Although radical cystectomy is still the standard of care for invasive bladder cancer, many groups exploring a multimodal treatment approach using transurethral resection of the bladder (TURBT), radiation and chemotherapy (RT/RCT) in an attempt to preserve the patients native bladder. Integral part of these strategies is salvage cystectomy for persistent or recurrent urothelial cancer. Nevertheless the treatment of superficial relapse after complete response (CR) to TURBT and RT/RCT remains ambiguous.
Materials/Methods
Between 1982 and 2006, a total of 531 patients with high-risk T1 (G3, associated Tis, multiple recurrences, >5 cm in diameter) or muscle-invasive T2-4 bladder cancer were treated on various bladder sparing protocols at our institution. A total of 146 patients received RT alone. Two-hundred-seventy-nine patients had concurrent cisplatin based chemotherapy, in 95 carboplatin was administered, while the remaining 11 were treated with 5-FU/carboplatin (n = 9) or 5-FU alone (n = 2). Sixty-eight patients developed superficial local recurrences (≤T1) after CR to RT/RCT and formed the subject of this study.
Results
Sixty-eight patients developed superficial local recurrences (≤T1). The median time from completion of therapy to detection of superficial failure was 15.4 months (range: 3.58–102.7 months). The median follow-up from first superficial relapse was 49.4 months. Of all 68 patients with superficial recurrence after CR to combined modality treatment, 29 patients are still alive and 21 died, all without evidence of disease (50/68 = 73.5%). Sixteen patients died from urothelial cancer (16/68 = 23.5%), in one patient the cause of death is unknown and one patient was lost to follow-up after 63 months. Disease-specific survival rates for all 68 patients were 87% and 72% at 5 and 10 years, respectively. The respective figures for overall survival were 79% and 51% at 5 and 10 years. Overall survival with bladder preserved was 78% and 39% at 5 and 10 years, implicating that about 98% maintained their own bladder at 5, while after 10 years only 76% where alive with their bladder preserved.
Conclusions
For low risk superficial recurrence after CR to combined modality treatment in bladder cancer a further bladder sparing approach with TURBT with or without intravesical therapy is reasonable. In case of high-risk superficial relapse immediate cystectomy should be considered as treatment of option. Nevertheless combined modality treatment mandates lifelong cystoscopic surveillance for all patients with their bladder preserved.
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