Presentation Authors: Takehisa Onishi, Sho Sekito*, Takashi Terabe, Takuji Shibahara, Ise, Japan
Introduction: Neoadjuvant chemotherapy (NAC) achieves pathologic down-staging and improves survival for patients undergoing radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC). However RC has a high rate of morbidity and mortality, and major impact on quality of life. The objective of this study was to investigate the clinical outcomes of patients with MIBC who were treated with NAC and then refused subsequent immediate radical cystectomy (RC).
Methods: We retrospectively assessed the data of 74 patients with T2-4aN0-1M0 who underwent maximum transurethral resection of bladder tumor (TURBT) followed by NAC and then refused immediate RC from 2006-2018. Clinical restaging was performed with imaging and 2nd-TURBT after NAC. Non-invasive down-staging (NID) was defined as non-invasive tumor (cT0/Ta/T1N0) on 1st-TURBT after NAC and absence of tumor on the 2nd-TURBT. We evaluated the response to NAC, and assessed overall survival (OS), and cystectomy-free survival (CFS) according to the response of NAC.
Results: Twenty four (32.4%) patients achieved cT0N0, 16 (21.6%) demonstrated cTa/T1N0, and 34 (46%) remained MIBC on 1st-TURBT after NAC.ã€€Twenty patients with residual tumor on the 2nd-TURBT received delayed RC (RC group), while 40 patients with NID and 14 patients with non-NID who refused RC were placed on a strict active surveillance and delayed intervention. Six (11%) relapsed with muscle invasive tumors, and proceeded to salvage RC. At median follow-up of 35 months (5-120 months), 5-year OS rates in the entire cohort, RC group, patients with NID, and non-NID were 68.5, 73.2%, 86% and 48.2%, respectively. 5-year CFS rates in patients with NID, and non-NID were 88.7% and 41.1%, respectively. Kaplan-Meier analysis of OS and CFS demonstrated significant differences between the groups (Figure).
Conclusions: Conservative management may be a reasonable option in highly selected group of patients with MIBC who achieved non-invasive down-staging (cT0/Ta/T1N0 on 1st-TURBT and no residual tumor on the 2nd-TURBT after NAC) with NAC, although careful surveillance and rapid identification of relapse is critical in the management.