Frank, Igor

Objective To evaluate the incidence, predictors and oncological outcomes of pT 0 prostate cancer ( PC a). Methods We conducted a retrospective analysis of 20 222 patients undergoing radical prostatectomy ( RP ) for PC a at the Mayo Clinic between 1987 and 2012. Disease recurrence was defined as follow‐up PSA >0.4 ng/mL or biopsy‐proven local recurrence. Systemic progression was defined as development of metastatic disease on imaging. Comparisons of baseline characteristics between pT 0 and non‐ pT 0 groups were carried out using chi‐squared tests. Recurrence‐free survival was estimated using the Kaplan–Meier method and compared using the log‐rank test. Results A total of 62 patients (0.3%) had pT 0 disease according to the RP specimen. In univariable analysis, pT 0 disease was significantly associated with older age ( P = 0.045), lower prostate‐specific antigen ( PSA ; P = 0.002), lower clinical stage ( P < 0.001), lower biopsy Gleason score ( P = 0.042), and receipt of preoperative transurethral resection, hormonal and radiation therapies (all P < 0.001). In multivariable analysis, lower PSA levels, lower Gleason score, and receipt of preoperative treatment were independently associated with pT 0 (all P < 0.05). Seven patients (11%) with pT 0 PC a developed disease recurrence over a median follow‐up of 10.9 years. All seven patients had preoperative treatment(s) and three had recurrence with a PSA doubling time of <9 months. Compared with non‐ pT 0 disease, pT 0 disease was associated with longer recurrence‐free survival ( P < 0.05). Only one (1.6%) patient with pT 0 disease developed systemic progression. Conclusions pT 0 stage PC a is a rare phenomenon and is associated with receipt of preoperative treatment and features of low‐risk PC a. Although pT 0 has a very favourable prognosis, some men, especially those who received preoperative treatment, experience a small but non‐negligible risk of disease recurrence and systemic progression.

ObjectivesTo evaluate the differences in estimated glomerular filtration rate decline by urinary diversion type (incontinent diversion vs continent diversion) and preoperative estimated glomerular filtration rate among patients undergoing radical cystectomy and urinary diversion.MethodsWe evaluated 1383 patients treated with radical cystectomy between 1980–2006 who had a preoperative estimated glomerular filtration rate of 45‐89 mL/min/1.73 m2. Estimated glomerular filtration rate was estimated using Chronic Kidney Disease Epidemiology Collaboration equations, and patients were stratified by preoperative estimated glomerular filtration rate into chronic kidney disease 2 (estimated glomerular filtration rate 60–89 mL/min/1.73 m2) and chronic kidney disease 3a (estimated glomerular filtration rate 45–59 mL/min/1.73 m2). Multiple definitions of estimated glomerular filtration rate decline were evaluated: (i) 10‐point decline in estimated glomerular filtration rate; (ii) 20% decline in estimated glomerular filtration rate; and (iii) 10% decline in estimated glomerular filtration rate. Time to estimated glomerular filtration rate decline was compared using the Kaplan–Meier method stratified by diversion type. Cox regression models were used to evaluate the association of diversion type with estimated glomerular filtration rate decline risk.ResultsIn total, 74% (1021/1383) of patients underwent incontinent diversion and 26% (362/1383) underwent continent diversion. Preoperative chronic kidney disease 2 and chronic kidney disease 3a were noted among 59% and 41% of patients who underwent incontinent diversion, versus 74% and 26% with continent diversion. Median follow up after RC was 11.2 years. The rate of estimated glomerular filtration rate decline in patients with incontinent diversion versus continent diversion was similar when stratified by preoperative chronic kidney disease 2 and preoperative chronic kidney disease 3a, regardless of estimated glomerular filtration rate decline definition. On multivariable analysis, continent diversion was not associated with estimated glomerular filtration rate decline for patients with preoperative chronic kidney disease 3a.ConclusionsThe risk of estimated glomerular filtration rate decline over 10 years was not significantly different after incontinent diversion versus continent diversion among patients with preoperative chronic kidney disease 2 or chronic kidney disease 3a. Continent diversion does not appear to confer an independently increased risk of estimated glomerular filtration rate decline in patients with preoperative chronic kidney disease 3a.

ObjectiveTo review our experience with radical cystectomy for small cell carcinoma of the bladder, to compare outcomes with a cohort of patients with urothelial carcinoma, and to determine the effect of adjuvant chemotherapy and pathology re‐review in this setting.MethodsAmong 2427 patients who underwent radical cystectomy, 68 patients had small cell carcinoma of the bladder. Patients with small cell carcinoma of the bladder were compared with an unmatched cohort of 1146 patients with urothelial carcinoma, and were then matched (1:2) based on TNM stage. Survival was estimated using the Kaplan–Meier method, and Cox models were used to evaluate association of clinicopathological features with outcome.ResultsAmong the 68 small cell carcinoma of the bladder patients, 37 (54%) were found to have small cell carcinoma of the bladder only after pathology re‐review. Patients with small cell carcinoma of the bladder had a higher rate of advanced (pT3/4) tumor stage (84% vs 46%; P < 0.0001) and pN+ disease (37% vs 20%; P = 0.001) compared with patients with urothelial carcinoma. When matched for stage and lymph node status, no significant difference in 5‐year cancer‐specific survival was observed between the two groups (27% vs 29%; P = 0.64). Among small cell carcinoma of the bladder patients, those receiving adjuvant chemotherapy had improved 5‐year overall survival compared with patients who did not receive adjuvant chemotherapy (43% vs 20%; P = 0.03), and a trend toward superior cancer‐specific survival (40% vs 23%; P = 0.07).ConclusionsSmall cell carcinoma of the bladder is often an unrecognized pathological entity, which is associated with a higher rate of locally advanced and N+ disease. However, although when matched for pathological features, survival outcomes appear similar to urothelial carcinoma. Small cell carcinoma of the bladder patients receiving adjuvant chemotherapy had improved overall survival and cancer‐specific survival, and these results require further investigation.

Objectives To evaluate oncological outcomes after combination intravesical therapy with gemcitabine ( GC ) and mitomycin C ( MMC ) in the setting of recurrent non‐muscle‐invasive bladder cancer ( NMIBC ) after failure of previous intravesical therapy. Patients and Methods We retrospectively identified patients with recurrent NMIBC after previous intravesical therapy, who refused or were not candidates for cystectomy, between 2005 and 2011. GC and MMC were sequentially instilled weekly for 6–8 weeks. Data were collected regarding patient demographics, bladder cancer history, and number and type of intravesical therapies before GC / MMC . Outcomes evaluated included time to recurrence and/or progression after GC / MMC . Recurrence‐free outcomes were estimated using the Kaplan–Meier method, and Cox proportional hazards regression models were used to test the association of clinicopathological features with outcomes. Results In all, 27 patients were identified, 23 with high‐risk disease (high‐grade or carcinoma in situ ) and four with intermediate‐risk disease (multifocal or recurrent low‐grade). All patients received prior intravesical therapy, and 17 patients (63%) received multiple courses. Twenty‐four patients were treated with BCG . The median (range) disease‐free survival of all patients was 15.2 (1.7–39.3) months. Seventeen patients (63%) developed recurrent bladder cancer, a median of 15.2 months after therapy. One patient progressed to muscle‐invasive disease 5 months after treatment, and one developed metastatic disease 22 months after treatment. Three patients went on to cystectomy. Ten patients (37%) had no evidence of disease at last follow‐up, with a median follow‐up of 22.1 months. Conclusion The combination of intravesical GC and MMC could offer durable recurrence‐free survival to some patients with recurrent NMIBC who are not candidates for, or refuse, cystectomy.

BACKGROUNDThe authors evaluated sarcopenia as a predictor of cancer‐specific survival (CSS) and overall survival (OS) among patients with urothelial cancer of the bladder undergoing radical cystectomy (RC).METHODSThe lumbar skeletal muscle index (SMI) of 205 patients treated with RC for urothelial cancer between 2000 and 2007 was measured. Sarcopenia was classified according to international consensus definitions (SMI of < 55 cm2/m2 for men and < 39 cm2/m2 for women). The CSS and OS were estimated using the Kaplan‐Meier method and compared with the log‐rank test. Variables associated with CSS and all‐cause mortality were summarized with hazard ratios (HRs).RESULTSOf 205 patients, 141 (68.8%) were sarcopenic. Patients with sarcopenia were older, but were otherwise similar to patients without sarcopenia with respect to sex, Charlson comorbidity index, American Society of Anesthesiologists score, Eastern Cooperative Oncology Group performance status, receipt of neoadjuvant chemotherapy, TNM stage of disease, and tumor grade (P > .05 for all). The median follow‐up was 6.7 years, during which time 135 patients died, including 91 who died of bladder cancer. Sarcopenic patients had significantly worse 5‐year CSS (49% vs 72%; P = .003) and OS (39% vs 70%; P = .003) compared with patients without sarcopenia. Moreover, sarcopenia was found to be independently associated with both increased CSS (HR, 2.14; P = .007) and all‐cause mortality (HR, 1.93; P = .004) on multivariable analysis.CONCLUSIONSThe presence of sarcopenia was found to significantly increase a patient's risk of CSS and all‐cause mortality after undergoing RC for bladder cancer. Cancer 2014;120:2910–2918. © 2014 American Cancer Society.

Objective To evaluate survival among patients with urothelial carcinoma ( UC ) within the prostate in order to assess the impact of depth of tumour invasion as well as the importance of a concurrent bladder tumour. Patients and Methods We identified 201 patients who underwent radical cystectomy ( RC ) between 1980 and 2006 and were found to have UC involving the prostate. All specimens were re‐reviewed by a genitourinary pathologist. Survival was estimated using the K aplan– M eier method and compared with the log‐rank test. Cox hazard regression models tested the association of clinicopathological variables with outcome. Results In all, 93 patients had pTis disease in the prostate, 43 had pT2 tumours, and 66 patients were pT4a . The median follow‐up was 10.5 years. The 5‐year cancer‐specific survival for patients with pTis , pT2 , and pT4a prostate UC was 73%, 57%, and 21% respectively ( P < 0.001). On multivariable analysis, higher prostate tumour stage (hazard ratio [ HR ] 2.09; P = 0.01), positive lymph node status ( HR 2.09; P = 0.002), and concurrent ≥ pT3 bladder cancer ( HR 4.16; P < 0.001) were significantly associated with an increased risk of death from UC . Conclusions Among patients with prostatic UC involvement, depth of tumour invasion was significantly associated with cancer‐specific mortality, validating the staging reclassification. Concurrent locally advanced bladder cancer also negatively impacted survival, suggesting the potential prognostic value of reporting a secondary tumour stage in such cases.