Introduction

Neoadjuvant cisplatin-based chemotherapy prior to radical cystectomy (RC) for muscle invasive bladder cancer is underutilized beside has been supported by guidelines. This study was undertaken to determine the rate of neoadjuvant gemcitabine and cisplatin (NGC) use before radical cystectomy (RC) and lymphadenectomy and to assess its effect on the pathologic response rates, surgical outcome and complication rate.

Methods

This retrospective study examined all patients having a RC between January 2012 and September 2016. We collected patient demographics, pre-treatment clinical stage, post-RC pathologic data and survival data. Response Evaluation Criteria in Solid Tumors (RECIST, ver. 1.0) was used to asses clinical response to NGC (CR for complete response, PR for partial response, PD for progression of disease and SD for Stable disease on CT). Pathological Tumor Regression Grade (TRG) was evaluated (AJSP).

Results

A total of 84 RC were performed of which 74 (88%) were for stage cT2-T4 urothelial carcinoma of the bladder. Salvage cystectomy were excluded (n=10). Of the 74 patients, 30 (40.5%) received NGC. Based on CT scan, clinical response to NGC was evaluated (RECIST criteria): CR was observed in 2 pts (6%), PR in 18 (60%); PD in 1 (3%) and SD in 9 (30%) regarding primary bladder tumor. In 12 pts with enlarged lymph-nodes, the response to NGC was CR in 1, PR in 10 and SD in 1. Patients receiving neoadjuvant GC had a greater chance of achieving a pathologically lower stage compared to the untreated population: organ-confined cancer in 53,3% (16/30) vs. 33% (p < 0.001). Lymph-node metastasis resulted in 25% patients after GC (n=10) vs 45.5% of untreated patients (n=20; p < 0.001). Considering patients resulted CR and PR after NGC (n=20), 70% had down-staging on pathologic report after RC. Complication rates were higher in NGC group (4 thromboembolisms; 2 sepsis; 12 hematologic complications); all complications were not related to surgery. Pathological TRG after NGC was not correlated to clinical regression grade. The OS (mean follow-up 30 months) of patients who received NGC resulted of 66.6% compared with 56% of patients undergoing cystectomy alone (p<0,001). Fifty percent of patients in NGC group were alive without cancer vs 40,1% in cystectomy alone group (p<0,001).

Conclusions

Neoadjuvant chemotherapy for muscle-invasive bladder cancer increases the rate of down-staging and cancer specific survival. NGC is associated with an increased risk of complications that may be prevented using tailored strategies. Pathological regression grades after NGC are not correlated to RECIST criteria based on CT.

Funding

none