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cisplatin combination chemotherapy for urothelial carcinoma
501 THE ROLE OF RESCUE RADICAL CYSTECTOMY (RCT) IN A BLADDER PRESERVATION PROGRAM BASED ON TUR PLUS CHEMOTHERAPY FOR PATIENTS WITH INVASIVE BLAADER CANCER
502 THE USE OF ENDOVASCULAR STENTS IN CASES OF OCCLUSION OF THE ILIO-FEMORAL VEINS DUE TO INVASIVE PELVIC UROLOGIC TUMOURS Yachia D.‘, Faragi G.‘. Gremitsky A.‘. Bartal G.’
Solsona E., Iborra I.. Rices J.V., Monros J.L.. Dumont R., Rubio J., Casanova J.L. IVO, Dept. of Urology, Valencia, Spain INTRODUCTION & OBJECTIVES: RCT is the main rescue therapy in patients with invasive bladder cancer included in bladder preservation programs when therapy fails. However, the efficacy of this procedure remains controversial. The objective is to evaluate the efftcacy of RCT after failure in patients included in a bladder preservation program based on TUR and chemotherapy. MATERIAL & METHODS: Patients with TZ2 tumours and complete TUR with negative biopsies on perivesical fat but with positive biopsies on muscular layer of tumour bed were included in a program of bladder preservation receiving 3 courses of cisplatin-based chemotherapy. Patients who did not respond (cNR= TZ2) at 3. months evaluation and those with invasive recurrence after complete response (cCR=TO) or partial response (cPR=Ta-I-Tis) were treated with RCT. Patients with cPR received intravesical BCG and patients with cCR were only observed. RESULTS: We evaluated 61 patients with a minimum follow-up of24 ms. (x=62. I ms.). Among these patients, 22 (36.1%) did not respond (20, T2-3 and 2, TO-3Ml). Of these patients, 18 were treated with RCT. 2 with XRT and 2 with other chemotherapy regimens. Of 39 patients who reached cCR or cPR. 14 (35.9%) developed invasive recurrence (10, T2-3 and 4, TO-3Ml). Among these patients, 7 were treated with RCT, 3 with XRT and 4 with palliative therapy or chemotherapy. Other 3 patients underwent RCT, 2 by bladder toxicity and 1 with cPR by their own decision. As a whole, 28 patients underwent RCT, 19 were performed initially after chemotherapy failure and 12 (63.1%) patients died of tumour while only 2 (22.2%) of 9 patients treated with delayed RCT after invasive recurrence. These data were similar to those of patients receiving up-front chemotherapy to RCT who showed P?2 in RCT specimen, 26 (68.4%) of 38 died of tumour. As a whole, 66.6% (38/ 57) of patients who did not respond (T or P>2) to induction chemotherapy died of tumour.
‘Hillel Yaffe Medical Center, Urology. Hadera, Israel. ‘Hillel Yaffc Medical Ccmer. Radiology, Hadera, Israel INTRODUCTION & OBJECTIVES: Patients with pelvic urologic invasive malignancies may develop swelling and pain of the lower extremities, as a result of compression and/or occlusion of the tumour on the pelvic veins and lymphatic vessels. Compared with the underlying disease, the venous drainage of the lower extremities is seen as a less important problem, and is managed by conservative means, hoping that the drainage will be obtained by the venous collaterals. Although the use of stents for relieving gynaecological or surgical venous obstruction has been published, we could not find reports on the use of vascular stents in pelvic urologic malignancies. We are presenting our experience in which endovascular stenting of the Ilio-femoral vein was used for relieving the obstruction caused by invasive bladder turnours. MATERIAL & METHODS: Two patients diagnosed with locally invasive bladder TCC presented with severe ipsilateral lower extremity edema and pain. The evaluation included Doppler ultrasound and CT venography, which revealed complete occlusion of the ilio-femoral veins. Endovascular recanalization was performed with balloon dilatation. insertion of a vena cava filter and mechanical thrombolysis (in case I) followed by insertion of a stent graft (“Wallstent ! Boston Scientific”). The occluded iliac veins were stented from the IVC to the femoral vein. Patients were put on anticoagulant therapy after stent placement. RESULTS: Mean follow-up was 7 months (range 3-12 months). No immediate or late complications were seen. In one patient the edema disappeared within 2 weeks after the procedure, and in the second within 1 week. allowmg them to rcsumc using their regular footwear.
CONCLUSIONS: Although cNR to chemotherapy is a poor prognostic factor, RCT is justified in patients who did not respond with a 5-years CSS around 34% and it is totally effective in patients who developed mvasive recurrence after clinical response.
CONCLUSIONS: Endovascular stent placement is a non-surgical alternative for reestablishment venous flow and sustained relief of pain and edema of the lower limbs in patients with locally invasive bladder TCC. Despite the immediate high cost of this approach, when compared to the total cost of the continuous treatment these patients need is high (such as physiotherapy. special stockings, medication, frequent hospitalisation, etc) making this approach reasonable, giving almost immediate benefit to the patients. This underused, relatively simple and a viable palliative option for reducing the misery of these patients may be used almost in any hospital having an interventional radiology department.
503
504
THROMBOCYTOPENIA IN COMBINATION CHEMOTHERAPY CARCINOMA
GEMCITABINEKISPLATIN FOR UROTHELIAL
THE INFLUENCE CHEMOTHERAPY
OF LYMPH NODE ON SURVIVAL
Miillcr E., Echtlc D., Kontaxis D., Frohnebcrg Niovgen J.B.W., Berdjis N., Hakenberg
Urology, Dresden. Germany
INTRODUCTION & OBJECTIVES: For the polychemotherapy of advanced urothelial carcinoma Gemcitabine and Cisplatin chemotherapy has become a treatment option because of similar efficacy but lower toxicity compared to standard MVAC/MVEC regimens. The aim of this study was to evaluate whether in unselected patients treatment with gemcitabineicisplatin also produces low toxicities. MATERIAL & METHODS: 40 consecutive patients (mean age 66 years, range 43-81) with advanced bladder carcinoma underwent gemcitabine/cisplatin chemotherapy between January 2000 and December 2002. A total of 127 treatment courses were given, 3.16 (l-6) courses/patient on average. Gemcitabine was given on days 1, 8 and 15 at a dose of 1 g/m’, cisplatin on day 2 at a dose of 70 mg/m’. I RESULTS: Grade 1 thrombocytopenia (CTC) necessitating postponement of treatment occurred in 24 courses (19%), mostly due to thrombocytopenia on day 15 (in some cases also on day 8). Severe grade 4 thrombocytopenia (CTC) occurred 29 courses (35%) and 3 patients suffered major haemomhages 111” (CTC) with thrombocytopenia (7,5%). CONCLUSIONS: Our experience is that thrombocytopenia is significantly more common under Gemcitabine/Cisplatin chemotherapy in older patients with advanced urothelial carcinoma than previously reported in the licensing study (Masse et al, JClinOncol 2000), where thrombocytopenia grade 4 was reported in 29% and haemorrhage grade 3 in only 2%. European
AND
ADJUVANT
D
O.W., Manseck A., Wirth M.P. Klinikum Karlsruhe,
Technical University.
STATUS
Urology Supplements 2 (2003) No. 1, pp. 128
Urologische
Klinik. Karlsruhc.
Germany
INTRODUCTION & OBJECTIVES: The extent of lymph node involvement is considered an important prognostic factor. The goal of this retrospective study was to evaluate the prognostic significance of lymph node status and chemotherapy. MATERIAL & METHODS: In the past 10 years, 554 cystectomies were performed. 4X2/554 on patients with invasive urothelial carcinomas of the urinary bladder (stages pT1 G3 pN0 MO - pT4 G3 pN2 MO). The routine lymphadenectomy included the bilateral obturator and iliac lymph nodes. All 482 patients were evaluated: the mean age was 65.7 (29.87), there were 3.8 more men than women, and the mean follow-up was 48 (3-125) months. 1011482 (20.9%) showed invasion of the lymph nodes; 411482 (8.5%) were staged at pN1 and 601482 (12.4%) at pN2. RESULTS: Organ-confined tumours were found in 2261349 (64.7%) of the pNO-staged patients, 15/4 1 (36.6%) of pN 1 and I5/60 (25.0%) of pN2. In terms of survival rate there was no significant difference noted in pN0 and pN I stage organ-confined tumours (table).
CONCLUSIONS: In patients with minimal lymph node invasion, a lymphadenectomy may result in both exact staging and in a potential therapeutic benefit. The statistics for these patients show a significant difference in survival rate.
502 THE USE OF ENDOVASCULAR STENTS IN CASES OF OCCLUSION OF THE ILIO-FEMORAL VEINS DUE TO INVASIVE PELVIC UROLOGIC TUMOURS Yachia D.‘, Faragi G.‘. Gremitsky A.‘. Bartal G.’
Solsona E., Iborra I.. Rices J.V., Monros J.L.. Dumont R., Rubio J., Casanova J.L. IVO, Dept. of Urology, Valencia, Spain INTRODUCTION & OBJECTIVES: RCT is the main rescue therapy in patients with invasive bladder cancer included in bladder preservation programs when therapy fails. However, the efficacy of this procedure remains controversial. The objective is to evaluate the efftcacy of RCT after failure in patients included in a bladder preservation program based on TUR and chemotherapy. MATERIAL & METHODS: Patients with TZ2 tumours and complete TUR with negative biopsies on perivesical fat but with positive biopsies on muscular layer of tumour bed were included in a program of bladder preservation receiving 3 courses of cisplatin-based chemotherapy. Patients who did not respond (cNR= TZ2) at 3. months evaluation and those with invasive recurrence after complete response (cCR=TO) or partial response (cPR=Ta-I-Tis) were treated with RCT. Patients with cPR received intravesical BCG and patients with cCR were only observed. RESULTS: We evaluated 61 patients with a minimum follow-up of24 ms. (x=62. I ms.). Among these patients, 22 (36.1%) did not respond (20, T2-3 and 2, TO-3Ml). Of these patients, 18 were treated with RCT. 2 with XRT and 2 with other chemotherapy regimens. Of 39 patients who reached cCR or cPR. 14 (35.9%) developed invasive recurrence (10, T2-3 and 4, TO-3Ml). Among these patients, 7 were treated with RCT, 3 with XRT and 4 with palliative therapy or chemotherapy. Other 3 patients underwent RCT, 2 by bladder toxicity and 1 with cPR by their own decision. As a whole, 28 patients underwent RCT, 19 were performed initially after chemotherapy failure and 12 (63.1%) patients died of tumour while only 2 (22.2%) of 9 patients treated with delayed RCT after invasive recurrence. These data were similar to those of patients receiving up-front chemotherapy to RCT who showed P?2 in RCT specimen, 26 (68.4%) of 38 died of tumour. As a whole, 66.6% (38/ 57) of patients who did not respond (T or P>2) to induction chemotherapy died of tumour.
‘Hillel Yaffe Medical Center, Urology. Hadera, Israel. ‘Hillel Yaffc Medical Ccmer. Radiology, Hadera, Israel INTRODUCTION & OBJECTIVES: Patients with pelvic urologic invasive malignancies may develop swelling and pain of the lower extremities, as a result of compression and/or occlusion of the tumour on the pelvic veins and lymphatic vessels. Compared with the underlying disease, the venous drainage of the lower extremities is seen as a less important problem, and is managed by conservative means, hoping that the drainage will be obtained by the venous collaterals. Although the use of stents for relieving gynaecological or surgical venous obstruction has been published, we could not find reports on the use of vascular stents in pelvic urologic malignancies. We are presenting our experience in which endovascular stenting of the Ilio-femoral vein was used for relieving the obstruction caused by invasive bladder turnours. MATERIAL & METHODS: Two patients diagnosed with locally invasive bladder TCC presented with severe ipsilateral lower extremity edema and pain. The evaluation included Doppler ultrasound and CT venography, which revealed complete occlusion of the ilio-femoral veins. Endovascular recanalization was performed with balloon dilatation. insertion of a vena cava filter and mechanical thrombolysis (in case I) followed by insertion of a stent graft (“Wallstent ! Boston Scientific”). The occluded iliac veins were stented from the IVC to the femoral vein. Patients were put on anticoagulant therapy after stent placement. RESULTS: Mean follow-up was 7 months (range 3-12 months). No immediate or late complications were seen. In one patient the edema disappeared within 2 weeks after the procedure, and in the second within 1 week. allowmg them to rcsumc using their regular footwear.
CONCLUSIONS: Although cNR to chemotherapy is a poor prognostic factor, RCT is justified in patients who did not respond with a 5-years CSS around 34% and it is totally effective in patients who developed mvasive recurrence after clinical response.
CONCLUSIONS: Endovascular stent placement is a non-surgical alternative for reestablishment venous flow and sustained relief of pain and edema of the lower limbs in patients with locally invasive bladder TCC. Despite the immediate high cost of this approach, when compared to the total cost of the continuous treatment these patients need is high (such as physiotherapy. special stockings, medication, frequent hospitalisation, etc) making this approach reasonable, giving almost immediate benefit to the patients. This underused, relatively simple and a viable palliative option for reducing the misery of these patients may be used almost in any hospital having an interventional radiology department.
503
504
THROMBOCYTOPENIA IN COMBINATION CHEMOTHERAPY CARCINOMA
GEMCITABINEKISPLATIN FOR UROTHELIAL
THE INFLUENCE CHEMOTHERAPY
OF LYMPH NODE ON SURVIVAL
Miillcr E., Echtlc D., Kontaxis D., Frohnebcrg Niovgen J.B.W., Berdjis N., Hakenberg
Urology, Dresden. Germany
INTRODUCTION & OBJECTIVES: For the polychemotherapy of advanced urothelial carcinoma Gemcitabine and Cisplatin chemotherapy has become a treatment option because of similar efficacy but lower toxicity compared to standard MVAC/MVEC regimens. The aim of this study was to evaluate whether in unselected patients treatment with gemcitabineicisplatin also produces low toxicities. MATERIAL & METHODS: 40 consecutive patients (mean age 66 years, range 43-81) with advanced bladder carcinoma underwent gemcitabine/cisplatin chemotherapy between January 2000 and December 2002. A total of 127 treatment courses were given, 3.16 (l-6) courses/patient on average. Gemcitabine was given on days 1, 8 and 15 at a dose of 1 g/m’, cisplatin on day 2 at a dose of 70 mg/m’. I RESULTS: Grade 1 thrombocytopenia (CTC) necessitating postponement of treatment occurred in 24 courses (19%), mostly due to thrombocytopenia on day 15 (in some cases also on day 8). Severe grade 4 thrombocytopenia (CTC) occurred 29 courses (35%) and 3 patients suffered major haemomhages 111” (CTC) with thrombocytopenia (7,5%). CONCLUSIONS: Our experience is that thrombocytopenia is significantly more common under Gemcitabine/Cisplatin chemotherapy in older patients with advanced urothelial carcinoma than previously reported in the licensing study (Masse et al, JClinOncol 2000), where thrombocytopenia grade 4 was reported in 29% and haemorrhage grade 3 in only 2%. European
AND
ADJUVANT
D
O.W., Manseck A., Wirth M.P. Klinikum Karlsruhe,
Technical University.
STATUS
Urology Supplements 2 (2003) No. 1, pp. 128
Urologische
Klinik. Karlsruhc.
Germany
INTRODUCTION & OBJECTIVES: The extent of lymph node involvement is considered an important prognostic factor. The goal of this retrospective study was to evaluate the prognostic significance of lymph node status and chemotherapy. MATERIAL & METHODS: In the past 10 years, 554 cystectomies were performed. 4X2/554 on patients with invasive urothelial carcinomas of the urinary bladder (stages pT1 G3 pN0 MO - pT4 G3 pN2 MO). The routine lymphadenectomy included the bilateral obturator and iliac lymph nodes. All 482 patients were evaluated: the mean age was 65.7 (29.87), there were 3.8 more men than women, and the mean follow-up was 48 (3-125) months. 1011482 (20.9%) showed invasion of the lymph nodes; 411482 (8.5%) were staged at pN1 and 601482 (12.4%) at pN2. RESULTS: Organ-confined tumours were found in 2261349 (64.7%) of the pNO-staged patients, 15/4 1 (36.6%) of pN 1 and I5/60 (25.0%) of pN2. In terms of survival rate there was no significant difference noted in pN0 and pN I stage organ-confined tumours (table).
CONCLUSIONS: In patients with minimal lymph node invasion, a lymphadenectomy may result in both exact staging and in a potential therapeutic benefit. The statistics for these patients show a significant difference in survival rate.