Current Role of Partial Current Role of Partial Cystectomy: Are we Cystectomy: Are we

scarifying patientscarifying patient’’s survivals survival

Dr Eric LiDepartment of SurgeryPamela Youde Nethersole hospital

Bladder tumorBladder tumor

►TCC bladder (90%)TCC bladder (90%)►SCC bladder (7-9%)SCC bladder (7-9%)►Adenocarcinoma (1-2%)Adenocarcinoma (1-2%)►SacromaSacroma►Small cell carcinomaSmall cell carcinoma►Urachal carcinomaUrachal carcinoma

Gading of TCC Gading of TCC

►Degree of anaplasia of the tumor cellsDegree of anaplasia of the tumor cells►correlation exists between tumor grade correlation exists between tumor grade

and stage and stage Jewett and Strong, 1946 Jewett and Strong, 1946

►correlation between tumor grade and correlation between tumor grade and prognosis prognosis

► low-grade tumors and high-grade low-grade tumors and high-grade tumors have fundamentally different tumors have fundamentally different origins origins Knowles et al, 1994 ; Spruck et al, 1994 ; Reznikoff et al, 1996 ; Cote and Knowles et al, 1994 ; Spruck et al, 1994 ; Reznikoff et al, 1996 ; Cote and

Chatterjee, 1999Chatterjee, 1999

Staging of TCC Staging of TCC (1997 AJCC-UICC, TNM Staging )(1997 AJCC-UICC, TNM Staging )

► Ta: Papillary, epithelium confinedTa: Papillary, epithelium confined► Tis: Flat carcinoma in situTis: Flat carcinoma in situ► T1: Lamina propria invasionT1: Lamina propria invasion► T2a: Superficial muscularis T2a: Superficial muscularis

propria invasionpropria invasion► T2b: Deep muscularis propria T2b: Deep muscularis propria

invasioninvasion► T3a: Microscopic extension into T3a: Microscopic extension into

perivesical fatperivesical fat► T3b: Macroscopic extension into T3b: Macroscopic extension into

perivesical fatperivesical fat► T4a: Cancer invading pelvic T4a: Cancer invading pelvic

viscera (e.g., prostatic stroma, viscera (e.g., prostatic stroma, vaginal wall, rectum, uterus)vaginal wall, rectum, uterus)

► T4b: Extension to pelvic T4b: Extension to pelvic sidewalls, abdominal walls, or sidewalls, abdominal walls, or bonybony

Staging of TCC Staging of TCC

► N0: No histologic pelvic node metastasesN0: No histologic pelvic node metastases► N1: Single positive node ≤2 cm in diameter, N1: Single positive node ≤2 cm in diameter,

below common iliacsbelow common iliacs► N2: Single positive node 2-5 cm in greatest N2: Single positive node 2-5 cm in greatest

diameter or multiple positive nodesdiameter or multiple positive nodes► N3: Positive nodes >5 cm in diameterN3: Positive nodes >5 cm in diameter► Nx: Nodal status unknownNx: Nodal status unknown► M0: No distant metastasesM0: No distant metastases► M1: Distant metastases documentedM1: Distant metastases documented► Mx: Distant metastases status uncertainMx: Distant metastases status uncertain

PATTERNS OF PATTERNS OF DISSEMINATION DISSEMINATION

►Direct ExtensionDirect Extension►Lymphatic spreadLymphatic spread►Vascular spreadVascular spread► Implantation Implantation

Biology of TCCBiology of TCC

►Multicentric Origin Multicentric Origin ClonalClonal Field changeField change

►almost all patients who develop almost all patients who develop metastases develop muscle-invasive metastases develop muscle-invasive recurrences before or at the time recurrences before or at the time metastases are recognized metastases are recognized Jewett and Strong, 1946 ; Jewett and Strong, 1946 ;

Freeman et al, 1995a Freeman et al, 1995a

Treatment decisionTreatment decision

►Superficial versus Infiltrating Superficial versus Infiltrating TumorTumor ? ?

Non-muscle invasive TCCNon-muscle invasive TCC

►Transurethral Resection of Bladder Transurethral Resection of Bladder Tumor (TURBT)Tumor (TURBT)

► Intravesical TherapyIntravesical Therapy BCGBCG Mitomycin CMitomycin C

Muscle Invasive TCCMuscle Invasive TCC

►Radical CystectomyRadical Cystectomy En bloc cystectomyEn bloc cystectomy Bilateral pelvic iliac lymph node dissectionBilateral pelvic iliac lymph node dissection Urinary diversionUrinary diversion

Radical cystectomyRadical cystectomy

►69% recurrence-free survival at 5 years69% recurrence-free survival at 5 years►60% overall survival at 5 years60% overall survival at 5 years►Survival significantly related to Survival significantly related to

pathologic stage and lymph node statuspathologic stage and lymph node status►9% overall local pelvic recurrence9% overall local pelvic recurrence

Donald G. Skinner 2007Donald G. Skinner 2007

ComplicationComplication

Complication ( Local Data ) Complication ( Local Data ) SOMIP 2008-2009SOMIP 2008-2009

Operative procedureOperative procedure 30day mortality 30day mortality raterate

Total cystectomy surgeryTotal cystectomy surgery 3.93.9

Aorta surgeryAorta surgery 3.63.6

Bile duct excision surgeryBile duct excision surgery 3.63.6

OesophagectomyOesophagectomy 3.33.3

Carotid artery surgeryCarotid artery surgery 2.92.9

Major pancreas resectionMajor pancreas resection 2.42.4

Peripheral vascular surgeryPeripheral vascular surgery 2.32.3

Major heptectomyMajor heptectomy 1.81.8

Colorectal SurgeryColorectal Surgery 1.41.4

Complication ( Local Data ) Complication ( Local Data ) SOMIP 2008-2009SOMIP 2008-2009

Operative procedureOperative procedure 30day morbidity rate30day morbidity rate

Pharyngolaryngo-esophagectomy Pharyngolaryngo-esophagectomy 64.364.3

OesophagectomyOesophagectomy 55.855.8

Free flap surgeryFree flap surgery 38.038.0

Major pancreas resectionMajor pancreas resection 37.337.3

Liver transplantLiver transplant 36.036.0

Total cystectomy surgeryTotal cystectomy surgery 36.036.0

Bile duct excision surgeryBile duct excision surgery 35.735.7

Exploration of CBD and Bypass Exploration of CBD and Bypass surgerysurgery

34.534.5

Renal transplantRenal transplant 34.234.2

Other treatment modalityOther treatment modality

►Radiation TherapyRadiation Therapy►Transurethral Resection ( TUR)Transurethral Resection ( TUR)►Combined modality therapyCombined modality therapy

Partial cystectomyPartial cystectomy

►Lower surgical riskLower surgical risk►Preservation of bladder functionPreservation of bladder function►Preservation of sexual functionPreservation of sexual function►??Scarifying survival??Scarifying survival

Results of Partial cystectomyResults of Partial cystectomy

►58 patients undergone Partial 58 patients undergone Partial cystectomy for primary bladder tumor cystectomy for primary bladder tumor from 1995 to 2001 in MSK Cancer from 1995 to 2001 in MSK Cancer Centre analyzedCentre analyzed

►Overall 5-year survival 69%Overall 5-year survival 69%►Concomitant CIS and multifocality at Concomitant CIS and multifocality at

high risk of recurrencehigh risk of recurrence

J M Holzbeierlein et al 2004J M Holzbeierlein et al 2004

Results of Partial CystectomyResults of Partial Cystectomy

► 37 Patients with muscle invasive urothelial 37 Patients with muscle invasive urothelial carcinoma underwent partial cystectomy with carcinoma underwent partial cystectomy with curative intent in M.D. Anderson Cancer curative intent in M.D. Anderson Cancer CenterCenter

► 5-year overall survival rate 67%5-year overall survival rate 67%► Higher pathological stage was associated Higher pathological stage was associated

with shorter recurrence-free survivalwith shorter recurrence-free survival► Lifelong followup with cystoscopy is Lifelong followup with cystoscopy is

recommendedrecommended

W Kassouf et al 2006W Kassouf et al 2006

highly selective patienthighly selective patient

►Solitary massSolitary mass►No concomitant CISNo concomitant CIS►Adequate surgical marginAdequate surgical margin►Functional bladderFunctional bladder

Brannan et al, 1978 Brannan et al, 1978

ConclusionConclusion

►Radical cystectomy remain standard Radical cystectomy remain standard therapy of muscle-invasive urothelial therapy of muscle-invasive urothelial bladder cancerbladder cancer

►Survival rate of highly selected patient Survival rate of highly selected patient who undergo partial cystectomy is who undergo partial cystectomy is comparable to those with radical comparable to those with radical cystectomycystectomy

►Lifelong survelliance is required for Lifelong survelliance is required for patient underwent partial cystectomy patient underwent partial cystectomy

Thank youThank you