Refining Patient Selection for Neoadjuvant Chemotherapy before Radical Cystectomy

Abstract

Purpose We evaluated the survival of patients with muscle invasive bladder cancer undergoing radical cystectomy without neoadjuvant chemotherapy to confirm the utility of existing clinical tools to identify low risk patients who could be treated with radical cystectomy alone and a high risk group most likely to benefit from neoadjuvant chemotherapy. Materials and Methods We identified patients with muscle invasive bladder cancer who underwent radical cystectomy without neoadjuvant chemotherapy at our institution between 2000 and 2010. Patients were considered high risk based on the clinical presence of hydroureteronephrosis, cT3b-T4a disease, and/or histological evidence of lymphovascular invasion, micropapillary or neuroendocrine features on transurethral resection. We evaluated survival (disease specific, progression-free and overall) and rate of pathological up staging. An independent cohort of patients from another institution was used to confirm our findings. Results We identified 98 high risk and 199 low risk patients eligible for analysis. High risk patients exhibited decreased 5-year overall survival (47.0% vs 64.8%) and decreased disease specific (64.3% vs 83.5%) and progression-free (62.0% vs 84.1%) survival probabilities compared to low risk patients (p <0.001). Survival outcomes were confirmed in the validation subset. On final pathology 49.2% of low risk patients had disease up staged. Conclusions The 5-year disease specific survival of low risk patients was greater than 80%, supporting the distinction of high risk and low risk muscle invasive bladder cancer. The presence of high risk features identifies patients with a poor prognosis who are most likely to benefit from neoadjuvant chemotherapy, while many of those with low risk disease can undergo surgery up front with good expectations and avoid chemotherapy associated toxicity.

Treatment of muscle-invasive bladder cancer in Canada: A survey of genitourinary medical oncologists and urologists

“…6,22 An alternate strategy is to use a risk-stratified approach, in which patients with high-risk features receive NC and lowrisk patients who are upstaged receive adjuvant chemotherapy (AC). 28 However, local expertise, experience with this approach and available diagnostic imaging and resources should be considered. It should be noted that less than a third of patients who were upstaged received AC -this is in line with data indicating that NC is more often successfully administered than AC (87%-97% vs. 50%-77%), 4,29 perhaps because of postoperative complications, poor performance status and renal insufficiency.…”

“…18,22,29,30 As those receiving AC had better disease-specific survival than those who did not, the inability to administer chemotherapy adjuvantly is a significant concern. 28 Adoption of new treatment paradigms can be challenging. Even within this group of GU oncology specialists, 8% to 12% of clinicians do not offer NC -some expressed skepticism about the value of NC and were concerned about surgical delay in those not responding to NC.…”

Survival of patients with bladder cancer after radical cystectomy

“…Метастатическое пора-жение ЛУ снижает выживаемость больных РМП после РЦЭ. По данным различных авторов, 5-летняя ОВ пациентов с метастазами в ЛУ колеблется от 21 до 31 % [3,7,9,14].…”

“…Это утверждение основа-но на анализе результатов РЦЭ у большого числа оперированных больных. Данные литературы показы-вают: РЦЭ с регионарной лимфодиссекцией обеспе-чивает наилучшие показатели отдаленной выживае-мости в сочетании с низкой степенью локальных рецидивов [1][2][3]; смертность и частота послеопераци-онных осложнений за последние десятилетия сущест-венно снизились [4][5][6]; переходно-клеточный рак имеет тенденцию резистентности к лучевой терапии даже в высоких дозах [3]; системная химиотерапия в виде монотерапии или в комбинации с органосохра-няющими операциями демонстрирует худшую отда-ленную выживаемость и большую частоту местных рецидивов по сравнению с РЦЭ [7]. Кроме того, РЦЭ ОНКОУРОЛОГИЯ 1'2016 ТОМ 12 CANCER UROLOGY 1'2016 VOL.…”

“…Исключалась смерть вследствие причин, не связанных с РМП. Рецидивы РМП мы различали как местные, или тазовые, и отдаленные -вне мало-обеспечивает точное патоморфологическое стадиро-вание первичной опухоли мочевого пузыря и статус регионарных лимфатических узлов (ЛУ), что позволя-ет установить группу пациентов, которым показана адъювантная полихимиотерапия [3,8]. Наряду с мы-шечно-инвазивным РМП, РЦЭ показана при рециди-вирующих поверхностных опухолях, обладающих вы-соким риском прогрессии, при БЦЖ-резистентном раке in situ, T1G 3 [5,6].…”