Page 10 - Canadian Urological Association/Genitourinary Medical Oncologists of Canada consensus statement: Management of unresectable locally advanced and metastatic urothelial carcinoma

CUAJ – Consensus Statement Warren et al
Unresectable locally advanced and metastatic urothelial carcinoma

Selection criteria which should be applied to the decision of consolidative treatment
following IC are not clear from the above studies. In general, outcomes are better in patients with
a response to IC; however both Ho and Meijer report a 20% 5 year OS in patients with stable
disease on IC 66,67 , indicating these patients can still obtain benefit. In general, the choice of
consolidative treatment is best made on an individual basis with multidisciplinary input.
Nonetheless, there are two situations which would sway our decision towards HDRT as opposed
to surgery. The first is a patient with persistent N3 disease after IC, where the risk of relapse is
high and HDRT represents a less invasive treatment option. The second is for a patient with
cT4b disease who fails to obtain down staging with IC, where surgery is usually not feasible.

The role of aggressive surgical / radiotherapeutic management in oligometastastic disease.
– Routine practice of metastasectomy / localized treatment to metastatic disease in
patients with oligometastatic or limited metastatic disease is not recommended.
However, such treatment may be appropriate in selected cases. (See discussion).
– In metastatic UC of the bladder, the routine practice of RC or HDRT (+/-
chemotherapy) to the primary is not recommended. However, such treatment may
be appropriate in selected cases (See discussion).
– The decision to treat oligometastatic disease with local therapies should be made in
a multidisciplinary context with involvement of an experienced medical oncologist,
uro-oncologist and radiation oncologist where appropriate.
The targeting of oligometastatic disease with surgical resection and / or ablative
radiotherapy has only been tested in small series of highly selected patients with no randomized
studies to guide practice. While outcomes have been impressive with reports of 5 year OS of up
to 65% 69,70 , uncertainty exists as to whether favourable outcomes were the result of selection
bias or from a therapeutic benefit of the localized therapy studied. Further compounding the
problem of applying these studies to routine practice is the fact that the majority of studies were
retrospective without clearly defined criteria for which patients should receive the localized
treatment under consideration. The same limitation applies to the evidence for aggressive
localized treatment of the pelvic primary with RC or HDRT (+/- concurrent chemotherapy) in a
patient with metastatic disease. In short, the literature provides no level 1 evidence to be either
prescriptive or proscriptive with regard to the above treatments. The existing literature is prone
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to methodological bias.
Individualization of local treatment following systemic treatment is the most judicious
approach. The aggressiveness of the local treatment will vary according to the initial local stage
and the subsequent local and systemic response to the chemotherapy. In any given patient,
TURBT (trans-urethral resection of bladder tumor), pelvic radiotherapy with or without
concurrent chemotherapy, metastasectomy or ablative radiotherapy may be appropriate.
Recognizing this dearth of compelling data emphasizes that individually tailored treatment by a
multidisciplinary team will serve the patient best.