Long-Term Outcomes of Organ Preservation for Bladder Cancer in a Large Cohort

Abstract

Radical cystectomy (RC) still remains the standard of care for patients with muscle-invasive bladder cancer (MIBC), but combined modality therapy (CMT) has been assessed over the past decades as a feasible alternative for patients unfit for surgery or who prefer to preserve their bladder. In this retrospective study, our purpose was to examine radiotherapy (RT) after transurethral resection of bladder tumor (TURBT), and to determine survival, toxicity and bladder conservation outcomes of this approach. From 1992 to 2016, 101 consecutive patients (M/F 82/17; median age 73y) with T2-4a N0-2 M0 MIBC were treated by CMT in our institution. T stage was T2 in 55.6% and T3-4a in 44.4%. N stage was N0 in 89.9% and N1-2 in 10.1%. Hydronephrosis was observed in 24.2% and R2 margin in 61.6%. Average follow-up at the time of analysis was 50.8 months (IQR 13.9-65.7). All patients had 3D RT and/or IMRT. Neoadjuvant or concurrent chemotherapy (QT) was delivered to 25.3% and 54.5% respectively. Average RT doses delivered to the tumor and whole bladder were 62 and 59.4 Gy respectively. 54.5% also received pelvic irradiation. Toxicity was assessed according to CTCAE v3 criteria. After treatment, patients were followed at regular intervals. Endpoints of the study were overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), bladder conservation, acute toxicity and late urinary function. Kaplan-Meier, log-rank test and Pearson’s χ2 were performed for statistical analysis. 99 patients were evaluable for response: 84 achieved CR at first evaluation. 45 patients relapsed during follow-up. 7 of them (15.6%), were non-infiltrant local relapses. 2 and 5-year rates were 77.1 and 52.4% for OS, 57.3 and 44.2% for PFS, and 80.2 and 67.9% for DSS. 2 patients (2%) received salvage cystectomy and remain without evidence of relapse at last control. Multivariate analysis showed that T2 stage, N0 stage and R0 category associate better local control rates (p<0.04). Acute grade ≥ 3 toxicity was observed in 14.1% of patients. 71.4% reported excellent or good late urinary function. According to our data, CMT offers survival and local control rates comparable to modern RC series with the important advantage of bladder function preservation with low rates of salvage cystectomy. This modality should be offered as an alternative to RC in selected patients. The most appropriate cases for CMT are those with T2 R0 N0 disease.