EVALUATION OF MULTIMODAL THERAPY USING ENDOSCOPIC RESECTION WITH CONCURRENT GEMCITABINE AND RADIOTHERAPY IN THE TREATMENT OF MUSCLE-INVASIVE BLADDER CANCER

Background: Radical cystectomy is the preferred line of treatment for MIBC. Multimodal therapy including concomitant chemo-radiotherapy gives promising results comparable to cystectomy especially in those patients with solitary, low stage, small size tumors that are amenable to complete resection.
Aim of the work: to evaluate the role of bladder preservation protocol including concomitant chemo-radiotherapy in the treatment of muscle invasive bladder cancer as regard: local control, systemic control, and quality of life.
Materials and methods: Forty patients with primary (T2-4a, Nx, M0) TCC of the bladder with adequate performance status and eligible for cystectomy were enrolled over a period from March 2011 to July 2013. All patients are subjected to maximal TURBT, Intra-venous gemcitabine infusion (300 mg/m² body surface area weekly during radiotherapy), and 60 Gy /6 weeks using linear accelerator 4-6 mev. 1st phase:- total pelvic radiation of 40 Gy by dose of 20 fractions in 20 days. While 2nd phase:- localized pelvic field dose of 20 Gy by 10 fractions in 10 days. The endpoint of the study is either treatment failure or completion of the follow up period via cystoscopy every three months for 2 years, and upper tract surveillance was performed by ultrasonography every six months and CT yearly.
Results: After phase I; 22 (55%) patients had complete response (complete disappearance of all measurable lesions), 8 (20%) patients had partial response (more than 50% reduction of all measurable lesions or no increase in any lesion or no new lesions) and 10 (25%) patients had stable disease (less than 50% reduction of measurable lesions or < 25% increase of measurable lesions). Patients who had stable disease were subjected to salvage cystectomy. Patients who had CR and PR (totally 30 patients) started phase II. After phase II, only 3 patients underwent salvage chemotherapy and 27 patients had CR. At the end of treatment protocol, 27 (67.5%) patients had CR with bladder preservation while 13 (32.5%) patients were subjected to salvage cystectomy. Kaplan-Meier analysis of recurrence-free survival, overall survival of the patients was done.
Conclusion: Bladder preservation protocol including concomitant chemo-radiotherapy gives comparable results with cystectomy in local control of the disease and survival rates of the patients with better quality of life especially in those patients with solitary T2, high grade tumors that are less than 5 cm and are amenable to complete resection.