Transurethral Resection of Bladder Tumors Followed by Radiotherapy with or without Chemotherapy for Bladder Preservation in Patients with Invasive Bladder Transitional Cell Carcinoma: Preliminary Ntuh

Abstract

Purpose: Radical cystectomy has been the standard treatment for invasive transitional cell carcinoma (TCC) of urinary bladder. Transurethral resection of bladder tumors (TUR-BT) and radiotherapy (RT) provide an alternative option to cystectomy for organ preservation. The trimodality therapy (TMT) incorporating neoadjuvant and concurrent chemotherapy (CHT) seems to improve the treatment result. This study is to evaluate the short-term outcome and treatment-related toxicity of the TMT for bladder preservation. Materials and Methods: From 2000 to 2004, 37 patients with invasive bladder TCC undergoing bladder preservation therapy were reviewed retrospectively. Among them, 21 patients received radical TUR-BT followed by RT alone. The other 16 patients who had complete response or good partial response after radical TUR-BT and neoadjuvant CHT received further RT or concurrent chemoradiation. The RT protocol was 45Gy to small pelvis field and 50.4Gy to whole bladder, plus tumor bed boost to a total dose of 64.8Gy with daily fraction size of 1.8Gy in the TMT group. Patients in the RT alone group received 60Gy to whole bladder or 40Gy to whole pelvis plus 20Gy boost to whole bladder with daily fraction size of 2.0 Gy. Interval cystoscopy was performed to confirm the status of complete response for continuation of RT in the TMT group. Results: The median age was 61.8 in the TMT group and 76.8 in the RT alone group. Thirty patients were male and seven were female. In the TMT group, fourteen patients had complete response after radical TUR-BT and induction CHT. Seven patients (43.7%) in the TMT group had grade 3 or 4 acute toxicity, and two of them died of treatment toxicity. The other five patients completed their treatment course with modification of CHT. In the RT alone group, only one patient (4.7%) had grade 3 acute toxicity. The median follow-up was 14.6 months in the TMT group and 21 months in the RT alone group. In the 14 patients completing TMT, two patients experienced local recurrence and none of 16 patients had distant metastasis. In the RT alone group, eight of 21 patients had local recurrence while 7 patients had distant metastasis. The one-year locoregional control rates were 93.3% in TMT group and 72.0% in RT alone group (p=0.11). The one-year metastasis-free survival, disease-free survival, and overall survival were 100% and 73.3% (p=0.047), 93.3% and 62.3% (p=0.05), and 87.5% and 79.8% (p=0.23), respectively. Conclusion: At the cost of increased acute toxicity, TMT for bladder preservation provides significant better metastasis-free survival and favorable disease-free survival. Our protocol seems feasible and well tolerated in most patients. With limited follow-up, the result of TMT remains satisfactory in selected patients. Longer observation is needed to confirm the ultimate success of bladder preservation.