San Antonio, Texas USA (UroToday.com) For patients with muscle invasive bladder cancer (MIBC) who undergo neoadjuvant chemotherapy (NAC) the best predictor of response and prognosis is pT0 stage in the cystectomy specimen. There has been recent evidence that cystoscopy evidence of cT0 may be a good clinical surrogate of pT0 in the cystectomy specimen. Several groups are now looking into omitting radical cystectomy for patients with good response to NAC who appear to be cT0 on cystoscopic evaluation or following a repeat TURBT.
Dr. Kukreja, from MD Anderson Cancer Center presents a retrospective institutional review of patients with MIBC who received a TURBT prior to cystectomy. The aim of the study was to assess the concordance rates between cT0 on TURBT and pT0 on cystectomy specimen. Secondary end-points were recurrence-free survival (RFS) and cancer-specific survival (CSS) in the cohort.
On review of their prospectively collected bladder cancer data base they identified 159 patients who had evidence of cT0 on repeat TUBRBT immediately prior to cystectomy, with 72 (45.3%) patients receiving NAC. On pathological evaluation of the cystectomy specimen 66.7% of patients with cT0 showed evidence of residual tumor on the pathological specimen with 41% showing pathological stage ≥ pT2 disease. Lymph node involvement was noted in 20 (12.6%) patients. On multivariate analysis accounting for clinical stage, grade, NAC, lympho-vascular invasion (LVI), and CIS, only LVI and CIS were found to be predictive of residual disease in the cystectomy specimen. In the analysis there was no statistical difference in achieving pT0 in patients with TURBT alone compared to patients who received NAC + TUBRT. In controlling for pathological stage there was no difference in RFS and CSS of those who achieve pT0 and those who did not.
The authors conclude that complete tumor removal on TURBT does not predict pT0 at cystectomy. Furthermore, a notable amount of patients though to be cT0 at TURBT were found to have locally advance and/or lymph node positive disease.
This study provides important information for clinicians who are hoping for bladder presentation strategies in patients with a complete cystoscopic response following NAC. The study does have some limitations which include its retrospective nature which adds selection bias into the study. In addition, there is no standardization of the type of TURBT performed, which may range from an aggressive TURBT to a cold cup biopsy. Further trials should be performed controlling for NAC provided and TURBT performed to further characterize this patients with the hope that genomic markers could be found as better surrogates for pT0.
Authors: Janet Baack Kukreja, Sima Porten, Vishnukamal Golla, Graciela Noguera-Gonzales, Neema Navai, Ashish Kamat, Colin Dinney, Jay Shah
Written By: Andres F. Correa, MD, Society of Urologic Oncology Fellow, Fox Chase Cancer Center
17th Annual Meeting of the Society of Urologic Oncology - November 30 -December 2, 2016 – San Antonio, Texas USA