Radical surgery for metastatic to bladder disease previously treated with RT or RP

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When prostate cancer advances into the bladder, it is possible to surgically remove the whole of the bladder (racical cystectomy) together with the whole prostate. (If no prostate cancer, a limited cystectomy which preserves the prostate is possible.)

The first paper below is a report with success with this strategy.

It is only a report to a medical conference, and has not been subject to criticism by others in a peer-reviewed journal, so it cannot be considered as the strongest evidence.

Nevertheless, it may be a strategy your doctor considers under certain conditions.

If presented by your doctor with this choice, artificially internal or external control of continence will be an issue.

The second paper below is from a peer-reviewed journal and points out some of the complications with such treatment.

It concludes that, despite complications, this is the treatment of choice for high-risk bladder cancer.

Survival Rate High After Cystectomy for T4 Prostate Cancer

Becky McCall

March 1, 2012 (Paris, France) — Cystectomy in men with clinical stage T4 prostate cancer provides excellent local tumor control and a cancer-specific survival rate of 35% at 10 years, according to a study presented here at the European Association of Urology 27th Annual Congress.

Martin Spahn, MD, a surgical urologist from the University Hospital Würzburg, Germany, presented the results of a retrospective multicenter study of 62 patients with clinical stage T4 prostate cancer who were treated with radical cystectomy.

Data were drawn from the European Multicenter Prostate Cancer Clinical and Translational Research Group (EMPaCT), a consortium of 8 European tertiary referral centers and the Mayo Clinic in Rochester, Minnesota.

The poster by Dr. Spahn and his colleagues was selected as the best poster in the high-risk disease session of the conference.

Patients with stage T4 prostate cancer are at high risk for disease progression and cancer-related death, the investigators note in their poster. "Surgery is gradually becoming accepted as a first step in a multimodality treatment in selected patients, although controversy remains regarding this approach. Radical prostatectomy is often unable to achieve complete tumor removal, and positive resection margins may have a deleterious effect on the outcome," they write in their poster.

After a mean follow-up of 59.9 months, the investigators found that 35% of patients who underwent a cystectomy were tumor free and 20% were metastasis free 10 years after surgery. There was no difference between cancer-specific survival and overall survival.

"Local tumor control was excellent and there was no hospital readmission due to local tumor recurrence in these patients," reported Dr. Spahn.

Generally, survival is limited in these very high-risk prostate cancer patients. "This is exciting because these patients with tumor invasion into the bladder are very difficult to treat. If the patients are irradiated or they just receive hormonal treatment, then they have a high rate of local complications. There is no standardized treatment for these patients, and no clear recommendations," Dr. Spahn told Medscape Medical News.

Current guidelines from the European Association of Urology and the National Comprehensive Cancer Network recommend radiotherapy combined with hormonal treatment for at least 2 to 3 years, brachytherapy combined with hormonal treatment, radical prostatectomy with or without hormones (in very selective cases), or hormonal treatment alone for very high-risk patients. But there is a lack of high-quality evidence to support any of these, and cystectomy is not recommended currently.

"We all know patients with locally advanced T4 disease." We wondered whether ultraradical pelvic surgery would be a viable treatment option in these patients, Dr. Spahn explained.

He provided some insight into how the disease affects these patients, noting that many of these very high-risk patients are young, otherwise healthy, and should have a long life expectancy. The mean age in this study was 64.1 years, and the Charlson comorbidity scores were not higher than 2. However, the Gleason scores were from 8 to 10.

"Because they have local tumor symptoms, such as bladder outlet obstruction, hematuria, and infiltration of the ureteral orifices with concurrent hydronephrosis, hospital readmission is frequent among these men when treated nonsurgically. Treatment of these local symptoms obviously affects their quality of life."

During cystectomy, the prostate and the complete bladder are removed. "These tumors are huge, and by removing both bladder and prostate these patients might not be cured because they have metastasis. But, as mentioned before, local tumor control is excellent and all the complications we see from local tumor growth and recurrence in conservatively treated men can be avoided."

After surgery, half the patients had positive surgical margins and half had lymph node involvement. Because of the high tumor load, many patients received adjuvant radiotherapy, hormonal therapy, and chemotherapies, according to institutional practices. Dr. Spahn and his colleagues then conducted a statistical analysis to determine patient survival.

The researchers wanted to determine whether they could identify which patients would most benefit from cystectomy. Using Cox multivariate regression analysis, they found that the only independent predictors of cancer-specific survival were positive surgical margins (95% confidence interval [CI], 0.25 to 0.99; P = .05) and adjuvant hormone therapy (95% CI, 1.0 to 4.2; P = .05).

"If tumors are locally controlled and patients receive adjuvant hormonal treatment in a multimodality approach, this is beneficial," added Dr. Spahn.

"This multimodal strategy in prostate cancer might prevent local symptoms; it should be evaluated prospectively," he concluded.

One of the session moderators, Bernardo Rocco, MD, from the division of urology at the European Institute of Oncology, Milan, Italy, remarked that this work is intriguing. "Of course, we need to be sure it is the best for the patient. It is key that a cystoscopy was performed before the procedure; investigators sampled the bladder and found tumors with 100% certainty of clinical stage T4 disease," he told Medscape Medical News in an interview.

Dr. Spahn has disclosed no relevant financial relationships. Dr. Rocco reports being a consultant to the Italian distributor of Intuitive Surgical Inc., the maker of da Vinci Surgical Systems.

European Association of Urology (EAU) 27th Annual Congress. Presented February 26, 2012.

Courtesy of:

Medscape Medical News © 2012 WebMD, LLC

Urology. 2003 Feb;61(2):342-7; discussion 347.

Radical cystectomy for bladder cancer after definitive prostate cancer treatment.

Schuster TG, Marcovich R, Sheffield J, Montie JE, Lee CT.

Source

Department of Urology, University of Michigan Hospitals, Ann Arbor, MI 48109-0330, USA.

Abstract

OBJECTIVES:

To review our perioperative experience with patients presenting with high-risk bladder cancer who had undergone prior therapy for prostate cancer. With the increase in diagnosis and subsequent treatment of prostate cancer, more patients presenting with high-risk bladder cancer have undergone prior therapy for prostate cancer. Radical cystectomy in these patients can be technically challenging and may be associated with added morbidity.

METHODS:

A retrospective review of 458 patients treated with radical cystectomy between January 1993 and January 2002 revealed 29 patients (mean age 72 years) who had received definitive treatment for prostate cancer prior to cystectomy for bladder carcinoma. The initial treatment in this cohort was radical prostatectomy or external beam radiotherapy in 12 (41%) and 17 (59%) men, respectively. Cystectomy was performed for transitional cell carcinoma in 25 (86%), small cell carcinoma in 2 (6%), and sarcoma in 2 (6%) patients.

RESULTS:

At the time of cystectomy, the mean blood loss was 1175 mL (range 275 to 3500), and the median length of hospitalization was 8 days (range 4 to 23). No intraoperative or perioperative deaths occurred in this cohort. Twenty-seven early complications were identified in 16 (55%) of 29 patients; no rectal injuries occurred. Patients with prior radiotherapy had a higher rate of extravesical bladder carcinoma (60%) than those patients treated with prior prostatectomy (33%). An orthotopic neobladder diversion was created in 5 patients (17%).

CONCLUSIONS:

Patients with bladder cancer previously treated for prostate cancer with external beam radiotherapy or radical prostatectomy have an increased risk of perioperative complications compared with patients undergoing cystectomy without prior therapy. This risk is not prohibitive, and radical cystectomy should remain the treatment of choice for high-risk bladder cancer in this population. Furthermore, orthotopic urinary diversion may be a reasonable option and should be considered in select patients.

PMID: 12597943