Department of Urology, Columbia University Irving Medical Center,NY.
Department of Urology, Columbia University Irving Medical Center,NY.
Urol Oncol. 2021 Nov;39(11):787.e9-787.e15. doi: 10.1016/j.urolonc.2021.03.025. Epub 2021 Apr 14.
Prior studies have shown that pathologic complete response at radical cystectomy, a significant prognostic factor, can be attributed to both neoadjuvant chemotherapy (NAC) and high-quality transurethral resections (TURBT) prior to NAC. It remains unclear whether the visual completeness of TURBT prior to NAC plays an important role in subsequent outcomes. We sought to assess the association of completeness of TURBT prior to NAC with response and survival outcomes.
We retrospectively reviewed all patients with clinically localized muscle-invasive bladder cancer at our institution who received NAC from 2000 to 2017. Complete TURBT was defined as resection of all visible tumor in entirety, resection to normal-appearing muscle, and/or repeat pre-NAC TURBT revealing cT0. Patients who were restaged as cT0 after NAC and refused cystectomy were placed on an active surveillance/delayed intervention (ASDI) protocol. The primary endpoints were overall and cancer-specific survival. The secondary endpoints were recurrence-free and muscle-invasive recurrence-free survival.
Of 93 patients, 62 (67%) underwent complete TURBT prior to chemotherapy. Compared to patients with incomplete TURBT, those with complete TURBT had lower rates of variant histology (13% vs. 32%) and hydronephrosis (15% vs. 39%). Also, 36% of patients with incomplete TURBT had ≥cT3 disease prior to NAC, compared to none in the complete TURBT cohort. Patients with complete TURBT were more likely to defer RC and pursue ASDI (61% vs. 32%). Those with complete TURBT had lower rates of pT2 or higher disease at cystectomy (48% vs. 75%), with a lower rate of N+ disease trending towards significance (17% vs. 37%). Patients with complete TURBT had higher 5-year overall (77% vs. 46%, P = 0.003) and cancer-specific (85% vs. 50%, P = 0.001) survival. On Cox regression analysis, complete TURBT was significantly associated with superior cancer-specific, recurrence-free, and muscle-invasive recurrence-free survival.
A complete TURBT prior to NAC is associated with improved survival and oncologic outcomes in this cohort with muscle-invasive bladder cancer. The extent to which complete TURBT simply represents a proxy for less aggressive disease or is actually a beneficial therapeutic intervention which improves response to chemotherapy is difficult to define retrospectively.
先前的研究表明，根治性膀胱切除术的病理完全缓解是一个重要的预后因素，这可归因于新辅助化疗（NAC）前的高质量经尿道膀胱肿瘤切除术（TURBT）。目前尚不清楚 NAC 前 TURBT 的视觉完整性是否对后续结果有重要影响。我们旨在评估 NAC 前 TURBT 的完整性与反应和生存结果之间的关联。
我们回顾性分析了 2000 年至 2017 年间在我院接受 NAC 的局限性肌层浸润性膀胱癌患者。完全 TURBT 定义为整块切除所有可见肿瘤，切除至正常外观的肌肉，和/或重复 NAC 前 TURBT 显示 cT0。NAC 后分期为 cT0 且拒绝行膀胱切除术的患者被置于主动监测/延迟干预（ASDI）方案中。主要终点是总生存率和癌症特异性生存率。次要终点是无复发生存率和无肌层浸润复发率。
93 例患者中，62 例（67%）在化疗前进行了完全 TURBT。与不完全 TURBT 的患者相比，完全 TURBT 的患者具有较低的变异组织学发生率（13%比 32%）和肾盂积水发生率（15%比 39%）。此外，36%的不完全 TURBT 患者在 NAC 前就有≥cT3 疾病，而完全 TURBT 组中没有患者存在该情况。完全 TURBT 的患者更有可能推迟行 RC 并选择 ASDI（61%比 32%）。在接受膀胱切除术的患者中，完全 TURBT 的患者中 pT2 或更高疾病的发生率较低（48%比 75%），N+疾病的发生率较低（17%比 37%），但差异无统计学意义。完全 TURBT 的患者 5 年总生存率（77%比 46%，P=0.003）和癌症特异性生存率（85%比 50%，P=0.001）更高。Cox 回归分析显示，完全 TURBT 与癌症特异性、无复发生存率和无肌层浸润复发率的改善显著相关。
在该肌层浸润性膀胱癌队列中，NAC 前完全 TURBT 与生存和肿瘤学结果的改善相关。NAC 前完全 TURBT 是代表疾病侵袭性较低，还是实际上是改善对化疗反应的有益治疗干预，这一点很难从回顾性研究中确定。
