How to improve patient selection for neoadjuvant chemotherapy in bladder cancer patients candidate for radical cystectomy and pelvic lymph node dissection

Abstract

Purpose To improve patient selection for neoadjuvant chemotherapy (NAC) before radical cystectomy (RC) in bladder cancer patients (BCa). Methods Retrospective evaluation of 1057 patients with cT2-4N0M0 BCa treated with RC and pelvic lymph node dissection between 1990 and 2018 at 3 referral centers. Adverse pathologic features (APF) were defined as pT3-pT4/pN + disease at RC. A regression tree model (CART) was used to assess preoperative risk group classes. A multivariable logistic regression (MVA) was performed to identify predictors of APF at RC. Results Median age was 70 years and most of the patients were men (83%). Of the 1057 patients included in our study, 688 (65%) had APF. CART analysis was able to stratify patients into 3 risk groups: low (cT2 and single disease, odds ratio [OR] 0.62), intermediate (cT2 and multiple disease, OR 1.08), and high (cT3-cT4, OR 1.28). On MVA APF were associated with variant histology (odds ratio [OR] 3.97, 95% confidence interval [CI] 1.46-10.83, p = 0.007), multifocality at TUR (OR 2.56, CI 1.27-5.17, p = 0.09), completeness of resection (OR 0.47, CI 0.23-0.96, p = 0.04) and clinical extravesical disease (OR 3.42, CI 1.63-7.14, p = 0.001). Conclusion We defined three pre-operative risk classes. Our results indicate that patients with a cT3-T4 disease are those who might benefit more from NAC whereas those with T2 single disease should be those to whom NAC probably shouldn't be proposed. Given the high rate of understaging in BCa patients, NAC can be proposed in selected cases of cT2/multifocal disease.

Progression of Disease after Bacillus Calmette-Guérin Therapy: Refining Patient Selection for Neoadjuvant Chemotherapy before Radical Cystectomy

“…Lastly, we recognize that available guidelines support nonrisk-stratified NAC for all MIBC patients. However, risk-stratified approaches are generally supported by the literature 22,23 in the absence of prospective trial data and are reflected in national practice patterns. 24…”

Characteristics of Patients Undergoing Open Radical Cystectomy for Management of Muscle Invasive Bladder Cancer in A Tertiary Centre in Egypt

“…Five patients were given neoadjuvant chemotherapy NAC. The selection for NAC is usually based on the clinical stage with more priority to locally advanced disease (≥T3), presence of variant histology, multifocality of the tumor, the patients' co-morbidities, the baseline renal function, the delay time during diagnosis and importantly the patient preference [36,37]. The value of neoadjuvant chemotherapy has been demonstrated, Neoadjuvant cisplatincontaining combination chemotherapy (NAC) improves overall survival (OAS) (5-8% at five years), irrespective of the type of definitive treatment used [38][39][40][41].…”