AUA 2022: Case Presentation: Is there a Role of Radical Cystectomy in cN1-2 Disease? Pro

(UroToday.com) The 2022 Annual Meeting of the American Urological Association (AUA) was host to The International Bladder Cancer Group (IBCG) AUA Bladder Cancer Forum which featured a case-based debate regarding the role of radical cystectomy in cN1-2 disease. This session was moderated by Dr. Kamal Pohar, and Dr. Brant Inman was tasked with providing arguments in favor of radical cystectomy in this setting.

Dr. Pohar began the debate by presenting a case of a patient that completed 5 of 6 planned cycles of dd-MVAC (limited by toxicities) for cT2N1 disease. Post-chemotherapy CT imaging demonstrated an almost complete response in the pelvic node (now 2x3 mm).

Dr. Inman began his presentation by noting that cN+ cases are on the rise.

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Principle 1: The treatment of bad bladder cancer is multidisciplinary

  • Surgery alone is often inadequate
  • Same for chemotherapy
  • Same for radiation
Inman_AUA22_Figure2.png

 

It is currently well-established that neoadjuvant chemotherapy improves outcomes in cN+ based on data by Galsky et al. using NCDB data, Hermans et al. from the Netherlands, and Afferi et al using multi-institutional data.

 Inman_AUA22_Figure3.png

Radiation remains an option in the cN+ disease space, but there are fewer reports.

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Principle 2: The better the response to systemic therapy, the better the outcome

  • Be careful about offering surgery to patients that progress

 Inman_AUA22_Figure5.png

How commonly does chemo lead to pN0 in cN+ patients? Based on multiple series, it appears that this outcome ranges between 33% and 57% with a pT0N0 rate of 9-55%.

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Principle 3: The more positive nodes there are, the worse the outcomes and the more careful you have to be about patient selection

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Principle 4: Pick the best treatment for the patient, not the best patient for the treatment

 

Dr. Inman concluded his talk as follows:

  • Cisplatin & cystectomy eligible
    • NAC Cystectomy Nivolumab(?)
  • Cisplatin ineligible, cystectomy eligible
    • Chemoradiation versus cystectomy Gem/Carbo or ICI (?)
  • Cystectomy ineligible
    • Chemoradiation
    • Trial: TAR-200/Cetrilimab versus chemoradiation
  • Too old, too sick, too much cancer
    • Palliative systemic therapy versus palliative care

  

Presented By: Dr. Kamal S Pokar, MD, Julius and Diana Skestos Endowed Chair in Urology, Vice Chair for Faculty, The Ohio State University, Columbus, OH

Dr. Brant Inman, MD, MS, Professor, Department of Urology, Duke Health, Durham, NC

Written By: Rashid Sayyid, MD, MSc – Urology Chief Resident, Augusta University/Medical College of Georgia, @rksayyid on Twitter during the 2022 Annual Meeting of the American Urological Association, New Orleans, LA, May 13 – 16, 2022

Related Content: AUA 2022: Case Presentation: Is there a Role of Radical Cystectomy in cN1-2 Disease? Con