UROLOGICAL ONCOLOGY

doi: 10.1590/S1677-553820100001000029

Outcome of patients who refuse cystectomy after receiving neoadjuvant chemotherapy for muscle-invasive bladder cancer
Herr HW
Department of Urology, Memorial Sloan-Kettering Cancer Center, Weill-Cornell Medical College, New York, NY, USA
Eur Urol. 2008; 54: 126-32

• Objectives: 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.

• Editorial Comment
  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.
  

Dr. Andreas Bohle
Professor of Urology
HELIOS Agnes Karll Hospital
Bad Schwartau, Germany
E-mail: boehle@urologie-bad-schwartau.de