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Lack of pathologic down-staging with neoadjuvant chemotherapy for muscle-invasive urothelial carcinoma of the bladder
A contemporary series
Article first published online: 6 JAN 2009
Copyright © 2009 American Cancer Society
Volume 115, Issue 4, pages 792–799, 15 February 2009
How to Cite
Weight, C. J., Garcia, J. A., Hansel, D. E., Fergany, A. F., Campbell, S. C., Gong, M. C., Jones, J. S., Klein, E. A., Dreicer, R. and Stephenson, A. J. (2009), Lack of pathologic down-staging with neoadjuvant chemotherapy for muscle-invasive urothelial carcinoma of the bladder. Cancer, 115: 792–799. doi: 10.1002/cncr.24106
- Issue published online: 2 FEB 2009
- Article first published online: 6 JAN 2009
- Manuscript Accepted: 15 SEP 2008
- Manuscript Revised: 6 SEP 2008
- Manuscript Received: 25 JUN 2008
- urinary bladder neoplasms;
- neoplasm staging;
- neoadjuvant therapy;
- neoadjuvant chemotherapy
The postcystectomy survival benefit associated with the combination of methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC) neoadjuvant chemotherapy (NC) for muscle-invasive bladder cancer has been most evident in patients who achieve a pathologic complete response. The outcome of NC and open radical cystectomy (RC) was evaluated in a contemporary cohort of patients in a tertiary referral setting.
From January 2006 to November 2007, 117 patients underwent open RC at Cleveland Clinic for muscle-invasive bladder cancer, 29 (25%) of whom received NC. Patient information was obtained from a prospective database.
Clinical stage at the time of diagnosis in the NC cohort was T2 in 23 (79%) and T3-4a in 6 (21%) patients. A total of 20 (69%) patients received the combination of gemcitabine and cisplatin (GC), 4 (14%) received MVAC, and 5 (17%) received other regimens. The median interval from the time of diagnosis of muscle-invasive bladder cancer to RC was 208 days (interquartile range, 149 days -327 days) in the NC cohort. Overall, only 2 patients (7%; 95% confidence interval [95% CI], 0 patients-17 patients) achieved a pathologic complete response, 18 (62%; 95% CI, 43 patients-81 patients) had nonorgan-confined residual cancer, and the overall median progression-free survival was 10.5 months (95% CI, 7 months -14 months).
Few RC patients in these investigators' recent experience achieved a pathologic complete response with NC, and most experienced rapid disease progression. These poor outcomes may be related to the use of non-MVAC-based regimens or excessive delay in performing RC. In the absence of supportive data for GC in the neoadjuvant setting, MVAC remained the preferred regimen. Excessive delays in performing RC may negate the benefit of NC. Cancer 2009. © 2009 American Cancer Society.