Urológicas/terapia , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/terapia , Humanos , Incidência , Neoplasias Urológicas/complicações , Tromboembolia Venosa/complicaçõesRESUMO
INTRODUCTION: Platinum-based neoadjvant chemotherapy (NAC) before radical cystectomy (RC) is the gold standard in the treatment of muscle invasive bladder cancer (MIBC). We aimed to compare the peri-operative morbidity in patients treated by NAC then RC and patients having RC alone. METHODS: Between 1st January 2008 and 31st December 2015, we retrospectively included consecutive patients undergoing RC for MIBC in 2centers. We collected clinical, pathological and peri-operative data (30day post operative complications according to the Clavien-Dindo score, delayed complications, pathological results). Patients treated by NAC (NAC-RC group) before RC were compared to patients performing RC alone. The NAC-RC group received 1 to 6cycle of high-dose MVAC, MVAC or gemcitabine-cisplatine chemotherapy. Logistic regression identified independant factors of peri-operative complications. RESULTS: We included 199 patients: 48in the NAC-RC group and 151in the RC group. Complications rate was 73.9% in the NAC-RC group versus 73.8% in the RC group (P=1.0). In multivariate analyses, only the Charlson score was associated with an increased risk of peri-operative complications (P=0.05). PT0 tumour rate was significantly higher in the NAC-CR group (50% vs 7%, P<0.001). CONCLUSION: NAC does not increase the peri-operative morbidity of the RC. Patients' pre operative comorbidities is the main risk factor for peri-operative complications.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Cistectomia/métodos , Complicações Pós-Operatórias/epidemiologia , Neoplasias da Bexiga Urinária/terapia , Idoso , Cisplatino/administração & dosagem , Desoxicitidina/administração & dosagem , Desoxicitidina/análogos & derivados , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante/métodos , Invasividade Neoplásica , Estudos Retrospectivos , Fatores de Risco , Neoplasias da Bexiga Urinária/patologia , GencitabinaRESUMO
INTRODUCTION: The prevalence of bladder cancer (BC) in neurological patients seems to be similar to that of the general population. However, they are more aggressive with a higher rate of muscle-invasive forms and squamous cells carcinomas. The aim of the current study was to report etiologies, management and outcomes of BC in neurological population. MATERIAL AND METHOD: Were enrolled all neurological patients with a BC diagnosed between 2004 and 2017. The following data were retrospectively reported: age, gender, duration of the disease, mode of discovery, histological type, treatment and outcomes. RESULTS: In total, 27 patients were included: 11 spinal cord injuries, 7 Parkinson's disease, 5 multiple sclerosis, 3 head trauma, 3 brain strokes, 2 cerebral palsies and 1 spina bifida. The histological subtypes were as follows: 22 transitional cells carcinomas, 4 squamous cell carcinomas (SCC), one mucinous adenocarcinoma, one sarcomatoid and one neuroendocrine with 19 high-grade tumors and 15 muscle-invasive bladder cancer. Seven patients (26%) were diagnosed before 15 years history of neurogenic bladder. The mean follow-up was 14 months (1-210 months). Eight deaths were observed, with 5 related to bladder cancer. In our study, smoking habits, voiding mode, lithiasis or infection histories were not related with a more aggressive pattern, such as SCC. CONCLUSION: The high rate of muscle-invasive bladder cancer and aggressive patterns justify neuro-urological follow-up, even before 15 years of neurogenic bladder. LEVEL OF EVIDENCE: 4.
Assuntos
Neoplasias da Bexiga Urinária/etiologia , Neoplasias da Bexiga Urinária/terapia , Bexiga Urinaria Neurogênica/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de RiscoRESUMO
PURPOSE: Postoperative serum C-reactive protein (CRP) can be measured after major abdominal surgery to predict of complications at postoperative day (POD) 4. However, in urology, no studies have been conduced to analyze the role of CRP after radical cystectomy. The present study aims to analyze the relationship between a high postoperative level of CRP and the presence of complications after radical cystectomy for cancer. MATERIALS AND METHODS: This multicenter retrospective study included 313 patients treated with radical cystectomy for cancer between January 2013 and July 2016. Among the patients, 57.5% of patients received urinary diversion using a Bricker ileal conduit, 30.5% an orthotropic ileal neobladder, and 11.5% had an ureterocutaneostomy. RESULTS: Three hundred and thirteen patients were included (mean age 68.1±9.2 years). Among the patients, 26.5% had grade≥2 complications, according to the Clavien-Dindo classification. In multivariate analysis, only CRP level at POD 4 predicted the risk of a complication (P<0.001). CRP>150mg/L at POD 4 was strongly associated with a risk of a postoperative complication after a cystectomy (OR=81.42, 95% CI [25.6-258.3], P<0.001). CRP assessed on POD4 was reliable at ruling out the existence of an infectious complications with a negative predictive value of 0.94. The main limitation of our study was it observational design. CONCLUSIONS: CRP at POD4 with a threshold of 150mg/L would reliably predict the risk of postoperative complications after cystectomy. Monitoring postoperative CRP could help adapt rehabilitation protocols after radical cystectomy and also the early management of complications.
Assuntos
Proteína C-Reativa/metabolismo , Cistectomia/efeitos adversos , Infecções Intra-Abdominais/diagnóstico , Infecções Intra-Abdominais/etiologia , Idoso , Biomarcadores/sangue , Cistectomia/métodos , Feminino , França , Humanos , Infecções Intra-Abdominais/sangue , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco , Sensibilidade e Especificidade , Neoplasias da Bexiga Urinária/cirurgia , Derivação Urinária/efeitos adversosRESUMO
The algorithms for treatment of metastatic cancers are evolving due to positive results obtained with immunotherapy. Therapeutics approaches to stimulate the immune system have already been used in the treatment of kidney and bladder cancer, such as the administration of cytokines and BCG therapy, confirming the immunogenicity of these tumors. The aim of immunotherapies is not only to activate the immune system against tumor cells, but also to take into account the tumor-induced suppressive microenvironment, in particular by removing the anergy of T-cell lymphocytes, and by targeting the co-stimulation inhibitors molecules. Among the genito-urinary cancers, second-line clinical trials have clearly shown that kidney and bladder cancers are sensitive to the inhibition of PD-1/PD-L1 axis and have already achieved FDA approvals for some molecules. Numerous other clinical trials are underway, particularly in first-line treatment in bladder and renal cancers. Refractory testicular cancer could also benefit from these treatments. Other approaches using vaccine therapy especially in castration-resistant prostate cancer are also of interest. We will see, in this chapter dedicated to the urogenital cancers, the benefit of the immunotherapy by resituating it in the genetic and immunological context of each organ. We will also present briefly the therapeutic outlines and the place of biomarkers.
Assuntos
Imunoterapia , Neoplasias Urogenitais/terapia , Antineoplásicos Imunológicos/uso terapêutico , Antígeno B7-H1/antagonistas & inibidores , Antígeno B7-H1/imunologia , Humanos , Neoplasias Renais/tratamento farmacológico , Neoplasias Renais/imunologia , Neoplasias Renais/terapia , Masculino , Terapia de Alvo Molecular , Proteínas de Neoplasias/antagonistas & inibidores , Proteínas de Neoplasias/imunologia , Receptor de Morte Celular Programada 1/antagonistas & inibidores , Receptor de Morte Celular Programada 1/imunologia , Neoplasias da Próstata/tratamento farmacológico , Neoplasias da Próstata/imunologia , Neoplasias da Próstata/terapia , Neoplasias Testiculares/tratamento farmacológico , Neoplasias Testiculares/imunologia , Neoplasias Testiculares/terapia , Microambiente Tumoral , Neoplasias da Bexiga Urinária/tratamento farmacológico , Neoplasias da Bexiga Urinária/imunologia , Neoplasias da Bexiga Urinária/terapia , Neoplasias Urogenitais/tratamento farmacológico , Neoplasias Urogenitais/imunologiaRESUMO
INTRODUCTION: Urothelial carcinomas are the fourth leading cause of cancer in humans. Their incidence is increasing by more than 50% in 25 years. The superficial forms (70% cases) require a close active surveillance to identify frequent recurrences and progression to invasive stage. Our main goal was to identify prognostic molecular markers for bladder cancer that could be used alone or in combination in routine clinical practice. In this aim, we evaluated the capability of the BCA-oligo test based on a CGH array to correctly classify tumoral grade/stage. METHOD: Urinary DNA was extracted from 81 patients with superficial bladder cancer and has been hybridized on the BCA-oligo array. The results from the molecular analysis were correlated with the tumoral grade and stage. RESULTS: Several chromosomal alterations were significantly more frequent in tumors of higher grade and more advanced stage. A significant association was observed between a high grade and the presence of one of these alterations: loss on 6p, gain on 8q or 13q, loss or gain on 9q or 11q, with an odds ratio of 6.91 (95% CI=2.20-21.64; P=0.0009). Moreover, a significant association was found between a more advanced stage (pT1) and the presence of one of these alterations: loss on 6p, gain on 8q, loss or gain on 5p, with an odds ratio of 15.2 (95% CI=3.71-62.58; P=0.0002). CONCLUSION: Our results showed that molecular analyses of superficial bladder cancers based on urinary DNA and the BCA-oligo test could be used as prognostic factor for the tumor evolution, allowing then a more adapted clinical management.
Assuntos
Biomarcadores Tumorais/urina , Carcinoma/genética , Carcinoma/patologia , Aberrações Cromossômicas , DNA/urina , Etilenodiaminas , Morfolinas , Neoplasias da Bexiga Urinária/genética , Neoplasias da Bexiga Urinária/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma/urina , Feminino , Genômica , Humanos , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Estadiamento de Neoplasias , Hibridização de Ácido Nucleico/métodos , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Fatores de Risco , Sensibilidade e Especificidade , Neoplasias da Bexiga Urinária/urina , Urotélio/patologiaRESUMO
The most important criterion for optimal cancer treatment is a correct classification of the tumour. During the last three years, several very important progresses have been made with a better definition of urothelial carcinoma (UC), especially from a molecular point of view. We start having a global understanding of UC, although many details are still not completely understood.
Assuntos
Carcinoma de Células de Transição/classificação , Patologistas , Neoplasias Urológicas/classificação , Biomarcadores Tumorais/análise , Carcinoma Papilar/química , Carcinoma Papilar/classificação , Carcinoma Papilar/patologia , Carcinoma de Células de Transição/química , Carcinoma de Células de Transição/patologia , Humanos , Invasividade Neoplásica , Proteínas de Neoplasias/análise , Neoplasias Urológicas/química , Neoplasias Urológicas/patologia , Urotélio/patologia , Organização Mundial da SaúdeRESUMO
OBJECTIVE: Comment the new WHO histological classification of tumors of the urinary system and male genital organs 2016 and expose the state of art about urothelial carcinogenesis and molecular modifications of bladder cancer, with the consequences on the treatments. MATERIAL AND METHOD: A systematic review of the literature search was performed from the data base PubMed, focused on the following keywords: "bladder cancer", "molecular", "subtypes". RESULTS: The new WHO histological classification of tumors of the urinary system 2016 confirm the importance of pathology in determining the care of patients, especially the grade, the histological type and the infiltration, while taking into account the difficulties. In 2014, the Cancer Genome Atlas reported genetic modifications of bladder cancer. Recently, several studies explored molecular anomalies of bladder cancer and elaborated molecular classifications, analyzing their predictive value. According to the groups, different molecular subtype had been defined: Urobasal A, Urobasal B, genomically unstable, infiltrated, squamous cell carcinoma-like and p53-like luminal bladder cancers. This latter subgroup seems to be chemoresistant. CONCLUSIONS: The molecular biology and classifications allow a better understanding of bladder cancer and could complete in near future histological data to improve patient management.
Assuntos
Neoplasias da Bexiga Urinária/classificação , Neoplasias da Bexiga Urinária/patologia , Humanos , Técnicas de Diagnóstico Molecular , Neoplasias da Bexiga Urinária/genéticaRESUMO
INTRODUCTION: The aim of this study was to report perioperative and oncological outcomes of robot-assisted radical cystectomy (RARC) in a single-center series and to evaluate the impact of the experience on perioperative outcomes. METHODS: Between March 2012 and January 2016, 41 patients underwent RARC associated with extended pelvic lymphadenectomy for muscle-invasive bladder cancer. All RARC included were performed by a single-surgeon in one center. Perioperative and oncological datas were collected prospectively. Recurrence-free (RFS), overall (OS) and cancer-specific survivals (CSS) were estimated using the Kaplan-Meier Method. The impact of the experience on perioperative data was estimated using Spearman's correlation test. RESULTS: Mean age was 67,7years (±10.6). Most patients underwent neoadjuvant chemotherapy (73.2%). Mean operative time and mean estimated blood loss were respectively 319.5minutes (±85.3) and 662.5mL (±360.9). Eight patients needed perioperative blood transfusion (19.5%). Conversion to open surgery was necessary in 3 cases (7.3%). Ileal neobladder was performed in 26.8% of the cases (54.5% being performed intracorporeal), and non-continent urinary diversion in 73.2%. Mean nodal yield was 17.7 (±9.3). Positive surgical margins were observed in 1 patient (2.3%). Mean length of stay was 13.2 days (±9.8). Postoperative complication rate was 46,3%. After a median follow-up of 16months, estimated 2 year-OS and CSS were respectively 62 and 76.1%. Estimated 2-year RFS was 67.6%. Perioperative outcomes improved with experience with a significant decrease in operative time (P=0.04) and a significant increase of nodal yield (P=0.05). CONCLUSION: In this single-center prospective study, satisfactory perioperative and oncological outcomes after RARC were observed despite the learning curve. Perioperative outcomes improved with surgeon's experience. Further studies are needed to confirm these findings. LEVEL OF EVIDENCE: 4.
Assuntos
Cistectomia , Procedimentos Cirúrgicos Robóticos , Neoplasias da Bexiga Urinária/cirurgia , Idoso , Quimioterapia Adjuvante , Feminino , Humanos , Masculino , Terapia Neoadjuvante , Duração da Cirurgia , Complicações Pós-Operatórias , Estudos Prospectivos , Neoplasias da Bexiga Urinária/tratamento farmacológicoRESUMO
INTRODUCTION: Intravesical instillations of BCG represent an established treatment of high-risk non-muscle-invasive bladder cancer but also carry considerable toxicity. The aim of this work was to identify adverse effects, their impact on the treatment and the possible involvement of the BCG strain used. MATERIAL AND METHODS: To evaluate adverse events in terms of incidence, severity and moment of occurrence, we performed a retrospective analysis of all patients treated with BCG in our institution from 1998 to 2012. RESULTS: One hundred and forty-six patients were retained for analysis, 140 (95.9%) finished their first induction cycle. Thirty patients (20.6%) had to stop the treatment because of BCG-related adverse events, 80% of which happened during the first 3 BCG cycles (12 instillations). The strain used may have had a significant impact: 16 out of 42 patients (38.1%) treated with Connaught (Immucyst®) and 14 out of 104 patients (13.5%) treated with Tice (Oncotice®) had to stop treatment because of BCG related adverse events (P=0.0019) with an odds ratio of 2.83 (IC 95%: 1.52-5.23). CONCLUSION: BCG-related adverse events generally occur at the beginning of the treatment and therefore do not limit the use of BCG maintenance therapy. Good instillation practice and, in our series, the shift from Connaught to Tice strain enabled to significantly reduce BCG-related adverse events through time. The potential implication of the BCG strain used should be evaluated in prospective trials.
Assuntos
Vacina BCG/efeitos adversos , Mycobacterium bovis/classificação , Administração Intravesical , Adulto , Idoso , Idoso de 80 Anos ou mais , Vacina BCG/administração & dosagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
INTRODUCTION: Among available urinary diversion, continent cutaneous urinary diversion (CCUD) is not frequently used after cystectomy for malignancy. The aim of our work was to assess mid-term oncological and functional outcomes of CCUD in case of malignancies. PATIENTS AND METHODS: We retrospectively included all patients who underwent CCUD after radical cystectomy for cancer (according Mitrofanoff or Monti's principle) between July 2001 and November 2015 in our department. Perioperative data, oncological and functional outcomes were reported. To measure disease specific quality of life, we used the French version of Bladder Cancer Index. RESULTS: Overall 12 patients were involved in the study. With a median follow-up of 32 months, we noticed one death due to cancer recurrence. Early postoperative complications occurred in 8 patients, with one requiring reoperation. The late postoperative complication rate was 66%, whose 4 patients (33%) presented cutaneous stenosis. Overall satisfaction rate was scored 8.9/10 and body image was preserved for 75% of patients. At last follow-up, continence (no urinary leakage) was achieved for 62.5% of patient. Sexual impairment was significant for 5 patients. CONCLUSION: The CCUD is a valid alternative to other urinary diversions with similar oncological results and with a similar rate of complications. The high satisfaction rate was related to the preservation of body image and the high rate of continence. LEVEL OF EVIDENCE: 5.
Assuntos
Cistectomia , Neoplasias da Bexiga Urinária/cirurgia , Coletores de Urina , Adulto , Idoso , Procedimentos Cirúrgicos Dermatológicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Derivação Urinária/métodosRESUMO
INTRODUCTION: The fear of the deterioration of the patient's condition related to the toxicity of neoadjuvant chemotherapy is a barrier to its development. This multicenter retrospective study aims to present the secondary effects of neoadjuvant chemotherapy and its impact on the achievement of cystectomy. MATERIALS AND METHODS: Patients with urothelial carcinoma classified cT2 to cT4a N0M0 were included. Chemotherapy with 6 cycles of MVAC (methotrexate, vinblastine, adriamycin, and cisplatin) followed by a cysto-prostatectomy or anterior pelvectomy was scheduled. RESULTS: A total 32 patients were included. Six cycles of neoadjuvant chemotherapy were performed in all 11 patients. Shutdown causes were toxicity in 85% of cases. Cystectomy was performed in 86.6% of patients. Surgery was not performed in 6 patients. The reasons were the alteration of the general condition in 2 cases, 2 patients had advanced cancers diagnosed intraoperatively, and 2 refused surgery. Complications of grades 3 and 4 according to the classification of Clavien and Dindo had occurred respectively in 15.3% and 11.5%. DISCUSSION: This study reports results close to what is found in the literature on the effects of neoadjuvant chemotherapy on achieving cystectomy, but it has some limitations: the retrospective analysis of data on surgery and the lack of control group. In addition, the short follow-up does not yet allow to know the long-term oncological results. CONCLUSION: This study supports the fact that the toxicity of neoadjuvant chemotherapy does not seem to cause a significant risk of non-completion of cystectomy. LEVEL OF EVIDENCE: 4.
Assuntos
Carcinoma/terapia , Cistectomia/estatística & dados numéricos , Terapia Neoadjuvante , Neoplasias da Bexiga Urinária/terapia , Idoso , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Carcinoma/patologia , Quimioterapia Adjuvante , Cisplatino/uso terapêutico , Doxorrubicina/uso terapêutico , Feminino , Humanos , Masculino , Metotrexato/uso terapêutico , Pessoa de Meia-Idade , Invasividade Neoplásica , Complicações Pós-Operatórias , Estudos Retrospectivos , Neoplasias da Bexiga Urinária/patologia , Vimblastina/uso terapêuticoRESUMO
OBJECTIVE: Assess the toxicity of neoadjuvant chemotherapy (NAC), its impact on surgical schedule and postoperative morbidity of cystectomy for muscle-invasive bladder cancer (MIBC). PATIENTS AND METHODS: Retrospective multicentric study of 78 patients who underwent a cystectomy from January 2009 to March 2012 for MIBC. The following criteria have been studied: toxicity of NC (WHO classification), precystectomy interval, postoperative morbidity (Clavien), duration of stay, downsizing on CT-scan before cystectomy, and free of cancer pathology (pT0). RESULTS: Seventy-eight patients had been included, thirty-nine had a NAC. Thirty-three percent had a incomplete chemotherapy because of toxicity. Forty-eight percent had a significant toxicity and grade ≥ 3 toxicity was 33%. Median time between diagnosis and cystectomy was 12.6 weeks (0.7-38), 18 weeks with NAC (group 1) versus eight weeks without NAC (group 2) (P=0.01). In case of toxicity, the delay was 3.5 weeks longer (P=0.12). After cystectomy, 60% of patients had at least one postoperative complication; including 23% had major morbidity. NAC did not increase neither postoperative morbidity (P=0.15) nor duration of stay (18 vs 20 days; P=0.2). Radiological response rate to NC was 38%. pT0 rate was 79 vs 7.7%. The increase of precystectomy interval after NC did not worsen the pathological stage (P=0.5). CONCLUSION: NC had a high toxicity, but without impact on postoperative morbidity, and precystectomy interval did not have any impact on the prognosis. LEVEL OF EVIDENCE: 5.