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Eur Urol. 2019 Apr;75(4):649-658. doi: 10.1016/j.eururo.2018.11.052. Epub 2018 Dec 13.

Micropapillary Urothelial Carcinoma of the Bladder: A Systematic Review and Meta-analysis of Disease Characteristics and Treatment Outcomes.

Author information

1
Department of Urology, Medical University of Vienna, Vienna, Austria; Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan.
2
Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Kantonsspital Winterthur, Winterthur, Switzerland.
3
Department of Epidemiology, Harvard T.H Chan School of Public Health, Boston, MA, USA; Channing Division of Network Medicine, Department of Medicine, Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna, Austria.
4
Department of Urology, Medical University of Vienna, Vienna, Austria; Klinik für Urologie, Luzerner Kantonsspital, Lucerne, Switzerland.
5
Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Jikei University School of Medicine, Tokyo, Japan.
6
Department of Urology, Medical University of Vienna, Vienna, Austria.
7
Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
8
Department of Urology, University of Montreal, Montreal, Quebec, Canada.
9
Department of Urology, Medical University of Vienna, Vienna, Austria; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Urology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA. Electronic address: sfshariat@gmail.com.

Abstract

CONTEXT:

The optimal treatment of urothelial bladder cancer (UBC) with micropapillary (MP) variant histology is not clear.

OBJECTIVE:

To review the current literature on disease characteristics and treatment outcomes of MP UBC.

EVIDENCE ACQUISITION:

A systematic search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane Handbook for Systematic Reviews of Interventions. The primary end points were recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS).

EVIDENCE SYNTHESIS:

We identified 758 reports comprising a total of 3154 patients, of which 28 and 15 articles were selected for qualitative and quantitative analysis, respectively. In patients with T1 MP UBC, the 5-yr CSS rates for early radical cystectomy (RC) ranged from 81% to 100%, while they were between 60% and 85% for transurethral resection of the bladder and Bacillus Calmette-Guérin (BCG). In studies reporting on neoadjuvant chemotherapy (NAC), the rates of complete pathological response (ypT0) ranged from 11% to 55%. Nevertheless, the use of NAC did not improve RFS (hazard ratio [HR] 1.23, 95% confidence interval [CI] 0.52-2.93, p=0.6), CSS (HR 0.9, 95% CI 0.48-1.7, p=0.8), or OS (HR 1.35, 95% CI 0.98-1.86, p=0.1). Fifty-three percent (95% CI 43-63%) of patients who underwent RC alone had locally advanced disease (≥pT3), and 43% (95% CI 33-52%) were harbouring lymph node metastases. MP component at RC was not significantly associated with worse RFS (HR 1.25, 95% CI 0.88-1.78, p=0.2), CSS (HR 0.96, 95% CI 0.57-1.6, p=0.9), or OS (HR 1.20, 95% CI 0.88-1.62, p=0.3) when adjusted for pathological features.

CONCLUSIONS:

While MP UBC is associated with clinicopathological features of advanced disease, it is not associated with worse survival outcomes in patients undergoing RC. NAC results in pathological downstaging in a significant number of patients. Nevertheless, this does not translate into better survival outcomes. The optimal treatment of patients with cT1 remains controversial.

PATIENT SUMMARY:

Our results suggest that micropapillary urothelial bladder cancer does not necessarily mandate different treatment algorithms. Nevertheless, each case should be discussed individually considering other clinicopathological factors.

KEYWORDS:

Bacillus Calmette-Guérin therapy; Bladder cancer; Bladder sparing; Immediate cystectomy; Micropapillary; Prognosis; Transurethral resection; Urothelial carcinoma; Variant histology

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