Diagnostic Laparoscopy and Abdominal Cytology Reliably Detect Peritoneal Metastases in Patients with Urachal Adenocarcinoma.

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.

Penile sparing surgery for penile cancer-does it affect survival?

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.

Contemporary management of regional nodes in penile cancer-improvement of survival?

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.

Prostate sparing cystectomy for bladder cancer: 20-year single center experience.

PURPOSE: We evaluated long-term oncologic and functional results after prostate sparing cystectomy for bladder cancer. MATERIALS AND METHODS: A total of 120 patients with cT1-4N0-3 bladder cancer were treated with prostate sparing cystectomy between 1994 and 2013, of whom 110 had a followup of 2 years or greater and were eligible for analysis. To rule out tumor in the bladder neck, prostatic urethra or prostate cancer all patients underwent preoperative transurethral biopsy of the bladder neck and prostatic urethra, prostate specific antigen measurement and transrectal ultrasound with biopsies. We assessed oncologic outcomes (disease specific and recurrence-free survival), recurrence rates, prostate cancer and functional results (continence, voiding, and erectile and ejaculatory function). RESULTS: Mean patient ± SD age was 56.2 ± 8.3 years and median followup was 77.0 months (IQR 57-116). Two and 5-year disease specific survival rates were 76.2% and 66.5%, 2 and 5-year recurrence-free survival rates were 71.2% and 66.6%, and distant and local recurrence rates were 34.2% and 10.0%, respectively. One local recurrence was in the remnant prostatic urothelium. Prostate cancer was diagnosed in 2.7% of cases. Complete daytime and nighttime continence was achieved in 96.2% and 81.9% of patients, and erectile function and antegrade ejaculation were intact in 89.7% and 35.5%, respectively. CONCLUSIONS: Our long-term data show that prostate sparing cystectomy is an oncologically safe procedure with excellent functional results in a subset of carefully selected patients with bladder cancer without evidence of urothelial carcinoma in the prostatic urethra/bladder neck and no prostate cancer.

Occult lymph node metastases in patients with carcinoma invading bladder muscle: incidence after neoadjuvant chemotherapy and cystectomy vs after cystectomy alone.

OBJECTIVE: To investigate the effect of neoadjuvant chemotherapy (NAC) on the incidence of lymph node (LN) metastases in clinically node-negative (cN0) patients with carcinoma invading the bladder muscle (MIBC). PATIENTS AND METHODS: Between 1990 and 2012, 828 consecutive patients underwent radical cystectomy (RC) with extended pelvic LN dissection (ePLND), of whom 441 had cT2-4N0M0 stage disease. A total of 83 patients received NAC then underwent RC and 358 patients underwent RC only. The ePLND template and the indication for NAC remained the same during the study period. The incidence of occult LN metastases was compared between the groups. Unadjusted and adjusted odds ratios (ORs) were calculated to investigate the influence of NAC, cT stage, gender and the preoperative staging technique used (computed tomography [CT] or positron emission tomography/CT) on the occurrence of LN metastases. Overall survival (OS) and disease-specific survival were analysed using the Kaplan-Meier method. RESULTS: Patients in the NAC group more often had locally advanced MIBC than patients in the non-NAC group (cT3-4: 88.0 vs 30.2%). In the NAC group, 19.3% of patients had LN metastases vs 28.5% of the patients in the non-NAC group (P = 0.099). In the patients with cT3-4 disease, the occurrence of LN metastases was significantly lower in the NAC group than in the non-NAC group (21.9 vs 40.7%, respectively, P = 0.002). In multivariable analysis, adjusting for cT stage, gender and staging method, NAC was independently associated with a lower likelihood of LN metastases (OR: 0.41, 95% CI 0.21-0.79; P = 0.008). Among the patients with cT3-4 disease, the median OS was significantly longer in the NAC group than in the non-NAC group (68.0 vs 23.0 months, P = 0.047) CONCLUSION: These data suggest that, along with a downstaging effect on the primary bladder tumour, NAC is associated with a lower incidence of occult LN metastases at the time of RC.

Local control rate and prognosis after sequential chemoradiation for small cell carcinoma of the bladder.

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.

Extravasation of intravesical chemotherapy for non-muscle-invasive bladder cancer.

PURPOSE: To report our experience with symptomatic extravasation of intravesical chemotherapy administered within 24 h after transurethral resection (TUR) over the past 10 years. METHODS: We identified all consecutive patients who presented with symptomatic extravasation of intravesical chemotherapy following TUR between 2001 and 2011. We assessed the severity of the postoperative complications using the modified Clavien system. RESULTS: We identified 9 patients (mean age 59, range 40-76 years) with symptomatic extravasation. One patient had grade II, 2 had grade IIIa, and 5 patients had grade IIIb complications according to the Clavien system. Surgery was needed in 6 of 9 patients. One required ICU management (Clavien IV). No patients died in the postoperative course. CONCLUSION: Extravasation can cause severe complications and diagnosis is often protracted. Considering the growing practice of immediate intravesical instillations, the number of patients with symptomatic extravasation is expected to rise. An increased awareness of this possible complication is warranted.

Value of SPECT/CT for detection and anatomic localization of sentinel lymph nodes before laparoscopic sentinel node lymphadenectomy in prostate carcinoma.

UNLABELLED: Laparoscopic evaluation of sentinel nodes is useful for staging prostate cancer, but preoperative localization of deep abdominal sentinel nodes with planar lymphoscintigraphy is difficult. We evaluated the value of SPECT/CT for detecting and localizing sentinel nodes in prostate cancer. METHODS: (99m)Tc-nanocolloid was injected peri- and intratumorally, guided by transrectal ultrasonography, in 46 patients with prostate cancer of intermediate prognosis. Patients underwent planar imaging after 15 min and 2 h, SPECT/CT after 2 h, and laparoscopic sentinel node lymphadenectomy on the same day. SPECT was fused with CT and analyzed using 2-dimensional orthogonal slicing and 3-dimensional volume rendering. We evaluated the number of extra sentinel nodes found by SPECT/CT, the number of sentinel nodes found by SPECT/CT outside the area of the extended pelvic lymphadenectomy, and the anatomic information provided by SPECT/CT. Furthermore, we classified the value of the additional SPECT/CT images into 3 categories (no advantage, presumable advantage, and definite advantage) according to the extra anatomic information given and whether additional sentinel nodes were found by SPECT/CT. RESULTS: The patients had a mean age of 64 y (range, 53-74 y) and received a mean injected dose of 218 MBq (range, 147-286 MBq). The sentinel node visualization rate was 91% (42 patients) for planar imaging and 98% (45 patients) for SPECT/CT. In 29 of the 46 patients (63%), SPECT/CT revealed additional sentinel nodes (especially lymph nodes near the injection area) not seen on planar imaging. In 7 patients, those additional sentinel nodes were positive for metastasis (being the exclusive metastatic sentinel node in 4 patients). Overall, 15 patients (33%) had positive sentinel nodes. Sentinel nodes outside the area of extended pelvic lymphadenectomy were found in 16 patients (35%), whereas in 56% of these patients those nodes were not seen on planar imaging. Performing SPECT/CT had no advantage in 13% of the patients, a presumable advantage in 24%, and a definite advantage in 63%. Urologic surgeons used the SPECT/CT images to guide their trocar insertion sites and sentinel node finding with the probe. CONCLUSION: More sentinel nodes can be detected with SPECT/CT than with planar imaging alone. In comparison with planar imaging, SPECT/CT especially reveals extra sentinel nodes near the prostate and outside the area of the extended pelvic lymphadenectomy. Furthermore, the modality provides useful additional information about the anatomic location of sentinel nodes within and outside the pelvic area, leading to improved intraoperative sentinel node identification.

Long-term survival after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with peritoneal metastases of urachal cancer.

INTRODUCTION: 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). MATERIALS AND METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Induction chemotherapy followed by surgery in node positive bladder cancer.

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.

A phase II study of presurgical sunitinib in patients with metastatic clear-cell renal carcinoma and the primary tumor in situ.

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.

[Pregnancy following sexuality-preserving cystectomy for bladder carcinoma]. / Zwangerschap na seksualiteit preserverende cystectomie wegens blaaskanker.

Two women aged 33 and 28 years, respectively, were treated by sexuality-preserving cystectomy for urothelial cell carcinoma of the bladder, i.e. cystectomy with preservation of the uterus and appendages. Both became pregnant following this surgical intervention and had a healthy child following an uncomplicated vaginal delivery. There is a high risk for complications in such pregnancies and supervision should be carried out by both a gynaecologist and an urologist. The most important complications are repeated urinary tract infections, hydronephrosis, incontinence and pressure on the reconstruction from the growing uterus leading to smaller capacity and problems with self-catheterisation. From an oncological point of view it is wise to advise patients to postpone pregnancy until at least two years after surgery.

Cognitive complaints and cognitive impairment following BEP chemotherapy in patients with testicular cancer.

INTRODUCTION: There is growing concern that some cytotoxic regimens for cancer affect cognitive functioning. This study examined the prevalence of cognitive complaints and deficits in testicular cancer (TC) patients treated with the worldwide standard BEP (bleomycin, etoposide and cisplatin) chemotherapy. MATERIALS AND METHODS: Seventy TC patients treated with BEP chemotherapy after surgery (S + CT) were examined with interviews and neuropsychological tests. These patients were compared with 57 TC patients treated with radiotherapy after surgery (S + RT) and with 55 TC patients that received surgery only (S). Patients were examined a median of 3 years after completion of treatment. RESULTS: Thirty two percent of the S + CT patients reported cognitive complaints compared with 32% of the S + RT patients and 27% of the S patients (p = 0.85). No differences in mean cognitive test performance were observed between the groups. On individual impairment scores, more S + CT patients showed cognitive dysfunction compared with S patients, but not compared with S + RT patients (S + CT versus S [p = 0.038, OR = 4.6, CI = 1.1-19.7], S + CT versus S + RT [p = 0.70, OR = 0.8, CI = 0.3-2.4] and S + RT versus S [p = 0.070, OR = 3.7, CI = 0.8-15.7). Cognitive complaints were not related to cognitive test performance, but to emotional distress and fatigue. DISCUSSION: Cognitive complaints are common among TC patients, independent of treatment modality. These complaints are related to emotional distress and fatigue and not to formal cognitive deficits. The finding of a small group of TC patients treated with chemotherapy exhibiting cognitive deficits should be confirmed in a prospective study before we can decide on its cause and relevance.

Urinary diversions after cystectomy: the association of clinical factors, complications and functional results of four different diversions.

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.

Interferon alpha 2b as medical selection for nephrectomy in patients with synchronous metastatic renal cell carcinoma: a consecutive study.

OBJECTIVE: Up to 25% of the patients with synchronous metastatic renal cell carcinoma (mRCC) treated with nephrectomy and interferon alpha-2b (IFN-alpha) will progress rapidly at metastatic sites and undergo needless surgery for an asymptomatic primary. We reversed the timing of surgery and immunotherapy and evaluated the role of initial IFN-alpha as selection for nephrectomy. PATIENTS AND METHODS: Sixteen patients with mRCC and the primary in-situ received initial IFN-alpha for 8 weeks (2 weeks 5x3x10(6)IU/wk; 2 weeks 5x6x10(6)IU/wk; 2 weeks 5x9x10(6)IU/wk and 2 weeks 3x9x10(6)IU/wk). Patients with either partial remission (PR) or stable disease (SD) underwent nephrectomy followed by IFN-alpha maintenance at 3x9x10(6)IU/wk. Patients were evaluated with regard to age, sex, metastatic sites, morbidity, response, nephrectomy rate, time to progression and survival. RESULTS: Thirteen patients received 2 months of preoperative IFN-alpha; 3 stopped during the 2 months period due to progressive disease (PD). Eight patients developed either a PR (n=3) or SD (n=5) at metastatic sites and underwent nephrectomy. Survival at 1 year is 50% (4/8 patients). Median progression-free survival was 6 months (3-17 months). Two of the 3 patients with PR developed a CR after 2 months maintenance following surgery. Eight patients with PD did not undergo surgery and had a median survival of 4 months (range 1-8 months). CONCLUSIONS: Absence of progression at metastatic sites following IFN-alpha with the primary tumor in place may be used as selection for nephrectomy in patients with an intermediate prognosis. Currently, a randomized study is underway to assess the role of initial versus delayed nephrectomy in combination with IFN-alpha with regard to morbidity and survival.

Small cell carcinoma of bladder: a single-center prospective study of 25 cases treated in analogy to small cell lung cancer.

OBJECTIVES: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Salvage cystectomy after failure of interstitial radiotherapy and external beam radiotherapy for bladder cancer.

OBJECTIVE: To evaluate the long-term results of salvage cystectomy after interstitial radiotherapy (IRT) and external beam radiotherapy (EBRT) for transitional cell carcinoma, and to assess the morbidity and functional results of the different urinary diversions used. PATIENTS AND METHODS: The records of 27 patients treated with salvage cystectomy in one institution between 1988 and 2003 were retrospectively analysed. RESULTS: Salvage cystectomy was used after failure of IRT in 14 or EBRT in 13 patients, with a 3- and 5-year survival probability of 46% (95% confidence interval 26-65) and 33 (11-54)%. The 5-year overall survival after cystectomy was 54% after IRT and 14% after EBRT (P = 0.12). Tumour category, response to radiation, American Society of Anesthesiology score, and complete tumour resection had a significant influence on survival. Five of seven patients with incomplete resection died because of local disease, with a median survival of 5 months. There was clinical understaging after radiotherapy in 41% of patients. Nine patients had an orthotopic neobladder, with complete day- and night-time continence in eight and four, respectively. All patients but one had good voiding function. There were early complications in two and late complications in six patients (for Bricker, seven of 14 and none; for Indiana, none of four and two of four). The duration of hospitalization was not influenced by the type of diversion. Erectile function was maintained in four of six patients after a sexuality-preserving cystectomy and neobladder. CONCLUSIONS: Salvage cystectomy can be performed with acceptable morbidity using any type of urinary diversion. Understaging after radiotherapy is common, but preoperative selection needs improving. A very significant factor for an adverse outcome and death from local tumour recurrence was incomplete resection, suggesting that salvage cystectomy should only be attempted if complete resection is probable.