Neoadjuvant Chemotherapy Followed by Partial Cystectomy or Transurethral Resection of Bladder Tumor
The Medical Research Council (MRC) and Southwest Oncology Group (SWOG) trials evaluating neoadjuvant cisplatin-based chemotherapy prior to cystectomy demonstrated a survival advantage in patients with pT2N0 to pT4aN0 urothelial bladder cancers. Some of the patients who received neoadjuvant treatment had complete responses at the time of cystectomy. Consequently, it may be possible to perform partial cystectomy on these patients with similar oncological results as radical cystectomy but with less functional morbidity. In a prospective trial, Sternberg et al evaluated 104 patients with muscle-invasive disease who underwent 3 cycles of methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC) chemotherapy followed by TURBT alone (n = 52), partial cystectomy (n = 3), or radical cystectomy (n = 39) based on the response to neoadjuvant chemotherapy. Of the 52 patients who underwent TURBT alone, 29 had either a pathological complete response (pT0) or superficial disease after chemotherapy. In addition, 44% maintained an intact bladder, with a 5-year OS rate of 67%. In a separate study of 111 candidates for cystectomy with cT2 to cT3 disease who had undergone neoadjuvant MVAC chemotherapy, 60 were found to have a complete response (pT0) on restaging TURBT. Of these 60 patients, 43 had bladder-sparing surgery and 17 underwent radical cystectomy. The 10-year OS rate for the 43 patients who underwent partial cystectomy was 74% compared with 65% in the radical cystectomy group. In the bladder-sparing group, 40% of patients ultimately underwent cystectomy, due in part to the limitations of restaging TURBT in determining the full extent of disease in the bladder.
In the SWOG S0219 trial, 46% of the 74 evaluable patients who received 3 cycles of neoadjuvant paclitaxel, carboplatin, and gemcitabine chemotherapy for cT2 to cT4a bladder cancer had a pathological complete response on restaging TURBT. Of these 34 patients, 10 underwent immediate cystectomy. Six of the 10 patients who underwent cystectomy had persistent muscle-invasive disease despite a negative restaging TURBT. Although this study did not include cisplatin chemotherapy, neoadjuvant chemotherapy and TURBT are typically reserved for patients with extensive comorbid disease or a poor performance status.