UROLOGICAL ONCOLOGY

Is there a role for surgery in the management of metastatic urothelial cancer? The M. D. Anderson experience
Siefker-Radtke AO, Walsh GL, Pisters LL, Shen Y, Swanson DA, Logothetis CJ, Millikan RE
Center for Genitourinary Oncology and Department of Medical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, 77030-4009, USA
J Urol. 2004; 171: 145-8

• Purpose: Although rarely curative, chemotherapy remains the mainstay of treatment for metastatic urothelial cancer. The role of surgery for metastatic disease is not well established for urothelial cancer, but is sometimes undertaken in the face of persistent or recurrent disease that can be surgically resected.
• Materials and Methods: We identified 31 patients with metastatic urothelial cancer undergoing metastasectomy with the intent of rendering them free of disease. All gross disease was completely resected in 30 patients (97%). The most frequently resected location was lung in 24 cases (77%), followed by distant lymph nodes in 4 (13%), brain in 2 (7%) and a subcutaneous metastasis in 1 (3%).
• Results: Median survival from diagnosis of metastases and from time of metastasectomy was 31 and 23 months, respectively. The 5-year survival from metastasectomy was 33%. Median time to progression following metastasectomy was 7 months. Five patients were alive and free of disease for more than 3 years after metastasectomy.
• Conclusions: The results in this highly selected cohort, with 33% alive at 5 years after metastasectomy, suggest that resection of metastatic disease is feasible and may contribute to long-term disease control especially when integrated with chemotherapy. Further prospective studies should be undertaken to better characterize the selection criteria and benefit from this intervention.
  
  
• Editorial Comment
  These data look good on first sight, but it must be emphasized that patient selection is extraordinary and that only patients with an extremely good Karnowski Index can undergo excessive surgery for metastatic disease. After all, median time to progression following metastasectomy was only 7 months. Only 3 patients had no recurrence at last follow-up, of whom 2 have been disease-free for more than 5 years. If one looks closer into the data, these 2 disease-free patients might be those patients in whom necrotic tumor without viable cancer had been resected. Thus, the result might rather be contributed to chemotherapy.
  In conclusion, surgery does not play a major role in the management of metastatic urothelial cancer and should be reserved for highly selected patients only.

Dr. Andreas Böhle
Professor of Urology
HELIOS Agnes Karll Hospital
Bad Schwartau, Germany