Nonmuscle-Invasive Recurrence and Management During Surveillance in Patients with Muscle-Invasive Bladder Cancer Who Achieve Clinical Complete Response to Neoadjuvant Chemotherapy.

Abstract

PURPOSE: Many patients are medically unfit for or refuse radical cystectomy. Few postchemotherapy bladder-sparing active surveillance programs have reported on nonmuscle-invasive recurrences and treatment outcomes. In this study, we present data on nonmuscle-invasive recurrences and their management in this population. MATERIALS AND METHODS: This is a retrospective review of a prospectively maintained database. All patients received cisplatin-based neoadjuvant chemotherapy and were determined to have a clinical complete response (cCR) based on negative endoscopic resection, urine cytology, and cross-sectional imaging. Patient data were entered into a strict active surveillance protocol. Primary outcomes of interest were number of nonmuscle-invasive recurrences, grade and stage, and treatment. Secondary outcomes of interest were nonmuscle-invasive treatment response rate and muscle-invasive and metastatic recurrence rate. RESULTS: A total of 61 cCR patients were identified. In total, 28 patients experienced a median of 1 nonmuscle-invasive recurrence over a median follow-up of 28.3 months. There were a total of 46 nonmuscle-invasive recurrences, including 9 (20%) low-grade recurrences and 37 (80%) high-grade recurrences. Of the 37 high-grade recurrences, the majority (60%) were treated with Bacillus Calmette-Guérin induction. Nonmuscle-invasive recurrence was not associated with later muscle-invasive recurrence or metastasis. Genomic analysis of paired tumor samples demonstrated clonal relatedness in one patient sample while another sample demonstrated a likely precancerous urothelial field effect. CONCLUSIONS: There is a high rate of nonmuscle-invasive recurrences in patients who achieve cCR to neoadjuvant chemotherapy. However, most of these patients may be safely managed with bladder-preserving treatments. These findings emphasize the importance of vigilant surveillance protocols and appropriate patient selection.