Outcomes of patients undergoing salvage radical cystectomy post-trimodal therapy: Results of a multi-institutional Canadian cohort
Landan MacDonald1, Ronald Kool2, Gautier Marcq2, Girish S. Kulkarni3, Rodney Breau4, Bobby Shayegan5, Michael Kim3, Ionut Busca4, Hamidreza Abdi4, Michael Uy5, Mark Dawidek6, Gagan Fervaha7, Fabio L. Cury2,8, Nimira Alimohamed9, Jonathan Izawa10, Claudio Jeldres11, D. Robert Siemens7, Peter Black6, Wassim Kassouf2, Ricardo A. Rendon1.
1Department of Urology, Dalhousie University, Halifax, NS, Canada; 2Division of Urology, McGill University Health Centre, Montreal, QC, Canada; 3Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada; 4Ottawa Hospital Research Institute, Division of Urology, University of Ottawa, Ottawa, ON, Canada; 5Division of Urology, McMaster University, Hamilton, ON, Canada; 6Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada; 7Department of Urology, Queen’s University, Kingston, ON, Canada; 8Department of Radiation Oncology, McGill University Health Centre, Montreal, QC, Canada; 9Division of Medical Oncology, University of Calgary, Calgary, AB, Canada; 10Division of Urology, Western University, London, ON, Canada; 11Division of Urology, Université Sherbrooke, Sherbrooke, QC, Canada
Introduction: Trimodal therapy (TMT) is an alternative to radical cystectomy for the treatment of muscle-invasive bladder cancer (MIBC) in well-selected patients.[1] Rates of recurrence and non-response to TMT have been reported to be up to 30%.[2] Salvage radical cystectomy (sRC) is an option for patients with persistent or recurrent disease. Patient characteristics that predict success with sRC are not well-defined. We report the outcomes of patients undergoing sRC from a multi-institutional Canadian cohort.
Methods: Patients who underwent sRC post-TMT were identified retrospectively from the TMT Canadian Collaboration. This collaboration includes patients treated at 14 Canadian Institutions. Patient characteristics, histopathology findings, and survival outcomes were evaluated. Patients undergoing sRC were grouped into immediate (within six months post-TMT) and delayed sRC (more than six months post-TMT).
Results: There were 864 patients included in this series, of which 64 underwent sRC. Of those, 17 underwent immediate sRC and 47 delayed sRC. Patients who had an immediate salvage were more likely to be younger, male, have a higher tumor and nodal stage, variant histology, hydronephrosis, and radiation to bladder only (no chemotherapy) compared to those who underwent a delayed sRC (Table 1). Most patients underwent pelvic lymph node dissection (86%), with a median nodal count of 9 (4–16). Most patients underwent an ileal conduit (96.9%) and most had a negative margin (81.2%). The median overall survival (OS) for the entire cohort was 89 months. The OS between immediate and delayed sRC was 20 months and 129 months, respectively.
Conclusions: sRC is feasible and has acceptable oncological outcomes. Patients who undergo delayed sRC have a much better prognosis compared to those who undergo immediate sRC. This highlights the importance of patient selection when deciding between treatment options. Patients with higher T and N stage, variant histology, hydronephrosis, and treated with radiation only are at an increased risk for early salvage.
[1] Vashistha V, Wang H, Mazzone A, et al: Radical Cystectomy Compared to Combined Modality Treatment for Muscle-Invasive Bladder Cancer: A Systematic Review and Meta-Analysis. Int. J. Radiat. Oncol. Biol. Phys. 2017; 97: 1002–1020.
[2] Schuettfort VM, Pradere B, Quhal F, et al: Incidence and outcome of salvage cystectomy after bladder sparing therapy for muscle invasive bladder cancer: a systematic review and meta-analysis. World J. Urol. 2021; 39: 1757–1768.
