Neoadjuvant chemotherapy for locally advanced transitional cell carcinoma of the bladder: do local findings suggest a potential for salvage of the bladder?

Sixteen patients with locally advanced transitional cell carcinoma of the bladder were given two to four cycles of combination chemotherapy with methotrexate, vinblastine, doxorubicin hydrochloride (Adriamycin), and cisplatin (M-VAC) in an effort to reduce tumor size and enhance the potential for surgical resection. All patients had initial clinical staging (based on cystoscopy and cystoscopic biopsy, urine cytology, computed tomographic scanning, and excretory urography). Before each cycle, all patients had repeat clinical staging tests. Ten patients underwent postchemotherapy bilateral pelvic lymphadenectomy and radical cystoprostatectomy, and their bladders were examined histopathologically by step-sectioning techniques. One patient underwent abdominal exploration, bilateral pelvic lymphadenectomy, and ipsilateral partial cystectomy. Five patients had repeat clinical staging only without removal of their bladders. Of the 16 patients, 5 (31%) had residual invasive tumor and no tumor response. Three patients (19%) had a partial response, two of whom had only carcinoma in situ (one with prostatic duct involvement) and one of whom had stage pT1, NO, MO disease. Five patients (31%) had normal findings on computed tomographic scans, cystoscopy, biopsy, and urine cytology and thus had complete responses. In addition, 3 of 11 patients who underwent pathologic staging had no residual tumor on clinical and surgical staging and were complete responders. The overall (partial + complete) response rate was 69%, and the overall complete remission rate (pathologic + clinical staging) was 50%. These results suggest that the concept of possible salvage of the bladder with the current treatment program might be premature and must be applied selectively.(ABSTRACT TRUNCATED AT 250 WORDS)