Clinical Upstaging After Neoadjuvant Chemotherapy Impacting Eligibility for Vaginal-sparing Cystectomy: Identifying Bladder Cancer Patients Who May Benefit From Interim Imaging

• Published in: Urology (Ridgewood, N.J.) N.J.), 2024-09, Vol.191, p.102-109
• Main Authors: Liu, William J., Campbell, Rebecca A., Michael, Patrick D., Wood, Andrew, Haywood, Samuel C., Eltemamy, Mohamed, Kaouk, Jihad, Campbell, Steven C., Haber, Georges-Pascal, Weight, Christopher J., Remer, Erick M., Almassi, Nima
• Format: Article
• Language: English
• Subjects: Aged; Chemotherapy, Adjuvant; Cystectomy - methods; Female; Humans; Middle Aged; Neoadjuvant Therapy - methods; Neoplasm Invasiveness; Neoplasm Staging; Organ Sparing Treatments - methods; Patient Selection; Retrospective Studies; Urinary Bladder Neoplasms - diagnostic imaging; Urinary Bladder Neoplasms - drug therapy; Urinary Bladder Neoplasms - pathology; Urinary Bladder Neoplasms - surgery; Vagina - surgery
• ISSN: 0090-4295; 1527-9995; 1527-9995
• DOI: 10.1016/j.urology.2024.06.029

Limited data exist on the frequency with which clinical progression during neoadjuvant chemotherapy (NAC) for muscle-invasive bladder cancer (MIBC) impacts eligibility for a vaginal-sparing surgical approach or on the utility of interim imaging assessment. We sought to evaluate the incidence of clinical upstaging following NAC that would render a patient ineligible for a vaginal-sparing cystectomy. Eighty-nine female patients with non-metastatic MIBC treated with NAC and radical cystectomy (RC) (2012-2023) were retrospectively reviewed. Tumor location(s) was determined from transurethral resection of bladder tumor operative reports. Pre- and post-NAC clinical staging was determined from imaging. Outcomes of interest included clinical upstaging and upstaging to vaginal invasion after NAC. 75/89 patients had pre- and post-NAC imaging. Fifty-five had no change in clinical staging, 6 patients were upstaged (4 cT2→cT3, 2 cT3→cT4), and 14 patients were downstaged (13 cT3→cT2, 1 cT4→cT2). Of the 75 patients with pre- and post-NAC imaging, 39 had trigone tumors. Of these, 28 had no change in clinical staging, 2 were upstaged (1 cT2→cT3, 1 cT3→cT4) and 9 were downstaged (8 cT3→cT2, 1 cT4→cT2). Overall, 6/75 (8%) of patients demonstrated clinical upstaging after NAC. 2/39 (5%) of patients with trigone tumors clinically progressed after NAC and both had vaginal invasion (pT4) on final pathology. Although clinical upstaging after NAC was infrequent, 5% of patients with trigonal MIBC were rendered ineligible for vaginal-sparing cystectomy following NAC due to progression. Interim imaging assessment may identify non-responders and preserve eligibility for vaginal-sparing RC.