Current Role of Partial Cystectomy: Are we scarifying patient ’ s survival Dr Eric Li Department of Surgery Pamela Youde Nethersole hospital

Bladder tumor ► TCC bladder (90%) ► SCC bladder (7-9%) ► Adenocarcinoma (1-2%) ► Sacroma ► Small cell carcinoma ► Urachal carcinoma

Gading of TCC ► Degree of anaplasia of the tumor cells ► correlation exists between tumor grade and stage Jewett and Strong, 1946 ► correlation between tumor grade and prognosis ► low-grade tumors and high-grade tumors have fundamentally different origins Knowles et al, 1994 ; Spruck et al, 1994 ; Reznikoff et al, 1996 ; Cote and Chatterjee, 1999

Staging of TCC (1997 AJCC-UICC, TNM Staging ) ► Ta: Papillary, epithelium confined ► Tis: Flat carcinoma in situ ► T1: Lamina propria invasion ► T2a: Superficial muscularis propria invasion ► T2b: Deep muscularis propria invasion ► T3a: Microscopic extension into perivesical fat ► T3b: Macroscopic extension into perivesical fat ► T4a: Cancer invading pelvic viscera (e.g., prostatic stroma, vaginal wall, rectum, uterus) ► T4b: Extension to pelvic sidewalls, abdominal walls, or bony

Staging of TCC ► N0: No histologic pelvic node metastases ► N1: Single positive node ≤2 cm in diameter, below common iliacs ► N2: Single positive node 2-5 cm in greatest diameter or multiple positive nodes ► N3: Positive nodes >5 cm in diameter ► Nx: Nodal status unknown ► M0: No distant metastases ► M1: Distant metastases documented ► Mx: Distant metastases status uncertain

PATTERNS OF DISSEMINATION ► Direct Extension ► Lymphatic spread ► Vascular spread ► Implantation

Biology of TCC ► Multicentric Origin  Clonal  Field change ► almost all patients who develop metastases develop muscle-invasive recurrences before or at the time metastases are recognized Jewett and Strong, 1946 ; Freeman et al, 1995a

Treatment decision ► Superficial versus Infiltrating Tumor ?

Non-muscle invasive TCC ► Transurethral Resection of Bladder Tumor (TURBT) ► Intravesical Therapy  BCG  Mitomycin C

Muscle Invasive TCC ► Radical Cystectomy  En bloc cystectomy  Bilateral pelvic iliac lymph node dissection  Urinary diversion

Radical cystectomy ► 69% recurrence-free survival at 5 years ► 60% overall survival at 5 years ► Survival significantly related to pathologic stage and lymph node status ► 9% overall local pelvic recurrence Donald G. Skinner 2007

Complication

Complication ( Local Data ) SOMIP Operative procedure 30day mortality rate Total cystectomy surgery 3.9 Aorta surgery 3.6 Bile duct excision surgery 3.6 Oesophagectomy3.3 Carotid artery surgery 2.9 Major pancreas resection 2.4 Peripheral vascular surgery 2.3 Major heptectomy 1.8 Colorectal Surgery 1.4

Complication ( Local Data ) SOMIP Operative procedure 30day morbidity rate Pharyngolaryngo-esophagectomy64.3 Oesophagectomy55.8 Free flap surgery 38.0 Major pancreas resection 37.3 Liver transplant 36.0 Total cystectomy surgery 36.0 Bile duct excision surgery 35.7 Exploration of CBD and Bypass surgery 34.5 Renal transplant 34.2

Other treatment modality ► Radiation Therapy ► Transurethral Resection ( TUR) ► Combined modality therapy

Partial cystectomy ► Lower surgical risk ► Preservation of bladder function ► Preservation of sexual function ► ??Scarifying survival

Results of Partial cystectomy ► 58 patients undergone Partial cystectomy for primary bladder tumor from 1995 to 2001 in MSK Cancer Centre analyzed ► Overall 5-year survival 69% ► Concomitant CIS and multifocality at high risk of recurrence J M Holzbeierlein et al 2004

Results of Partial Cystectomy ► 37 Patients with muscle invasive urothelial carcinoma underwent partial cystectomy with curative intent in M.D. Anderson Cancer Center ► 5-year overall survival rate 67% ► Higher pathological stage was associated with shorter recurrence-free survival ► Lifelong followup with cystoscopy is recommended W Kassouf et al 2006

highly selective patient highly selective patient ► Solitary mass ► No concomitant CIS ► Adequate surgical margin ► Functional bladder Brannan et al, 1978 Brannan et al, 1978

Conclusion ► Radical cystectomy remain standard therapy of muscle-invasive urothelial bladder cancer ► Survival rate of highly selected patient who undergo partial cystectomy is comparable to those with radical cystectomy ► Lifelong survelliance is required for patient underwent partial cystectomy

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