AUA 2018: Where and How Does Cystoscopy Fall Short? Initial Results of a Prospective Cohort Study Evaluating Reliability of Endoscopic Evaluation in Predicting pT0 Disease at the Time of Radical Cystectomy

San Francisco, CA ( Daniel Parker, MD presented a prospective trial performed at the Fox Chase Cancer Center, led by Alexander Kutikov, MD.  Accurate preoperative prediction of pathologic T0 disease could spare a portion of patients from unnecessary cystectomy.  Previous studies have demonstrated an approximately 30% rate of pT0 following neoadjuvant chemotherapy and 12% after transurethral resection alone. 

A 2014 Journal of Urology publication was a retrospective review from 1988-2012 of 109 patients who received neoadjuvant chemotherapy.  32 patients were cT0, 25 of which refused cystectomy and >70% retained their native functional bladder. 

Additionally, a study by Reese et al. assessed 62 patients who received restaging TUR following neoadjuvant chemotherapy from 2011-2012.  21 of 48 patients were staged at cT0.  The negative predictive value did vary depending on the definitions utilized: 38% for pT0 and 67% for non-muscle invasive disease.  However, this study did not have cystoscopic biopsy performed routinely and restating was primarily performed with imaging, cystoscopy, and bimanual exam.  The SWOG 0219 study, where patients with muscle-invasive disease on two TURs had a third TUR after neoadjuvant chemotherapy.  This study demonstrated a negative predictive value of 40% for the restage cT0 group that went on to complete radical cystectomy, representing a high false negative rate.

Parker pursued this analysis to have a generalizable cohort with a standardized definition of T0 and endoscopic assessment with rigorous documentation. The hope is to utilize the specimens with future genomic testing. 

35 patients were included in the initial analysis with a median age of 71 years.  All patients were ECOG 0-1.  Clinical T stage included 37% <T2, 40% T2, 14% T3 and 9% T4.  54% of patients were treated with previous intravesical therapy and 60% with neoadjuvant chemotherapy.  Final pathology revealed 31% pT0, 26% pTis or pT1, and 80% N0.  The sensitivity of endoscopic evaluation to predict the presence of MIBC at cystectomy was 80% with a negative predictive value to rule out any residual cancer of 55%, and to rule out muscle-invasive disease of 78%. Of the 18 patients with no disease on endoscopic evaluation, 10 had concordant and 8 had discordant findings on pathology.

In conclusion, Parker stated that endoscopic assessment of the bladder prior to cystectomy is “imperfect”.  However, understanding the limitations of endoscopic assessment may assist in bladder preservation approaches in the future to better assess the clinical and oncologic risk to help drive bladder cancer care.

Presented by: Daniel Parker, MD, University of Oklahoma
Co-Authors: Aeen Asghar, John O'Neill, Richard Greenberg, Marc Smaldone, David Chen, Rosalia Viterbo, Robert Uzzo, Joshua Eccles, Daniel Geynisman, Matthew Zibelman, Eric Ross, Philip Abbosh, Elizabeth Plimack, Alexander Kutikov, Philadelphia, PA

Written by:  David B. Cahn, DO, MBS Fox Chase Cancer Center Philadelphia, PA @dbcahn at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA