Does grossly complete transurethral resection improve response to neoadjuvant chemotherapy?

Ghandour, Rashed; Kusin, Samuel B.; Wong, Daniel; Meng, Xiaosong; Singla, Nirmish; Freifeld, Yuval; Bagrodia, Aditya; Margulis, Vitaly; Sagalowsky, Arthur I.; Lotan, Yair; Woldu, Solomon L.

doi:10.1016/j.urolonc.2020.05.032

Cited by 12 publications

(8 citation statements)

References 28 publications

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“…3 Ghandour et al reported on 100 patients who received NAC followed by RC, and did not observe any differences in pathological outcomes or subsequent survival outcomes based on TUR completeness. 19 The rates of pathological response observed in their cohort were similar to our study. Even among patients rendered cT0 by TUR and NAC, Kukreja et al reported only 36% were ypT0 at cystectomy and did not identify any preoperative factors associated with pathological response in multivariable analysis.…”

Section: Discussionsupporting

confidence: 88%

“…[14][15][16][17] Conversely, other studies have found limited to no impact of maximal TUR on these same outcomes. 18,19 Specifically, the additional value of maximal TUR prior to NAC followed by RC is unclear. We sought to characterize the effect of maximal TUR prior to NAC on pathological outcomes at cystectomy and subsequent survival in a large, multi-institutional cohort.…”

Section: Impact Of Maximal Transurethral Resection On Pathologicalmentioning

confidence: 99%

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Impact of Maximal Transurethral Resection on Pathological Outcomes at Cystectomy in a Large, Multi-institutional Cohort

et al. 2023

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Purpose:While the presence of residual disease at the time of radical cystectomy for bladder cancer is an established prognostic indicator, controversy remains regarding the importance of maximal transurethral resection prior to neoadjuvant chemotherapy. We characterized the influence of maximal transurethral resection on pathological and survival outcomes using a large, multi-institutional cohort.Materials and Methods:We identified 785 patients from a multi-institutional cohort undergoing radical cystectomy for muscle-invasive bladder cancer after neoadjuvant chemotherapy. We employed bivariate comparisons and stratified multivariable models to quantify the effect of maximal transurethral resection on pathological findings at cystectomy and survival.Results:Of 785 patients, 579 (74%) underwent maximal transurethral resection. Incomplete transurethral resection was more frequent in patients with more advanced clinical tumor (cT) and nodal (cN) stage (P < .001 and P < .01, respectively), with more advanced ypT stage at cystectomy and higher rates of positive surgical margins (P < .01 and P < .05, respectively). In multivariable models, maximal transurethral resection was associated with downstaging at cystectomy (adjusted odds ratio 1.6, 95% CI 1.1-2.5). In Cox proportional hazards analysis, maximal transurethral resection was not associated with overall survival (adjusted HR 0.8, 95% CI 0.6-1.1).Conclusions:In patients undergoing transurethral resection for muscle-invasive bladder cancer prior to neoadjuvant chemotherapy, maximal resection may improve pathological response at cystectomy. However, the ultimate effects on long-term survival and oncologic outcomes warrant further investigation.

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Section: Discussionsupporting

confidence: 88%

Section: Impact Of Maximal Transurethral Resection On Pathologicalmentioning

confidence: 99%

Impact of Maximal Transurethral Resection on Pathological Outcomes at Cystectomy in a Large, Multi-institutional Cohort

et al. 2023

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“…It remains undetermined whether the feasibility of a visually complete TURBT of MIBC is a prognostic factor per se, or represents a surrogate marker of a lower local stage of the tumor. Moreover, there is conflicting evidence regarding the influence of a visually complete initial resection on the response rate to NAC as seen in RC specimens, and on the long-term prognosis of patients who undergo NAC-RC [ 42 , 43 ]. Nonetheless, given the positive influence of complete TURBT on outcomes of CMT and largely unknown patient preferences at the time of the initial resection, it seems justified to perform a maximal safely achievable TURBT.…”

Section: Transurethral Resectionmentioning

confidence: 99%

Combined Modality Bladder-Sparing Therapy for Muscle-Invasive Bladder Cancer: How (Should) We Do It? A Narrative Review

Lemiński

Michalski

Masojć³

et al. 2023

JCM

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Organ-sparing combined-modality treatment for muscle-invasive bladder cancer remains underutilized despite high-quality evidence regarding its efficacy, safety, and preservation of quality of life. It may be offered to patients unwilling to undergo radical cystectomy, as well as those unfit for neoadjuvant chemotherapy and surgery. The treatment plan should be tailored to each patient’s characteristics, with more intensive protocols offered to patients who are fit for surgery but opt for organ-sparing. After a thorough, debulking transurethral resection of the tumor and neoadjuvant chemotherapy, the response evaluation should trigger further management with either chemoradiation or early cystectomy in non-responders. A hypofractionated, continuous radiotherapy regimen of 55 Gy in 20 fractions with concurrent radiosensitizing chemotherapy with gemcitabine, cisplatin, or 5-fluorouracil and mitomycin C is currently preferred based on clinical trials. The response should be evaluated with repeated transurethral resections of the tumor bed and abdominopelvic-computed tomography after chemoradiation, with quarterly assessments during the first year. Salvage cystectomy should be offered to patients fit for surgery who failed to respond to treatment or developed a muscle-invasive recurrence. Non-muscle-invasive bladder recurrences and upper tract tumors should be treated in line with guidelines for respective primary tumors. Multiparametric magnetic resonance can be used for tumor staging and response monitoring, as it may distinguish disease recurrence from treatment-induced inflammation and fibrosis.

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“…7 Complete TURBT prior to administration of neoadjuvant chemotherapy (NAC) has also been associated with improved oncologic outcomes and overall survival (OS). 8 Conversely, others have recently noted that there is no association between completeness of TURBT and response to NAC 9 or survival outcomes following RC. 10 These discrepancies underscore the uncertainty surrounding the role of reTURBTddoes it truly portend a therapeutic advantage or is it instead a surrogate for lower pT stage, and thus improved outcomes?…”

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Repeat Transurethral Resection of Muscle-invasive Bladder Cancer Prior to Radical Cystectomy is Prognostic but Not Therapeutic

et al. 2023

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Purpose:We sought to evaluate the impact of repeat transurethral resection of bladder tumor prior to radical cystectomy on oncologic outcomes in a contemporary cohort at a tertiary care center.Materials and Methods:An Institutional Review Board approved review of 657 patients diagnosed with muscle-invasive bladder cancer who underwent radical cystectomy at our institution for clinical stage T2 urothelial carcinoma between 2005 and 2017 was performed. Patients with and without repeat transurethral resection of bladder tumor were matched 1-to-1 by propensity score. Matching was done by age, gender, receipt of neoadjuvant chemotherapy, preoperative hydronephrosis, variant histology, lymphovascular invasion, or carcinoma in situ on index transurethral resection of bladder tumor.Results:A total of 548 patients with muscle-invasive bladder cancer were included after matching (2 groups of 274 patients). Kaplan-Meier estimates of recurrence-free and overall survival demonstrated no significant difference based upon performance of repeat transurethral resection of bladder tumor (P = 1.0 and P = .3, respectively). When outcomes were stratified by pathology of repeat transurethral resection of bladder tumor specimens, those with pT0 had superior recurrence-free and overall survival compared to those with residual muscle invasive disease (P < .001 and P = .001, respectively). Notably, more than 60% of patients who were pT0 on repeat transurethral resection of bladder tumor had residual disease at the time of radical cystectomy.Conclusions:Repeat transurethral resection of bladder tumor prior to radical cystectomy, irrespective of receipt of neoadjuvant chemotherapy, was not associated with improved survival outcomes in this propensity score matched muscle-invasive bladder cancer cohort. The absence of residual tumor on pathological evaluation of repeat transurethral resection of bladder tumor specimen was prognostic and was associated with improved survival outcomes. However, a large percentage of patients with pT0 disease on repeat transurethral resection of bladder tumor had residual disease on radical cystectomy pathology.

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Does grossly complete transurethral resection improve response to neoadjuvant chemotherapy?

Cited by 12 publications

References 28 publications

Impact of Maximal Transurethral Resection on Pathological Outcomes at Cystectomy in a Large, Multi-institutional Cohort

Impact of Maximal Transurethral Resection on Pathological Outcomes at Cystectomy in a Large, Multi-institutional Cohort

Combined Modality Bladder-Sparing Therapy for Muscle-Invasive Bladder Cancer: How (Should) We Do It? A Narrative Review

Repeat Transurethral Resection of Muscle-invasive Bladder Cancer Prior to Radical Cystectomy is Prognostic but Not Therapeutic

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