ASCO 2018: Bladder-Sparing Strategies in Bladder Cancer
The 3 cases were:
1. 67 year old medically fit male patient who presented with hematuria. Cysto and TURBT demonstrates MIBC, new diagnosis. CT scan shows diffusely irregular bladder thickening and asymmetry in the posterior wall. No known family history. PS 0. Adequate organ function.
2. 65 year old man with prior HG pTa bladder cancer treated with BCG (induction + maintenance) who presents 4 years later with CT Urogram demonstrating right hydronephrosis, lobulated right bladder mass and pelvic adenopathy 2.5 cm (node-positive). TURBT shows HG MIBC with squamous differentiation. Right-sided stent placed, creatinine improves significantly. Gem/Cis 4 cycles completed, good response – hydro resolves, node < 1cm.
3. 84 year old elderly cachectic male presents with 2 months gross hematuria. CT Urogram with 6 cm bladder mass. TURBT with MIBC, new diagnosis. Creatinine 1.2, ECOG worsens to 1, lives with daughter now. Frail.
Zietman was tasked with discussing when cystectomy could be safely avoided in patients with MIBC.
He starts by noting that organ-sparing treatments are standard of care in many other malignancies – such as laryngeal cancer, breast cancer, anal cancer, limb sarcoma. The common feature to all these is that their organ sparing therapy consists of 3 things: limited surgery, lower radiation dose, and systemic therapy. In bladder cancer, this translates into aggressive TURBT (maximal tumor debulking), radiation therapy and concurrent chemotherapy.
Their schema for bladder preservation is as follows:
At the University of Toronto, our scheme is pretty similar. In both, patients with residual disease on cystoscopic / re-TURBT after chemoradiation go to cystectomy; usually, there is not much of a delay, as the chemoradiation usually last 4-6 weeks. However, patients who do have a good response go on to consolidative chemotherapy or chemoradiation. All patients require close monitoring after that – whole body imaging periodically as well as local surveillance with cystoscopy/labs. Hence, this requires buy-in and involvement from medical oncologists, urologists, and radiation oncologists.
Methods for trimodal therapy have improved, partly because:
1. Combining chemotherapy with XRT has been demonstrated to increase efficacy – chemosensitizers (low-dose) are well tolerated but also improve radiation efficacy.
2. Upfront maximal TURBT / debulking was demonstrated to help increase efficacy of TMT
A patient with complete TURBT (visible) were much less likely to require cystectomy and had better OS and DFS
3. Better XRT delivery with less side effects
4. Evidence-based selection of patients – with more experience, we were able to identify good candidates. Amongst all MIBC candidates, only about 20% are TMT candidates. Selection criteria include:
• Tumors allowing complete resection on TURBT
• Solitary cT2 tumors
• No tumor associated hydronephrosis
• UC histology – though, they have evidence that variant histology does well with TMT
MGH has one of the larger series of TMT / bladder preservation series. He presented updated results from their experience. 474 patients, 7.2 years median follow-up. 75% achieved a clinical complete response (CR). Actual rates of failure at 5-years were: 23% local recurrence (
They have begun to do QOL studies at TMT, and essentially, patients do quite well with TMT. 78% have compliant bladders despite chemoradiation. 85% have no urgency or rare urgency. 25% have bowel control symptoms – which is the main downside to TMT, especially in the elderly.
So, basically, TMT is an excellent option but should be used selectively.
Presented by: Anthony Zietman, MD
Read the Corresponding Case-based Discussions:
Gary Steinberg, Nuances of Surgical Management of Localized/Locally Advanced Urothelial Cancer
Jenny Aragon-Ching, Challenges of Perioperative Systemic Therapy of Localized Urothelial Cancer
Written by: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, Twitter: @tchandra_uromd at the 2018 ASCO Annual Meeting - June 1-5, 2018 – Chicago, IL USA