ANAHEIM, CA (UroToday.com) - Dr. Donald Skinner presented the John K. Lattimer lecture "The Management of Invasive Bladder Cancer: Lessons Learned" at the Tuesday Plenary Session of the AUA in Anaheim, May 22, 2007.

Dr. Lattimer, the Chair at Columbia University for 25 years recently died at the age of 92 years. His biography was reviewed and the lecture by Dr. Skinner is given in his honor. Dr. Skinner discussed the lessons learned over his 36 year career. TCC is a lethal disease, he said. 20% of all new patients presenting to a urologist with a new diagnosis of TCC will have high grade invasive disease. Ominous signs include CIS, lymphovascular invasion (LVI) and pT1b disease. A lack of consensus for treatment of high-grade TCC is affected by patient and physician factors, and impacts outcomes. Medicare patients between 1991-2000 showed that 35% had no treatment and only 23% received a cystectomy.

LVI in high grade TCC is an independent predictor of local, distant and overall recurrence and one should pay attention to this pathologic factor. His philosophy includes that an extended lower retroperitoneal and pelvic LND along with radical cystectomy will improve survival. In the USC database of 1,591 patients with invasive bladder cancer, most deaths from TCC following cystectomy occured in the first 3 years. Positive surgical margins at cystectomy universally are associated with local recurrence and death from TCC. 90% of patients with nodal metastasis who fail surgery and chemotherapy die within 24 months of surgery. However, 85% who have a cystectomy while the tumor is organ confined will be cured.

He advocated submitting the lymph nodes in packets, as the mean number of nodes recovered are twice as high as submitting them as a group (mean 68 vs. 31). Lymph node density, pathologic stage and adjuvant chemo improve survival. <20% LN positive density has a significantly better survival than >20% LN density. The outcomes of high volume surgeons at high volume centers are better with lower positive surgical margin rates. This supports good surgical technique. An extended LND improved survival at 4 different high-volume centers. Cystectomy cures 85% of patients with organ confined disease and provides pathologic staging. Regarding chemotherapy, he advocated chemo for LN+ patients, as it provided a 10% survival benefit. Neoadjuvant chemotherapy as reported in the SWOG 8710 trial needed scrutiny, he cautioned. The few numbers of patients enrolled over such a long period of time without surgical standardization or commitment to a LND are problematic. Those who did get an extended LND had a 2-fold higher survival rate. The meta-analysis shows only a small benefit. He feels that chemo has benefit and should be individualized. In his experience it does not benefit those with organ confined disease undergoing cystectomy. Stage pT3N0 patients did not show large benefit, and thus there will be significant overtreatment.

In the 29% of P1-2N0M0 patients with LVI, the 5-year survival is only 52%. Neoadjuvant chemo should be considered for certain histologic subtypes or those with P3N0 disease with LVI or with positive LN status. Chemotherapy will not make up for an inadequate operation and the goals should be focused on the best surgery to optimize outcomes, as chemotherapy will not cover for surgical deficiency, he concluded.

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Written by Christopher P. Evans, MD, a Contributing Editor with UroToday.

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