Selective bladder conservation using transurethral resection, chemotherapy, and radiation: Management and consequences of Ta, T1, and Tis recurrence within the retained bladder

Objectives. Although radical cystectomy remains the standard of care for in vasive bladder cancer in the United States, many groups are exploring the u se of trimodality therapy using transurethral resection of the bladder tumo r, radiation, and chemotherapy in an attempt to spare patients the need for cystectomy. As transitional cell carcinoma often arises from a urothelial field change, there is concern that the retained bladder is at risk of subs equent superficial (Ta, T1, Tis) tumors, some of which may have lethal pote ntial. This study reports the outcomes of those patients with superficial r elapse of transitional cell carcinoma after trimodality therapy. Methods. One hundred ninety patients were treated using a series of trimoda lity therapy protocols between 1986 and 1998. All patients received inducti on chemotherapy and radiation and were selected for bladder preservation on the basis of a cytologic and histologic complete response. One hundred twe nty-one patients had a complete response and formed the subjects of this st udy. Results. With a median follow-up of 6.7 years for patients still alive, 32 experienced a superficial relapse (26%). The median time to this failure wa s 2.1 years. Sixty percent of the superficial failures were carcinoma in si tu (Tis) and 67% arose at the site of the original invasive tumor. The risk of superficial failure was higher among those who had Tis associated with their original muscle-invasive tumor. Twenty-seven of these 32 cases were m anaged conservatively with transurethral resection and intravesical therapy . The irradiated bladder tolerated this therapy well and only 3 patients re quired treatment breaks. The 5 and 8-year survival was comparable for those who experienced superficial failure (68% and 54%, respectively) and those who had no failure at all (n = 74, 69% and 61%, respectively). However, a s ubstantially lower chance of being alive with the native bladder owing to t he need for late salvage cystectomies (61% versus 34%) was found. Cystectom y became necessary in 31% (10 of 32) either because of additional superfici al recurrence (n = 7) or progression to invasive disease (n = 3). Conclusions. A trimodality approach to transitional cell bladder cancer man dates lifelong cystoscopic surveillance. Although most completely respondin g patients retain their bladders free from invasive relapse, one quarter wi ll develop superficial disease. This may be managed in the standard fashion with transurethral resection of the bladder tumor and intravesical therapi es but carries an additional risk that late cystectomy will be required. UR OLOGY 58: 380-385, 2001. (C) 2001, Elsevier Science Inc.