FREE DAILY AND WEEKLY NEWSLETTERS OFFERED BY CONTENT OF INTEREST
Did you find this article relevant? Subscribe to UroToday-GUOncToday!
The fields of GU Oncology and Urology are advancing rapidly including new treatments, enrolling clinical trials, screening and surveillance recommendations along with updated guidelines. Join us as one of our subscribers who rely on UroToday as their must-read source for the latest news and data on drugs. Sign up today for blogs, video conversations, conference highlights and abstracts from peer-review publications by disease and condition delivered to your inbox and read on the go.
The neoadjuvant chemotherapy (NAC) has improved survival from 45% to 50% at 5 years. Although, when it comes to the octogenarians, it´s a problem still unsolved. There aren´t any level I evidence studies about this asset, since these patients were systematically excluded from the SWOG and MRC studies, and toxicity in this group of patients hasn’t been clearly defined, with toxic deaths approximately between 2.3 - 4.6%. This raises worries about adding morbidity when combining NAC and cystectomy.
In the USA, only 18% of octogenarians undergo cystectomy, 46% receive QT and RT, and 60% surveillance, the former percentage remarks the need for optional therapies in patients unfit for surgery. The TMT is gaining acceptance in patients who are not surgical candidates or who refuse surgery, incorporating maximal TURB, radiation, and chemotherapy as a radiosensitizer. The response to TMT has increased over all these years with a current rate of complete response of 86.1%, in contrast to 64.5% in 1986, and the key factor is patient selection. Nowadays, the trials include patients with better condition and disease in less advanced stages. Efstathiou et al, published in 2012 a cancer-specific survival (CSS) of 64%, and only 29% had to undergo cystectomy.
About the chemotherapy as a radiosensitizer in TMT, it has probe in randomized study to improve CSS and overall survival (OS) in comparison with radiotherapy alone (Fig 1), and there aren’t differences between the use of Cisplatin/5FU or a low dose of Gemcitabine, both with RT, as was shown in a randomized phase II multicenter trial published by ASCO 2018. Even when the TMT is a well established less-invasive option, it does not preclude complications, and severe toxicity has been reported in 7% of the patients, including 2% of salvage cystectomy due to contracted bladder, 1.5% bowel obstruction requiring surgery, and 3% who developed severe frequency due to reduced bladder capacity. As before, the best way to avoid these complications is the adequate selection of patients, and some factors have been associated with favorable oncologic outcomes, those are: Organ confined tumor (cT2) and less than 5cm, ability to remove all visible tumor with TUR, absence of hydronephrosis, absence of extensive CIS or diffuse multifocal disease, adequate bladder capacity and function, tumor with urothelial histology and Dr Kasouff strong recommend routine re-biopsy post TMT and prompt salvage cystectomy for nonresponders or recurrences.
The recurrence after complete response to TMT is 29%, with a median time to recurrence of 18 months. High-grade tumor was found in 95% of the recurrences, 60% were recurrence free after TURB and BCG, and 11% progressed to T2 disease. Therefore must of the recurrences are able to be treated conservatively, special attention must be paid in T1HG and prostatic urethral recurrences and may prefer a more aggressive approach in this cases.
Dr. Kassouf also highlighted some TMT limitations that don´t apply to elderly patients, such as secondary malignancies, the fact that most series have a follow-up time less than 10 years, and neobladder not advocated following salvage cystectomy, and those are due to the lower life expectancy in this group of patients and the lower renal function in elderly. Yet some questions remain unsolved, as if should pelvic nodes be included in the radiation field or if neoadjuvant chemotherapy prior TMT improves survival, and new trials have to be designed to solve these matters.
Finally, Kassouf concluded his talk by stating that radical cystectomy can be morbid, especially in elderly, the chronological age should not be used to exclude patients from definitive therapy, bladder preservation using TMT is a good option in selected patients and remains underutilized and NAC needs further evaluation in octogenarians.
Presented by: Wassim Kassouf, MD Medical Advisory and Research Board, McGill University, Montreal, QC
Written by: Ashmar Gómez Conzatti, MD, Urology Resident, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City and Ashish M. Kamat, MD, Professor of Urologic Oncology, MD Anderson Cancer Center, Houston, TX at the 2018 Congreso de la Asociación Mexicana de Urología Oncológica – July 25-28, 2018, Acapulco, GRO México;