Study supports early cystectomy for pT1G3 TCC

Anaheim, CA-It may be time to update treatment guidelines for transitional cell carcinoma. Retrospective data from Germany presented at the AUA annual meeting here suggest that radical cystectomy should be considered as the most appropriate first-line treatment for these aggressive tumors. Current guidelines from both AUA and the European Association of Urology recommend bladder preservation as first-line treatment.

"We have to be very careful with this type of tumor," said Pia Bader, MD, senior physician at the urology clinic, Stadtisches Klinikum, Karlsruhe, Germany, during a moderated poster presentation. "When you have a high-risk situation like this aggressive tumor type, you have to go for cystectomy immediately. Otherwise, you have a substantial risk of undertreating patients."

Dr. Bader and her colleagues analyzed chart data for all 735 patients who underwent radical cystectomy at Stadtisches Klinikum between November 1989 and December 2003. Patients were evaluated for frequency of pT1G3, clinical understaging on transurethral resection of the bladder, lymph node involvement, and both tumor-specific survival and overall survival. Patient follow-up data were available for a median of 46 months (range, 4 to 173 months).

Understaging found

The more disturbing news is that 17% of patients were understaged at the time of resection and showed tumors more advanced than pT1G3. Among the understaged patients, 29% already showed lymph node metastases at the time of their cystectomy.

Equally disturbing was the finding that in patients with pT1G3 or less advanced tumors, 5% had histologically proven regional lymph node metastases, including 2% who showed no tumor in the cystectomy specimen. Another 10% of these lower-staged patients showed evidence of tumor progression during follow-up.

"There is an ongoing controversy over the treatment of pT1G3 bladder cancer," Dr. Bader said. "The real question is, will you have the same oncological outcomes with and without cystectomy? These data tell us that transitional cell carcinoma pT1G3 justifies radical cystectomy as the primary therapy option."

The current standard of care for transitional cell carcinoma is transurethral resection and consecutive bladder instillations of bacillus Calmette-Guerin (BCG [TheraCys, TICE BCG]), Dr. Bader noted. The literature suggests that such conservative treatment will preserve the bladder in one-third of patients. Cystectomy will be needed as second-line treatment in another third of patients, and the final third will progress to metastatic disease.

Early cystectomy offers better survival, Dr. Bader said. Data from her institution showed an overall 5-year tumor-specific survival rate of 88% following early cystectomy for pT1G3 tumors. Of the 15 patients who died of transitional cell carcinoma, four had no residual tumor in the cystectomy specimen and five had a tumor stage less than pT1G3. Another two patients had residual pT1G3 disease and four had a tumor stage more advanced than pT1G3 on definitive histology.

The problem, Dr. Bader added, is that first-line cystectomy for all pT1G3 transitional cell carcinomas would result in overtreatment for about 35% of patients. The current state of pathology cannot distinguish between the patients who will be overtreated with cystectomy versus those for whom cystectomy is the appropriate first-line therapy.

"We did not have enough patients for a deeper statistical analysis," she said. "It may turn out that T0 is not really T0 in all patients."