258 Background: When neoadjuvant chemotherapy is administered prior to radical cystectomy in patients with muscle-invasive urothelial cancer, the patients who benefit most are those with pathologic T3-4 or N+ disease. Thus, some advocate reserving neoadjuvant chemotherapy for patients considered high risk based on presence of the following clinical parameters: lymphovascular invasion, hydroureteronephrosis, presence of a palpable or visible mass on exam under anesthesia or imaging (suggesting cT3 disease), and/or variant histology. The goal of this study was to report the outcome of patients who were classified as “not high risk” (i.e., lacking the above-mentioned criteria) and underwent radical cystectomy without neoadjuvant chemotherapy. Methods: On retrospective review of 858 patients who underwent radical cystectomy from 2000 to 2008, we identified 174 patients with muscle-invasive disease (cT2) who were classified as “not high risk” (i.e., did not have lymphovascular invasion, hydroureteronephrosis, variant histology, and/or palpable or visible mass on imaging studies) and underwent radical cystectomy without neoadjuvant chemotherapy. Endpoints of interest included pathologic upstaging (≥ pT3), pathologic lymph node positivity, need for adjuvant or salvage chemotherapy, disease recurrence, and disease specific survival (DSS). Results: Of the 174 patients, 155 (88.6%) were male and the median age was 67.6 years (range 39-86). At radical cystectomy, 75 patients (42.9%) were upstaged (pT3N0: 45; pT4N0: 6; pTxN+: 24). Thirteen patients (7.4%) received adjuvant chemotherapy for adverse pathology. After a median interval of 27 months, 38 patients (21.7%) developed recurrent disease; isolated pelvic recurrences: 4, distant recurrences: 34, and 2 had both. Eighteen patients with recurrent disease went on to receive salvage chemotherapy. Overall, 25 patients (14.3%) died of disease with a 5-year DSS of 82.3%. Conclusions: Although clinical understaging remains a problem in the management of patients with muscle-invasive urothelial cancer, our criteria for selection of patients for primary radical cystectomy without neoadjuvant chemotherapy results in a cohort with a 5-year DSS of 83%. No significant financial relationships to disclose.
Treatment options for muscle-invasive urothelial cancer for patients who were not eligible for cystectomy or neoadjuvant chemotherapy with methotrexate, vinblastine, doxorubicin, and cisplatin
