SAN FRANCISCO, CA USA (UroToday.com) - This year the GU Cancers Symposium meeting used a real case and a real-time audience-response system to generate discussion.
A 62-year-old healthy, but smoking, male presented with hematuria and was found to have high-grade cytology and normal imaging. On cystoscopy, a papillary tumor was identified.
The first question to the audience regarded the use of photodynamic diagnosis (PDD) in this index patient. Almost 40% of the audience said that they would use PDD in the management of this patient, although 50% said that they would do traditional TURBT. Dr. J. Alfred Witjes, presented data from a meta-analysis showing that detection of CIS using PDD is far superior to white-light cystoscopy. The patient went on to have high-grade, T1 disease. Re-resection revealed muscle-invasive bladder cancer (MIBC).
The next question to the audience regarded the use of neoadjuvant chemotherapy and/or bladder preservation. Fifty-four percent of the audience would have offered neoadjuvant chemotherapy, and 21% would have offered radical cystectomy +/- adjuvant chemotherapy. Dr. Marissa Kollmeier presented the case for bladder preservation, citing the high (> 60%) incidence of postoperative complications in cystectomy patients, even at high-volume centers. Dr. Witjes reviewed neoadjuvant and adjuvant chemotherapy. He said that there really is not good evidence for the effectiveness of adjuvant therapy, and showed that more patients actually receive neoadjuvant than adjuvant therapy in a randomized trial. Dr. Thomas Flaig highlighted the data for neoadjuvant chemotherapy, specifically in T3/T4 patients from the SWOG phase III trial, showing that those receiving this treatment probably benefit the most. The patient went on to have neoadjuvant chemotherapy and radical cystectomy, revealing a pT3N1 tumor with microscopic focus of tumor in one node and a 1 mm positive surgical margin. Ten nodes were removed. The audience could not reach a consensus about what the next step in management was, splitting between observation with chemotherapy for metastasis, adjuvant chemotherapy, adjuvant radiotherapy, and a few people supported more aggressive lymphadenectomy.
The role and significance of lymphadenectomy was reviewed. The pathology of lymph node metastasis is obviously dependent on the extent of lymphadenectomy, the number of packets sent to the pathologist, the number of nodes in the specimen, and the pathological processing of tissue. Dr. Hikmat Al-Ahmadie suggested that multiple parameters have no clear impact on disease status including number of nodes in specimen, number of positive nodes, lymph node density, extranodal extension, or even the volume of tumor within positive nodes. Classifying the patient’s tumor as chemo-resistant, based on his pathology, is obviously a poor prognosticator, but Dr. Flaig reviewed a retrospective study from MD Anderson Cancer Center suggesting that adjuvant chemotherapy in patients who receive neoadjuvant therapy is beneficial. Dr. Kollmeier pointed out that local recurrence can be a difficult-to-manage problem for patients, often causing pain or bowel obstruction, so local control with radiotherapy should be considered.
Finally, Dr. Witjes returned to the EAU bladder cancer guidelines, which he presented earlier, saying that extended lymphadenectomy seems to be superior to both limited and super-extended lymphadenectomy. Overall, the audience response system was an excellent tool to facilitate discussion both amongst the panel and the audience.
Highlights of a panel discussion conducted at the 2014 Genitourinary Cancers Symposium - January 30 - February 1, 2014 - San Francisco Marriott Marquis - San Francisco, California USA