(UroToday.com) The 2024 ASTRO annual meeting included a session on the management of small-cell neuroendocrine tumors of the genitourinary tract, featuring a presentation by Dr. Nima Almassi discussing the role of surgery in the management of genitourinary small-cell tumors.
Dr. Almassi started his presentation by discussing a case of a 69-year-old man who presented with gross hematuria, described as 6 weeks of intermittent, painless, gross hematuria with intermittent obstructive lower urinary tract symptoms. Of note, he had a history of recurrent urinary tract infections over the previous 6 months. He did not have a prior smoking history nor history of occupational exposure; work up included a cystoscopy and CT urogram, with the following findings:
Dr. Almassi notes that the quality of tissue sampling can impact the diagnostic accuracy, highlighted by the following table demonstrating differences between cystoscopy + bladder biopsy and TURBT:
Below highlights an example of an incomplete resection:
Genitourinary subspecialty pathology review can impact the diagnosis for these patients. In a study by Campbell et al.1, they performed an observational study of 173 patients who underwent TURBT at an outside hospital and who subsequently had a genitourinary subspecialty pathology re-review at the Cleveland Clinic (2021-2022). Overall, 21% of patients with non-muscle invasive bladder cancer had a change in risk stratification following subspecialty re-review, include changes in grade, cT stage, and identification of histologic variants. Overall, 18% of patients with muscle-invasive bladder cancer had a histologic variant identified only on subspecialty pathology re-review:
Going back to the case presentation, Dr. Almassi notes that a TURBT was not feasible secondary to inaccessibility in the narrow-necked diverticulum with the resectoscope. Thus, a flexible cystoscopy and biopsy was performed, noting a high-grade non-invasive urothelial carcinoma, with the remainder of the bladder normal on cystoscopic evaluation and on biopsy. Based on the previously noted CT scan, the patient had right hydronephrosis to the level of the mass. At this point, the patient was presented at multidisciplinary tumor board review. Ultimately, the patient underwent a robotic partial cystectomy with pelvic lymph node dissection and right ureteral reimplantation, with pathology noting: invasive small cell neuroendocrine carcinoma, pT3bN0 (0/24 lymph nodes) with negative margins. He subsequently received adjuvant carboplatin and etoposide and he remains disease-free at last follow-up (2 years post-operatively).
Dr. Almassi emphasized that most bladder neuroendocrine carcinomas are locally advanced (>= cT3) at the time of diagnosis and long-term disease-free survival is rare with radical cystectomy alone. However, radical cystectomy can have a role in consolidative treatment, including (i) a definitive approach to gross hematuria and malignant ureteral obstruction, (ii) improving quality of life patients with severe symptoms from the primary tumor, and (iii) allowing pathologic assessment for residual disease. Importantly, multi-disciplinary evaluation should be conducted when considering consolidative treatment.
With regards to quality of life outcomes following radical cystectomy, Clements et al.2 performed a prospective study evaluating health-related quality of life outcomes following radical cystectomy among 411 patients treated at Memorial Sloan Kettering Cancer Center between 2008 and 2014. Most health-related quality of life returned to baseline or improved by 6 months postoperatively, with the following notable findings:
- Body image quality of life was worse in patients receiving an ileal conduit.
- Sexual function quality of life was worse irrespective of urinary diversion.
Dr. Almassi provided the following strategies for optimizing quality-of-life outcomes after radical cystectomy:
- Offering continent urinary diversion for eligible patients, particularly given there has been a decrease in utilization seen nationally
- Nerve-sparing cystectomy helps preserve sexual function
- Vaginal sparing cystectomy can preserve vaginal length, may improve sexual function, and may reduce the risk of pelvic organ prolapse
Dr. Almassi concluded this presentation discussing the role of surgery in the management of genitourinary small-cell tumors with the following take-home points:
- TURBT is often a critical component of establishing the diagnosis of bladder neuroendocrine carcinoma and can palliate symptoms
- It is important to ensure adequate sampling and to understand whether a complete resection was performed
- Pathology assessment by a genitourinary pathologist is ideal
- Bladder neuroendocrine carcinoma is often advanced at diagnosis and surgical resection alone is rarely curative
- Partial or radical cystectomy as consolidative treatment can offer advantages in select circumstances
- Multidisciplinary evaluation and management is critical
Presented by: Nima Almassi, MD, Urologist, Cleveland Clinic, Glickman Urological Institute, Cleveland, OH
Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Associate Professor of Urology, Georgia Cancer Center, Wellstar MCG Health, @zklaassen_md on Twitter during the 2024 American Society for Radiation Oncology (ASTRO) Annual Meeting, Washington, DC, Sun, Sept 29 – Wed, Oct 2, 2024.
References:
- Campbell RA, Wood A, Michael PD, et al. Impact of pathologic re-review on grade, clinical stage, and risk stratification for patients with nonmuscle invasive bladder cancer. Urol Oncol. 2024 June 15.S1078-1439(24)00494-0.
- Clements MB, Atkinson TM, Dalbagni GM, et al. Health-related quality of life for patients undergoing radical cystectomy: Results of a large prospective cohort. Eur Urol. 2022;81(3):294-304.