Cancer Patients Undergoing Radical Cystectomy Research Articles

Extended Versus Limited Lymph Node Dissection in Bladder Cancer Patients Undergoing Radical Cystectomy: Survival Results from a Prospective, Randomized Trial

BackgroundThe extent of lymph node dissection (LND) in bladder cancer (BCa) patients at the time of radical cystectomy may affect oncologic outcome. ObjectiveTo evaluate whether extended versus limited LND prolongs recurrence-free survival (RFS). Design, setting, and participantsProspective, multicenter, phase-III trial patients with locally resectable T1G3 or muscle-invasive urothelial BCa (T2-T4aM0). InterventionRandomization to limited (obturator, and internal and external iliac nodes) versus extended LND (in addition, deep obturator, common iliac, presacral, paracaval, interaortocaval, and para-aortal nodes up to the inferior mesenteric artery). Outcome measurements and statistical analysisThe primary endpoint was RFS. Secondary endpoints included cancer-specific survival (CSS), overall survival (OS), and complications. The trial was designed to show 15% advantage of 5-yr RFS by extended LND. Results and limitationsIn total, 401 patients were randomized from February 2006 to August 2010 (203 limited, 198 extended). The median number of dissected nodes was 19 in the limited and 31 in the extended arm. Extended LND failed to show superiority over limited LND with regard to RFS (5-yr RFS 65% vs 59%; hazard ratio [HR]=0.84 [95% confidence interval 0.58–1.22]; p=0.36), CSS (5-yr CSS 76% vs 65%; HR=0.70; p=0.10), and OS (5-yr OS 59% vs 50%; HR=0.78; p=0.12). Clavien grade ≥3 lymphoceles were more frequently reported in the extended LND group within 90d after surgery. Inclusion of T1G3 tumors may have contributed to the negative study result. ConclusionsExtended LND failed to show a significant advantage over limited LND in RFS, CSS, and OS. A larger trial is required to determine whether extended compared with limited LND leads to a small, but clinically relevant, survival difference (ClinicalTrials.gov NCT01215071). Patient summaryIn this study, we investigated the outcome in bladder cancer patients undergoing cystectomy based on the anatomic extent of lymph node resection. We found that extended removal of lymph nodes did not reduce the rate of tumor recurrence in the expected range.

Orthotopic bladder substitution for bladder cancer patients undergoing radical cystectomy: A call to action.

Orthotopic bladder substitution for bladder cancer patients undergoing radical cystectomy: A call to action.

Phase II trial of neoadjuvant nivolumab with cisplatin and gemcitabine in muscle-invasive bladder cancer patients undergoing radical cystectomy.

TPS528 Background: Cisplatin-based neoadjuvant chemotherapy in muscle-invasive bladder cancer (MIBC) improves survival outcomes. The survival benefit correlates with pathologic response (PaR) and strategies to improve pathologic response at cystectomy are urgently needed to improve outcomes in these pts. while limiting toxicity. We are exploring the efficacy and safety of N with gemcitabine-cisplatin (GC) as neoadjuvant therapy for MIBC. Methods: This is a single-arm, multi-center phase II study for pts with MIBC eligible for neoadjuvant GC and planned for radical cystectomy. Pts will be treated with N+ GC every 21 days for 4 treatment cycles over 12 weeks followed by radical cystectomy. The primary endpoint of PaR will be evaluated in a single stage design; 41 adult pts will be enrolled and the treatment will be worthy of further study (and the null hypothesis rejected) if paR is seen at the time of cystectomy in more than 19 pts. Key inclusion criteria are presence of MIBC (predominantly urothelial carcinoma) with clinical stage T2-T4a and N≤1 disease (solitary lymph node measuring < 2 cm) and M0 and deemed eligible for radical cystectomy, ECOG PS of 0 or 1, Cr Cl ≥ 50 ml/min, adequate organ function, eligible to receive GC and no contraindications to receiving N. Patients will receive C (70mg/m2) IV on D1, G (1000mg/m2) on D1,D8 and N (360 mg) IV on D8 every 21 days for 4 cycles followed by radical cystectomy within 6-8 weeks. Secondary Objectives are to determine safety of N+GC in pts with MIBC prior to radical cystectomy and PFS. The correlative objectives include: 1)Whole Exome Sequencing (WES) of the pre-treatment bladder cancer biopsy tissues will be correlated with response.2) Molecular subtypes of bladder cancer will be performed using Genomedx to evaluate whether addition of N alters the response to neoadjuvant GC. 3)PD-L1 expression in tumor tissue at baseline will be correlated with response to N+GC therapy and 4) Nanostring pancan immune panel gene expression will be studied at baseline and at cystectomy.The extensive exploratory analyses are aimed at understanding correlation between genomic and immunologic changes in tumor tissues with clinical outcomes. (NCT03294304) Clinical trial information: NCT03294304.

A systematic review of exercise and psychosocial rehabilitation interventions to improve health-related outcomes in patients with bladder cancer undergoing radical cystectomy

Objective: Summarizing the evidence on the effects of pre- and postoperative exercise and psychosocial rehabilitation interventions on patient-reported outcomes (PROs) and physical fitness in bladder cancer patients undergoing radical cystectomy. Data sources: The Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Web of Science and the Physiotherapy Evidence Database were searched independently by two authors from inception until 10 November 2017. Cited references of the studies and citing references retrieved via Web of Science were also checked. Review methods: Randomized controlled trials (RCTs) and non-randomized studies assessing effects of exercise and psychosocial interventions in bladder cancer patients undergoing radical cystectomy were eligible. Primary outcome measures were PROs and physical fitness. Risk of bias was assessed using the Cochrane Collaboration tool and the Newcastle–Ottawa Scale. Results: Five RCTs (three exercise and two psychosocial studies) and one non-randomized psychosocial study comprising 317 bladder cancer patients were included. Timing of the intervention was preoperative (n = 2), postoperative (n = 2) or both pre- and postoperative (n = 2). Positive effects of exercise were found for physical fitness (n = 3), some health-related quality-of-life (HRQoL) domains (n = 2), personal activities in daily living (n = 1) and muscle strength (n = 1). Psychosocial interventions showed positive effects on anxiety (n = 1), fatigue (n = 1), depression (n = 1), HRQoL (n = 1) and posttraumatic growth (n = 1). Quality assessment showed most shortcomings with sample sizes and strong heterogeneity was observed between studies. Conclusion: The evidence relating to the effects of exercise in bladder cancer is very limited and is even less for psychosocial interventions.

Cancer and All-cause Mortality in Bladder Cancer Patients Undergoing Radical Cystectomy: Development and Validation of a Nomogram for Treatment Decision-making

To develop and validate a nomogram assessing cancer and all-cause mortality following radical cystectomy. Given concerns regarding the morbidity associated with surgery, there is a need for incorporation of cancer-specific and competing risks into patient counseling and recommendations. A total of 5325 and 1257 diagnosed with clinical stage T2-T4a muscle-invasive bladder cancer from January 1, 2006 to December 31, 2011 from Surveillance, Epidemiology, and End Results-Medicare and Texas Cancer Registry-Medicare linked data, respectively. Cox proportional hazards models were used and a nomogram was developed to predict 3- and 5-year overall and cancer-specific survival with external validation. Patients who underwent radical cystectomy were mostly younger, male, married, non-Hispanic white and had fewer comorbidities than those who did not undergo radical cystectomy (P < .001). Married patients, in comparison with their unmarried counterparts, had both improved overall (hazard ratio 0.76; 95% confidence interval 0.70-0.83, P < .001) and cancer-specific (hazard ratio 0.76; 95% confidence interval 0.68-0.85, P < .001) survival. A nomogram developed using Surveillance, Epidemiology, and End Results-Medicare data, predicted 3- and 5-year overall and cancer-specific survival rates with concordance indices of 0.65 and 0.66 in the validated Texas Cancer Registry-Medicare cohort, respectively. Older, unmarried patients with increased comorbidities are less likely to undergo radical cystectomy. We developed and validated a generalizable instrument that has been converted into an online tool (Radical Cystectomy Survival Calculator), to provide a benefit-risk assessment for patients considering radical cystectomy.

Neoadjuvant Platinum-Based Chemotherapy is an Independent Predictor for Preoperative Thromboembolic Events in Bladder Cancer Patients Undergoing Radical Cystectomy

Introduction: Neoadjuvant chemotherapy (NAC) confers a significant survival benefit in patients with muscle invasive bladder cancer. Platinum-based chemotherapy increases the risk of thromboembolic events (TEE). We determined the effect of cisplatin-based NAC on the incidence of preoperative TEEs in radical cystectomy patients. Materials and Methods: A retrospective matched case-control study was performed on 55 patients undergoing radical cystectomy for muscle invasive bladder cancer. Group 1 (n = 20) included patients that received NAC prior to radical cystectomy and Group 2 (n = 35) included patients that underwent radical cystectomy without NAC. Logistic regression analyses tested potential predictors for TEEs in both groups (age, American Society of Anesthesiologists grade, use of NAC, histological subtype, pathological stage). Results: In total, 6 patients of 55 developed a TEE. Five patients of 20 (25%) treated with NAC prior to radical cystectomy developed TEEs, while 1 of 35 (2.9%) treated with radical cystectomy alone developed a TEE. On univariate and multivariate regression analysis, NAC prior to radical cystectomy was an independent predictor for TEE prior to radical cystectomy (p = 0.033 and p = 0.043, respectively). The effect of perioperative anticoagulation on operative blood loss and postoperative hemoglobin level was not statistically significant between both groups (p = 0.22 and p = 0.08, respectively). Conclusion: Neoadjuvant cisplatin-based chemotherapy is a significant predictor for preoperative TEE in patients undergoing radical cystectomy.

Health information quality on the internet for bladder cancer and urinary diversion: a multi-lingual analysis.

Bladder cancer patients undergoing radical cystectomy and urinary diversion are faced with difficult decisions regarding mode of urinary diversion. Although these patients may use the Internet as a guide to diagnosis and treatment options, online resources remain largely unregulated leading to a great variation in quality of medical information. Further variation in quality is seen between languages. Fortunately, tools such as an automated toolbar developed by the World Health Organization Health on the Net (HON) Foundation exist to assist physicians in recommending quality online health information to patients. We set out to compare and assess the quality of bladder cancer, ileal conduit and orthotopic neobladder web sites in 2016 on the basis of the HON principles for English language. The Google search engine imbedded with the HON toolbar was used to assess 1350 Web sites using the keywords "bladder cancer", "ileal conduit" and "orthotopic neobladder" in English, Italian and Spanish. The first 150 results of each search were identified and screened. A further analysis was completed comparing results between 2009 and 2016. Less than 20% of English, Italian and Spanish "bladder cancer" and urinary diversion ("ileal conduit" and "orthotopic neobladder") web sites are HON-accredited. HON-accredited web sites featured preferentially in the first 50 search results for bladder cancer (P=0.0001) and ileal conduit (P=0.03) web sites. Comparing 2016 results to 2009, percentage of HON-accreditation has not shown statistically significant change (-13%, P=0.23), while overall number of search results has increased (+44%). A lack of validation of bladder cancer sites is present, which is consistent across modes of urinary diversion (orthotopic neobladder and ileal conduit) and languages. It is important that physicians involved in the care of bladder cancer patients undergoing radical cystectomy and urinary diversion participate in the development of informative, ethical, and reliable health Web sites and direct patients to them.

900 - Circulating tumor cells do not correspond with clinicopathological characteristics of muscle-invasive bladder cancer patients undergoing radical cystectomy: Interim results of the CirGuidance study

900 - Circulating tumor cells do not correspond with clinicopathological characteristics of muscle-invasive bladder cancer patients undergoing radical cystectomy: Interim results of the CirGuidance study

Can the Preoperative Neutrophil-to-Lymphocyte Ratio Significantly Predict the Conditional Survival Probability in Muscle-invasive Bladder Cancer Patients Undergoing Radical Cystectomy?

The present study investigated the prognostic value of the preoperative neutrophil-to-lymphocyte ratio (NLR) in bladder cancer patients undergoing radical cystectomy (RC), with a focus on the conditional survival (CS) estimates over time after surgery. We analyzed 385 bladder cancer patients who underwent RC from 1999 to 2012. The patients were classified into 2 groups according to the preoperative NLR (< 2.5 vs.≥ 2.5). The Kaplan-Meier survival analysis was used to calculate the conditional probabilities of cancer-specific survival and overall survival after surgery. Multivariate Cox regression models were used to identify the predictors of 5-year conditional cancer-specific survival and overall survival. Patients with an elevated preoperative NLR (≥2.5) had a greater proportion of advanced-stage tumors (≥ pT3), high-grade tumors, and lymphovascular invasion. Patients with an elevated preoperative NLR (≥ 2.5) had poor CS estimates compared with those with a lower NLR (<2.5) at baseline and 1 year after RC. However, no significant differences in CS probabilities were observed from 2 years after RC onward. In a multivariate Cox regression analysis, the preoperative NLR was identified as a significant predictive factor for 5-year CS at baseline and postoperative 1-year estimation; however, its significance was lost after 2 years postoperatively. Our study results suggest that the dynamic aspect of the NLR should be considered when assessing the prognosis of bladder cancer patients treated with RC over time after the initial estimates, in particular, in patients who have already survived for additional years after surgery.

Gender-related Outcome in Bladder Cancer Patients undergoing Radical Cystectomy.

Background: The impact of gender on oncological outcome after radical cystectomy (RC) is not fully understood yet. The aim of the study was to evaluate gender-related differences in histopathological parameters and prognosis of patients with bladder cancer undergoing RC.Methods: A retrospective analysis of a 10-year single-center cystectomy database was performed. Kaplan-Meier survival and Cox-regression analyses with sex-specific interactions were performed to determine the impact of gender on recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS), in addition to established clinicopathological factors.Results: 259 patients (212 [81.8%] men and 47 [18.2%] women) were enrolled. Although women had a greater propensity for extravesical (≥pT3) disease (53.2% vs. 33.9%, p=0.03) and heterotopic urinary diversion (72.3% vs. 49.5%, p=0.006), gender did not independently predict RFS, CSS or OS on multivariate analysis. Extravesical tumor disease was the sole independent predictor concerning RFS (hazard ratio [HR]=4.70; p<0.001), CCS (HR=2.77; p=0.013), and OS (HR=1.93; p=0.041). Orthotopic urinary diversion (HR=0.36; p=0.002) had an independent effect only on RFS. Rates of 5-year RFS (73.7% vs. 48.3%; p=0.001), CSS (72.5% vs. 44.9%; p<0.001) and OS (62.6% vs. 37.8%; p<0.001) were higher in orthotopic versus heterotopic diversions.Conclusion: In our series, women presented with more advanced tumors and higher rates of heterotopic urinary diversions, but their survival outcome was not significantly inferior to that of men. Extravesical disease was independently related to poorer survival after RC.

Assessment of risk factors for prostatic tumor invasion in patients undergoing radical cystectomy

Objective To identify the risk factors for prostate-sparing cystectomy by evaluating the risk of prostatic invasion or incidental prostatic adenocarcinoma(PCa) in bladder cancer(BCa) patients undergoing radical cystectomy. Methods The patients undergoing radical cystectomy from 2009 to 2014 in Fujian Medical University Union Hospital were enrolled to analyze the risk factors of prostatic tumor invasion. These factors included age, tumor size, location, quantity, histologic grade and pathologic stage. Results In the 123 male patients, the mean age was 60 years( range, 31-78 years); 23(18.7%) patients had BCa or PCa in the prostate; 14(11.4%) had prostatic Bca; 11(8.9%) had PCa. The risk factors of prostatic BCa included multifocal bladder tumors(OR=26.70, P=0.032), tumor in the bladder neck and trigone(OR=17.13, P=0.013), pathological stage(OR=26.70, P<0.001). Among the 11 patients with PCa, 3(27.3%) patients had Gleason score of ≥7 , 8(72.7%) patients ≤6 and 2(18.2%) patients had extracapsular extension. Three patients had clinically significant PCa. The factor of advanced age was associated with incidental PCa(P=0.003). Conclusion The risk factors of prostatic tumor invasion in patients undergoing radical cystectomy included advanced age, bladder tumor in bladder neck and trigone, multifocal bladder tumors, and advanced pathological stage. Key words: Bladder neoplasms; Prostate adenocarcinoma; Radical cystectomy; Prostate-sparing cystectomy

340 Applying fast-track protocols in bladder cancer patients undergoing radical cystectomy with ileal urinary diversions - early results of a prospective randomised controlled single center study

340 Applying fast-track protocols in bladder cancer patients undergoing radical cystectomy with ileal urinary diversions - early results of a prospective randomised controlled single center study

Association between diabetes mellitus and oncological outcomes in bladder cancer patients undergoing radical cystectomy

To determine the association between diabetes mellitus and oncological outcomes in urothelial bladder cancer patients undergoing radical cystectomy. From January 2004 to December 2014, 200 non-metastatic urothelial bladder cancer patients who underwent radical cystectomy were divided into two groups according to diabetes mellitus status at the time of surgery. Kaplan-Meier and Cox regression analysis were used to assess the association between diabetes mellitus and urothelial bladder cancer recurrence-free, cancer-specific and overall mortality. Of the 200 patients, 28 (14%) had diabetes mellitus and presented similar preoperative factors and pathological findings after radical cystectomy, including pathological stage, grade, lymph node invasion and positive surgical margin compared with non-diabetes mellitus patients (n=172). The 5-year cancer-specific survivals were 92.3% and 62.1% in the non-diabetes mellitus and diabetes mellitus groups, respectively (P=0.022). Multivariate Cox regression analysis showed that diabetes mellitus was a significant predictor for cancer-specific mortality (hazard ratio 1.785, P=0.038). The 5-year overall survival rate was 92.1% and 59.4% in the non-diabetes mellitus and diabetes mellitus groups, respectively (P=0.014), and diabetes mellitus was a significant factor for overall mortality by multivariate Cox regression analysis (hazard ratio 1.281, P=0.042). Among bladder cancer patients who underwent radical cystectomy, the diabetes mellitus patients had worse cancer-specific mortality and overall mortality outcomes than the non-diabetes mellitus patients. The mechanism of association between diabetes mellitus and urothelial bladder cancer should be investigated to validate the present results in a future prospective study.

The Prognostic Significance of the Early Postoperative Neutrophil-to-Lymphocyte Ratio in Patients with Urothelial Carcinoma of the Bladder Undergoing Radical Cystectomy.

Because the pretreatment neutrophil-to-lymphocyte ratio (NLR) is a reliable prognostic factor, the authors of this study hypothesized that posttreatment NLR also predicts the survival outcome for cancer patients. The study investigated the clinicopathologic features according to postoperative NLR and determined the prognostic significance of early postoperative NLR for bladder cancer patients undergoing radical cystectomy (RC). The study reviewed 385 bladder cancer patients treated with RC and pelvic lymph node dissection at the authors' institution between 1999 and 2012. The primary end points of the study were cancer-specific survival (CSS) and overall survival (OS) estimates from the Kaplan-Meier analysis. Multivariate Cox regression analysis was adopted to identify the independent prognostic factors for oncologic outcomes after surgery. Patients with elevated postoperative NLR (≥2.0) had higher rates of advanced pathologic tumor stage (≥pT3), lymphovascular invasion, and lymph node involvement. Notably, they showed poorer CSS and OS rates than patients with a postoperative NLR lower than 2.0. Additionally, patients with pre- and postoperative elevated NLR (≥2.1 → ≥2.0) demonstrated worse oncologic outcomes than other groups of NLR changes. Multivariate analysis showed that early postoperative NLR remained a key predictor for CSS and OS. When divided by pathologic T or N stage, patients with localized pathologic T stage or pN0 status showed significant differences in survival according to early postoperative NLR. In summary, postoperative NLR in the early recovery period can be a valuable biomarker for predicting oncologic outcomes for bladder cancer patients undergoing RC.

Association of Distance to Treatment Facility on Quality and Survival Outcomes After Radical Cystectomy for Bladder Cancer

To examine the association of travel distance on quality and survival outcome measures for bladder cancer patients undergoing radical cystectomy for urothelial carcinoma. Four hundred eight patients who underwent radical cystectomy for bladder cancer at a single institution from 2007 to 2013 were included. Multivariate logistic regression was used to determine the association of distance from treatment facility with 90-day mortality and quality-of-care endpoints including neoadjuvant chemotherapy use and time to cystectomy. Survival was assessed by multivariate Cox regression. Fifty-seven percent of patients lived within 50 miles of the treatment facility. There was no difference in time to cystectomy or the utilization of neoadjuvant chemotherapy between patients in different distance groups. On multivariate analysis, distance to treatment facility was the only predictor of 90-day mortality (odds ratio, 11.20; 95% confidence interval, 2.27-55.43; P= .003, for patients traveling >150 vs<50 miles). Although there was no difference in recurrence and cancer-specific survival between distance groups, greater distance was associated with worse overall survival on multivariate analysis (hazard ratio, 1.59; 95% confidence interval, 0.99-2.56; P= .05, for patients traveling >150 vs<50 miles). Distance to treatment facility did not impact quality measures including time to cystectomy or useof neoadjuvant chemotherapy, and there was no difference in cancer-specific mortality between distance groups. There was a detrimental association of increased travel distance with 90-day mortality, which could reflect disparities in access to care after cystectomy.

FDG PET-CT for lymph node staging of bladder cancer: a prospective study of patients with extended pelvic lymphadenectomy.

The purpose of this study was to evaluate the diagnostic accuracy of [(18)F] fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT) for lymph node (LN) staging of bladder cancer patients undergoing radical cystectomy (RC) with extended pelvic lymphadenectomy compared to conventional CT. A total of 61 patients underwent FDG PET-CT before RC and extended pelvic lymphadenectomy. A template for extended pelvic lymphadenectomy to the level of the inferior mesenteric artery was divided into 11 anatomic nodal packets. Definitive pathologic findings of resected LNs were correlated with the results of FDG PET-CT and CT alone in a patient- and nodal packet-based manner. Among the 61 patients, pathological staging confirmed LN metastasis in 17 patients (27.9 %). In total, 627 LN packets (2580 LNs) were resected and histologically evaluated. The mean number of LNs removed was 42 (median 40; range 22-118). Of the 627 LN packets removed, 27 packets (4.3 %) were positive for LN metastasis based on pathologic analysis. On a patient-based analysis, FDG PET-CT and conventional CT showed a sensitivity of 47.1 and 29.4 %, respectively, specificity of 93.2 and 97.7 %, respectively, positive predictive value (PPV) of 72.7 and 78.2 %, respectively, and negative predictive value (NPV) of 82.0 and 78.2 %, respectively. On a nodal packet-based analysis, sensitivity, specificity, PPV, and NPV were 14.8, 97.8, 23.5, and 96.2 %, respectively, for PET-CT and 11.1, 98.7, 27.3, and 96.1 %, respectively, for conventional CT. Combined FDG PET-CT did not improve the diagnostic accuracy of conventional CT for the detection of LN metastasis in bladder cancer patients scheduled for RC.

Outcomes After Urothelial Recurrence in Bladder Cancer Patients Undergoing Radical Cystectomy

To identify factors prognostic for survival after urothelial recurrence after radical cystectomy for bladder cancer. Of the 2029 patients with bladder cancer who underwent radical cystectomy at our institution, 80 (3.9%) patients experienced recurrence in the urothelium (upper urinary tract or urethra) and had sufficient follow-up for further analysis. Clinicopathologic characteristics were analyzed by univariate and multivariable analyses to identify factors prognostic for postrecurrence disease-specific (PRDSS) and overall (PROS) survival. At median follow-up of 12 years, 25 (31.3%) and 55 (68.7%) patients experienced recurrence in the upper tract and urethra, respectively. Median time to recurrence, PRDSS, and PROS were 25.9, 58.4, and 48.7 months, respectively. Older age (P = .018), patients with tumors that were upstaged at cystectomy compared with their clinical stage (P = .049), and positive surgical margins (P = .022) were associated with a lower PROS. The presence of symptoms at follow-up was associated with a poor PRDSS (P = .028), which was confirmed by multivariable analysis. Patients experiencing urothelial recurrence within 2 years of cystectomy had a lower PRDSS (P = .002) and PROS (P = .003), which was confirmed by multivariable analysis. Site of urothelial recurrence did not influence time to recurrence (P = .87), PRDSS (P = .72), or PROS (P = .57). Urothelial cancer relapse in the upper urinary tract or urethra has a comparable clinical course, and may be cured with extirpative surgery, with median PROS of 48.7 months after recurrence. Patients experiencing early urothelial recurrence face worse prognosis and should be considered candidates for adjuvant therapy.

Whole-lesion diffusion metrics for assessment of bladder cancer aggressiveness.

To explore associations of whole-lesion histogram diffusion metrics with pathologic findings and subsequent metastatic disease in bladder cancer patients undergoing radical cystectomy. Twenty-three bladder cancer patients (21M, 2F; mean 70 ± 11 years) underwent MRI before cystectomy. A volume-of-interest was placed on all slices on the ADC map encompassing each lesion. Whole-lesion mean, kurtosis, and skewness of ADC were calculated and compared with T stage and pelvic nodal status at cystectomy and with subsequent metastasis in 20/25 patients with available follow-up. At cystectomy, 39 % (9/23) were stage T2, 61 % (14/23) ≥T3, and 28 % (5/23) exhibited positive nodes; 35 % (7/20) developed later metastases. Mean ADC was significantly lower in stage ≥T3 than in lower stage tumors (1.20 ± 0.36 × 10(-3) vs. 1.55 ± 0.36 × 10(-3) mm(2)/s; p = 0.044), but showed no association with nodal or metastatic disease (p = 0.362-0.709). Kurtosis was significantly lower in tumors with, compared to without, nodal disease (-0.05 ± 0.29 vs. 0.91 ± 1.16; p = 0.037), and showed a non-significant decrease in tumors with, compared to without, later metastases (0.23 ± 0.63 vs. 0.83 ± 0.89; p = 0.088). Kurtosis was not associated with T stage (p = 0.811), and skew was not associated with any outcome (p = 0.516-0.643). Mean ADC achieved highest AUC for identification of stage ≥T3 (AUC = 0.754 vs. 0.516-0.643 for other metrics). Kurtosis achieved highest AUC for nodal disease (AUC = 0.811 vs. 0.522-0.556 for other metrics) and metastases (AUC = 0.736 vs. 0.516-0.626 for other metrics). Only difference in AUC between skewness and kurtosis for nodal disease was significant (p = 0.031). While requiring larger studies, kurtosis has potential to complement mean ADC in bladder cancer prognosis using whole-lesion histogram analysis.

Visceral obesity predicts adverse pathological features in urothelial bladder cancer patients undergoing radical cystectomy: a retrospective cohort study

To evaluate the pathological characteristics of patients with metabolic syndrome (MetS) undergoing radical cystectomy (RC) for urothelial bladder cancer (BCa). We retrospectively analyzed 262 consecutive patients with muscle-invasive urothelial BCa or non-muscle-invasive urothelial BCa bacillus Calmette-Guerin refractory undergoing RC with standard pelvic lymphadenectomy. The patients were stratified into those with or without MetS, and a bivariate logistic regression analysis was done to assess MetS and, separately, each single MetS component as independent predictors of higher pathological stage as well as of the presence of lymph vascular invasion (LVI) and lymph node metastasis (LM). Metabolic syndrome was found in 36.3 % of patients. At logistic regression analysis, the presence of MetS did not predict the risk of both higher pathological stage and LVI and LM. Investigating the single components of MetS after adjusting for age, gender, and smoking, the risk of higher pathological stage increased with body mass index [BMI (OR 1.307, 95 % CI 1.098-1.555)], waist circumference (OR 1.414, 95 % CI 1.364-1.668), and blood hypertension (OR 2.326, 95 % CI 1.147-4.717). Higher BMI also predicted the presence of LVI (OR 1.432, 95 % CI 1.173-1.748) and LM (OR 1.202, 95 % CI 0.951-1.519), whereas HDL cholesterol was inversely associated with the risk of LVI and LM. Metabolic syndrome does not represent an independent risk factor for worse pathological findings in BCa. Conversely, individual components of MetS could increase the risk of higher stage as well as LM.

Pelvic lymph node dissection in the context of radical cystectomy: a thorough insight into the connection between patient, surgeon, pathologist and treating institution

Pelvic lymph node dissection (PLND) in patients with bladder cancer varies widely in extent, technique employed, and pathological workup of specimens. The present paper provides an overview of the existing evidence regarding the effectiveness of PLND and elucidates the interactions between patient, surgeon, pathologist, and treating institution as well as their cumulative impact on the final postoperative lymph node (LN) staging. Bladder cancer patients undergoing radical cystectomy with extended PLND appear to have better oncologic outcomes compared to patients undergoing radical cystectomy and limited PLND. Attempts have been made to define and assess the quality of PLND according to the number of lymph nodes identified. However, lymph node counts depend on multiple factors such as patient characteristics, surgical template, pathological workup, and institutional policies; hence, meticulous PLND within a defined and uniformly applied extended template appears to be a better assurance of quality than absolute lymph node counts. Nevertheless, the prognosis of the patients can be partially predicted with findings from the histopathological evaluation of the PLND specimen, such as the number of positive lymph nodes, extracapsular extension, and size of the largest LN metastases. Therefore, particular prognostic parameters should be addressed within the pathological report to guide the urologist in terms of patient counseling.