Trimodality bladder-sparing approach without neoadjuvant chemotherapy for node-negative localized muscle-invasive urinary bladder cancer resulted in comparable cystectomy-free survival

Abstract

BackgroundTo retrospectively review the efficacy and organ preservation experience for muscle-invasive bladder cancer by trimodality therapy at our institution.MethodsBetween July 2004 and February 2012, seventy patients (M/F = 55/15; median age = 69 years) of lymph node negative localized muscle-invasive bladder cancer were treated primarily with trimodality approach including transurethral resection of bladder tumor (TURBT) prior to combined chemotherapy and radiotherapy (CCRT). Radiotherapy consisted of initial large field size irradiation with 3D conformal technique (3D-CRT), followed by cone-down tumor bed boost with intensity modulated radiotherapy (IMRT) technique. The median total doses delivered to bladder tumor bed and whole bladder were 59.4Gy and 40.0Gy, respectively. No patient received neoadjuvant chemotherapy (NAC). Weekly cisplatin was administered during radiotherapy. Toxicity was scored according to the RTOG criteria. Tumor response was evaluated both cystoscopically and radiographically 3 months after treatment.ResultsThe numbers of patients with T2, T3 and T4 lesions were 41, 16 and 13, respectively. Overall survival (OS) and progression-free survival (PFS) at 2 and 5 year were 65.7%, 51.9% and 50.8%, 39.9%, respectively, after a median follow-up time of 24 months. Local-regional control and distant metastasis free survival at 2 year were 69.8% and 73.5%, respectively. Complete response (CR) rate assessed three month after CCRT was 78.1%. Ten patients (20%) had local recurrence after initial CR (n = 50), 3 of them were superficial recurrence. One patient underwent radical cystectomy after recurrence. The overall 5-year bladder intact survival was 49.0% (95% CI, 35.5% to 62.5%). Acute toxicities were limited to grade 1-2. One patient developed late grade 3 GU toxicity.ConclusionsOur result suggested that trimodality bladder-sparing approach without NAC or dose-intensification could be well-tolerated with a high CR rate and bladder preserving rate for muscle-invasive bladder cancer.

Bladder-conserving Approach in Radical Treatment of Patients With Bladder Cancer – A Single-institution Experience

“…We found the results of a conservative approach with RT or CCRT gave 3-and 5-year OS rates of 66% and 58%, which are comparable to those reported in other prospective and retrospective series (6,(11)(12)(15)(16)(17)(18). For example, Lee et al reported very similar OS and DFS of 50.8% and 39.9%, with good toxicity profiles (15), as was also noted in our study. Murthy et al reported 3-year OS and DFS rates of 67% and 66% (17), which our observations are also very similar to.…”

Bladder preservation in non-metastatic muscle-invasive bladder cancer (MIBC): a single-institution experience

“…In our patients, the complications have been observed predominantly during adjuvant chemotherapy (G3 myelotoxicity, renal failure, and lung thromboembolism), confirming higher toxicity of concomitant and adjuvant chemotherapy in respect of concomitant only chemotherapy in bladder cancer preservation; this finding confirms the fragile general conditions of the bladder cancer patients. Indeed, the most recent bladder preservation reports claim that TURBT followed by concomitant chemoradiotherapy (with no adjuvant or neoadjuvant chemotherapy) may be considered the optimal approach in terms of tolerability and efficacy [ 26 ].…”

Alternativen zur Zystektomie

“…Durch dieses Therapiekonzept konnte bei 48% der Patienten im Gesamtkollektiv über eine Dauer von 5 Jahren ein blasenerhaltendes Vorgehen verfolgt werden [25]. [26]. Die größte Serie einer multimodalen Therapie wurde kürzlich veröf-fentlicht [27].…”

“…Die 5-und 10-Jahres-Gesamtüberlebensrate betrugen dabei 57% und 36%, die tumorspezifischen Überlebensraten 71% und 65% [27]. Der Erfolg der trimodalen Therapie ist abhängig von dem Vorhandensein der folgenden Prognoseparameter: kein organüberschreitendes lokales Tumorwachstum (T1/T2) mit kleinem Primarius (≤0,5 cm), Resektionsmaterial ist frei von begleitendem Carcinoma in situ, es ist nicht zu einer tumorbedingten Harntransportstörung gekommen und lymphovaskuläre und vaskuläre Infiltration liegen nicht vor [24,25,26,27,28]. Der Erfolg des trimodalen Behandlungskonzeptes kann eingeschränkt werden durch lokoregionäre Rezidive, die oft intra-oder perivesikal in dem Bereich der blasenerhaltenden Tumorresektion auftreten, sowie durch die Tatsache, dass im Rahmen der organerhaltenden Tumorresektion in einer Vielzahl der Fälle von einer Lymphadenektomie abgesehen wird.…”