AUA 2017: Bladder Cancer Tumor Board

Boston, MA ( Dr. Mark Soloway and the AUA assembled an all-star multi-disciplinary group for today’s Bladder Cancer Tumor Board plenary session at the 2017 AUA Annual meeting. Four cases were presented and discussed amongst the panelist.

The first case was a healthy 66-year-old male with a heavy smoking history and a 5-year history of periodic low grade Ta bladder tumors. His last TURBT was 9 months ago and his last upper tract evaluation was normal 2 years ago. A subsequent in office flexible cystoscopy indicated multiple small papillary tumors that were low grade appearing. Possible options presented to urologist Dr. Chad Ritch included (i) proceed to the OR for TURBT, (ii) observe until the tumors are larger and then proceed to the OR (ie. active surveillance), or (iii) cauterize the tumor in the office setting. As Dr. Ritch appropriately notes, this patient is at high risk of recurrence, but low risk of progression. In the setting of a positive cytology, one must be concerned with high grade disease. If negative, the feasibility of office fulguration is appropriate, however this may be limited by the number of tumors. As Dr. Ritch also suggests, the presence of upper tract urothelial carcinoma (UTUC) in patients with low grade Ta tumors is low at only 1-2%. Based on this information, including a relatively young man with multiple tumors and multiple recurrences, Dr. Ritch’s plan would be to resect the patient in the operating room, however with the addition of enhanced cystoscopy with either blue light cystoscopy or narrowband imaging and a post-operative dose of mitomycin. With regards to the upper tract, Dr. Ritch would repeat upper tract surveillance with a CT-urogram, since it has been two years since previous imaging and to eliminate the concern for upper tract source/seeding as a source for recurrence.

The second case was a 71-year-old male with a two-year history of gross hematuria and significant medical history for atrial fibrillation and a pacemaker. His upper tract imaging was negative, however a cystoscopy demonstrated a 3-cm high-grade Ta tumor. The patient had a TURBT that included muscle in the specimen, which was negative. The options for subsequent management presented to urologist Dr. Ashish Kamat, included (i) BCG, or (ii) re-TURBT. As Dr. Kamat astutely points out, the risk stratification for these patients differs between urologic jurisdictions: this patient would be high risk based on the EAU guidelines, however only intermediate risk based on the AUA/SUO guidelines. Dr. Kamat notes that the International Bladder Cancer Group has tried to simplify the risk stratification into high risk: any T1 or high grade tumor, including CIS; or intermediate risk: Ta low grade tumors that are recurrent/multiple/large. Furthermore Dr. Kamat acknowledges that blue light cystoscopy assistance decreases tumor recurrence rates over 9 months, resulting in a relative reduction rate of 16% comparing patients without blue light cystoscopy. Dr. Soloway proceeded with treating this patient with induction BCG, however on follow-up the patient recurred with two tumors and subsequent TURBT once again demonstrated high grade Ta disease. Dr. Kamat was then presented with additional options for management (i) re-TURBT, (ii) re-induction BCG, (iii) cystectomy, or (iv) intravesical chemotherapy. Dr. Kamat noted that re-induction BCG in these patients with a papillary recurrence is a possible treatment option, and as Dr. Kamat subsequently mentioned there is evidence that maintenance BCG in this setting decreases tumor recurrence and progression, quoting the prior SWOG randomized trial.

The third case was a 70-year old active healthy male that presented with gross hematuria and subsequently underwent a TURBT that demonstrated high grade T2 disease. As Dr. Soloway notes, the patient desired the best chance at cure as well as quality of life. Radiation oncologist Dr. Jason Efstathiou then deftly delineated seven considerations, specifically for the role of radiation therapy for these patients, noting that (i) organ conservation is commonplace in contemporary oncology, but not yet for bladder cancer; (ii) long-term results of trimodal therapy (TMT) are excellent and comparable to radical cystectomy, citing their own experience at MGH and a recently published propensity score matched analysis from Princess Margaret Hospital in Toronto; (iii) cystectomy is not being performed in 50% of patients and there is a huge unmet need, which he argues TMT can fill this gap; (iv) concurrent chemotherapy is important to the success of TMT; (v) maximal TURBT and salvage cystectomy are keys to success of TMT; (vi) long-term toxicity is acceptable and quality of life after bladder preservation is good, and may even be better than patients undergoing radical cystectomy; (vii) bladder preservation with TMT is supported by numerous guidelines, including the NCCN. As a rebuttal, Dr. Kamat notes that in the MGH series, there were a number of patients that either did not have a complete TURBT, had hydronephrosis, or had concomitant CIS, which should be contraindications to TMT in his opinion. Finally, in terms of follow-up, TMT with surveillance cystoscopy every 3-6 months with frequent imaging is not nearly as cost-effective as risk adjusted surveillance after radical cystectomy.

The final case presented by Dr. Soloway was a 75-year-old female who lives alone, had gross hematuria, and an 8cm bladder mass diagnosed on CT imaging, albeit without metastasis or lymph node involvement. On examination under anesthesia, the bladder was mobile and TURBT diagnosed a T3 high grade lesion. Medical oncologist Dr. Richard Lee was then queried as to the role of neoadjuvant or adjuvant chemotherapy in this setting. Dr. Lee then noted that in favor of adjuvant chemotherapy is the fact that there is pathologic evidence for true need for chemotherapy. However, two points that favor neoadjuvant chemotherapy in this setting include (i) the ability to affect micrometastatic disease and (ii) there is level 1 evidence supporting neoadjuvant chemotherapy. Dr. Lee does acknowledge there are risks with neoadjuvant chemotherapy in bladder cancer (deep vein thrombosis, anemia, etc) although the survival benefit is objective evidence in his opinion in clinically appropriate patients. Dr. Ritch offered a rebuttal, making the case for up front cystectomy in these patients, primarily given that patients may not be suitable for preoperative chemotherapy, arguing that candidates should be risk stratified for possible chemo toxicity using NSQIP risk calculators. Finally he notes that the survival benefit for neoadjuvant is modest, and that if the patient tolerates the cystectomy well and pathology suggests possible benefit from adjuvant therapy, then proceeding with systemic chemo-(or immune)therapy at that point in time is reasonable.

Moderator: Mark S. Soloway, Memorial Hospital, Hollywood, FL, USA

Panelists: Ashish Kamat, University of Texas MD Anderson Cancer Center, Houston, TX, USA; Chad Ritch, University of Miami, Miller School of Medicine, Miami, FL, USA; Richard Lee, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA; Jason Efstathiou, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA

Written By: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre
Twitter: @zklaassen_md

at the 2017 AUA Annual Meeting - May 12 - 16, 2017 – Boston, Massachusetts, USA