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

Abstract

Many patients are medically unfit for or refuse radical cystectomy. Few post-chemotherapy bladder-sparing active surveillance programs have reported on non-muscle-invasive recurrences and treatment outcomes. Here, we present data on non-muscle invasive recurrences and their management in this population. 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 based on negative endoscopic resection, urine cytology, and cross-sectional imaging. Patients were entered into a strict active surveillance protocol. Primary outcomes of interest were number of non-muscle-invasive recurrences, grade and stage, and treatment. Secondary outcomes of interest were non-muscle-invasive treatment response rate and muscle-invasive and metastatic recurrence rate. A total of 61 clinical complete response patients were identified. In total, 28 patients experienced a median of one non-muscle-invasive recurrence over a median follow-up of 28.3 months. There was a total of 46 non-muscle-invasive recurrences, including nine (20%) low-grade recurrences and 37 (80%) high-grade recurrences. Of 37 high-grade recurrences, the majority (60%) were treated with Bacillus Calmette-Guérin induction. Non-muscle-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. There is a high rate of non-muscle-invasive recurrences in patients who achieve clinical complete response to neoadjuvant chemotherapy. However, the majority of these patients may be safely managed with bladder-preserving treatments. These findings emphasize the importance of vigilant surveillance protocols and appropriate patient selection.