of patients who refuse cystectomy after receiving neoadjuvant chemotherapy
for muscle-invasive bladder cancer
Department of Urology, Memorial Sloan-Kettering Cancer Center, Weill-Cornell
Medical College, New York, NY, USA
Eur Urol. 2008; 54: 126-32
To determine the outcome of patients who refuse cystectomy after receiving
neoadjuvant chemotherapy for muscle-invasive bladder cancer.
Methods: Between 1995 and 2001, 63 patients were evaluated who declined
to undergo a planned cystectomy, because they achieved a complete clinical
response to neoadjuvant cisplatin-based chemotherapy. Patient, tumor,
and treatment features were assessed prospectively, and correlated in
univariate and multivariate analyses with overall survival. The median
follow-up was 86 mo and all patients were followed for more than 5 yr.
Results: Forty patients (64%) survived, with 54% of them having an intact
functioning bladder. The number and size of invasive tumors were strongly
associated with overall survival. The most significant treatment variable
predicting better survival was complete resection of the invasive tumor
on re-staging transurethral resection before starting chemotherapy.
Of 23 patients (36%) who subsequently died of disease, 19 (30%) relapsed
with invasive cancer in the bladder. Over 90% of surviving patients
had solitary, small, and low-stage invasive tumors completely resected,
and 83% survived without relapses in the bladder.
Conclusions: Selected patients with muscle-invasive bladder cancers
may survive after transurethral resection and neoadjuvant chemotherapy,
and tumor features can identify which patients responding completely
to chemotherapy may survive without cystectomy.
In Northern America neoadjuvant chemotherapy before radical cystectomy
became standard few years ago. What happens if patients (or their doctors,
the medical oncologists who deliver chemotherapy) refuse radical cystectomy
if a complete response is found in the bladder? This paper gives some
very important answers.
The study group was well chosen with only patients having residual muscle-invasive
tumors receiving neoadjuvant chemotherapy. After at least 85% of the
planned four cycles of cisplatinum-based chemotherapy, complete clinical
response and negative transurethral resection (TUR) of the primary tumor
site, these patients were deemed complete responders and were evaluable
for follow-up in this group.
The good news is that 64% of these patients survived at least 5 years
and 54% of them with functioning bladders. The bad news is that 36%
died of bladder cancer after a mean of 32 months. The survivors could
be identified by their good prognostic factors, namely single (p <
0.001), or small tumor (p < 0.01), complete restaging TUR (p = 0.02),
and noninvasive stage after relapse (p = 0.05). Thus patients with worse
tumor features, despite responding completely to chemotherapy, should
be strongly advised to undergo radical cystectomy at the earliest convenience.
Professor of Urology
HELIOS Agnes Karll Hospital
Bad Schwartau, Germany