Use of Adjuvant Chemotherapy in Patients with Advanced Bladder Cancer after Neoadjuvant Chemotherapy.

OBJECTIVES: To compare the outcomes of adjuvant chemotherapy (AC) versus observation in patients with non-organ confined disease after neoadjuvant chemotherapy and radical cystectomy (RC). MATERIALS AND METHODS: Using the National Cancer Database, we identified patients who received NAC prior to RC and had advanced stage (pT3/4) or pathologically involved nodes (pN+) at the time of surgery from 2004-2013. We determined whether patients then received AC or were managed with observation only and used multivariable proportional hazards regression to estimate the impact of AC on overall survival. RESULTS: Overall 34% (N = 705) of patients who received NAC and underwent RC were pT3/4 and/or pN+. Of these patients, 24% (N = 168) received subsequent chemotherapy and the rest were observed. Median survival for the entire cohort was 21 months (IQR 12-45). There was not a statistically significant difference in median survival between the AC and observation groups (23 months [IQR 14-46] versus 20 months [IQR 12-46], log-rank p = 0.52). On multivariate analysis there was no survival advantage for the AC cohort. Subgroup analysis of pN+ patients who received AC also did not show a survival advantage. CONCLUSIONS: Patients who are pT3/4 and/or pN+ after NAC and RC have a poor prognosis. The addition of AC does not seem to be beneficial. Further research should focus identifying patients who may benefit from additional chemotherapy.

Clinically localized type 1 and 2 papillary renal cell carcinomas have similar survival outcomes following surgery.

PURPOSE: We aimed to determine incidence, pathologic findings, prognostic factors and clinical outcomes for patients with clinically localized papillary RCC. METHODS: Demographic, clinical and pathologic findings were collected on all patients with PRCC undergoing surgery at four academic medical centers. The primary endpoint was cancer-specific survival (CSS). Relapse-free survival (RFS) and overall survival (OS) were secondary endpoints. Kaplan-Meier estimates were obtained, and Cox proportional hazard regression models were used to assess predictors of mortality and relapse. RESULTS: We identified 626 PRCC, of which 373 (60 %) were type 1 and 253 (40 %) were type 2, with three-quarters of all tumors being pT1. Compared to patients with type 1, those with type 2 were older (mean age: 63 vs 61; p = 0.02), presented more commonly with symptoms (13 vs 7 %; p = 0.02) and had larger mean tumor size (5.2 vs 4.3 cm; p = 0.001). With a median follow-up of 41 months (IQR: 16-68), 92 patients had died of PRCC (15 %), 48 (8 %) experienced relapse, and 101 died from all causes (16 %). The estimated 5-year CSS, RFS and OS were 83, 91 and 82 %, respectively. In multivariable analysis, older age, T stage and nodal status were predictors of CSS and OS. However, PRCC subtype was not a predictor of CSS, RFS or OS. CONCLUSION: While patients with type 2 PRCC appear to present with more advanced disease than patients with type 1, PRCC subtype does not appear to be an independent predictor of CSS, RFS or OS for treated localized disease.

Robot-assisted radical cystoprostatectomy in the post-radiation and chemotherapy patient.

We report a case of successful salvage radical cystoprostatectomy (RRCP) on a patient with recurrent high-grade T2 transitional cell carcinoma following external-beam radiation and systemic chemotherapy. The effect on tissue planes and the resulting adhesions after external radiation are well-known. While RRCPs have been successfully completed in many academic centers, there have been no reports of using this approach for salvage cystectomy after radiation. The RRCP was performed without complications, and was followed by an extended bilateral pelvic lymph node dissection and creation of an ileal conduit via the midline extraction incision.