SUO 2017: Biology and Management of MIBC and Oligometastatic Bladder Cancer – What is the Role of Surgery?

Washington, DC ( Metastatic disease occurs in 5-10% of patients upon initial presentation and between 20-70% of all patients who develop urothelial carcinoma (UC) of the bladder.  Traditionally, there has not been a distinct role of surgery in the metastatic setting, with systemic chemotherapy or radiation being much more commonly utilized. While 60-70% of patients will have a clinical response to chemotherapy, the majority of responses are not durable (10-12% complete responders).  The median survival for patients with metastatic UC is only 14 months. As part of the SUO session focusing on the biology and management of metastatic bladder cancer, Dr. Bernard Bochner from Memorial Sloan Kettering Cancer Center discussed the data surrounding the use of surgical resection in patients with metastatic bladder cancer.

Dr. Bochner reviewed the available literature for three specific subgroups of patients: those with clinical regional lymphadenopathy, those with distant lymphadenopathy, and those with visceral metastatic disease. For patients with post-chemotherapy pelvic lymphadenopathy, he reviewed 3 studies looking at patients who underwent cystectomy and pelvic lymphadenectomy.  Of these patients, the 2-year overall survival was 20-26%, indicating that some patients can have a durable response after surgical resection of clinically involved pelvic lymph nodes.  There were several series that evaluated resection of retroperitoneal and non-pelvic lymph nodes, with the median disease-specific survival of 10-14 months. For patients with visceral metastatic disease who undergo surgical resection, there are also some durable responses, with one study from Matsugama et al showing a 50% 5-year overall survival in patients with primarily a single visceral metastatic lesion <3cm.

There are several limitations to the studies which focused on the use of surgery for metastatic UC, however.  These studies were small and retrospective, and the selection criteria for patients was not well-defined.  Furthermore, these patients received variable chemotherapy regimens prior to surgery and the extent of tumor resection varied between studies. 

Dr. Bochner advocated careful selection when it comes to determining which patients may be surgical candidates.  Based on the data, he noted that patients who have a significant response to chemotherapy, patients with limited metastatic disease (primarily lymph node involvement), and patients in whom their disease appears to be amenable to complete resection appear to have better outcomes. 

Presented by: Bernard Bochner, Memorial Sloan Kettering Cancer Center, New York, NY

Written by: Brian Kadow, MD, Fox Chase Cancer Center, Philadelphia, PA at the 18th Annual Meeting of the Society of Urologic Oncology, November 20-December 1, 2017 – Washington, DC