最大限度TURBT联合全身化疗后明显降期的MIBC保留膀胱综合治疗长期疗效和安全性

Bladder-sparing treatment following noninvasive down-staging after transurethral resection of bladder tumor plus systemic chemotherapy for muscle-invasive bladder cancer

目的探讨最大限度经尿道膀胱肿瘤切除术(mTURBT)联合全身化疗治疗后达到明显降期(≤pT1期)的肌层浸润性膀胱癌(MIBC)患者保留膀胱综合治疗的长期疗效和不良反应。方法回顾性分析中国医学科学院肿瘤医院2013年12月至2020年12月行保留膀胱综合治疗的22例非转移性MIBC患者的病例资料,男10例,女12例。中位年龄66岁。单发肿瘤17例,多发肿瘤5例。治疗前肿瘤分期T2期17例,T3期5例。中位肿瘤大小为3.0(0.8~5.3)cm;所有患者均无原位癌和上尿路积水。患者首先接受mTURBT,切除所有肉眼可见的肿瘤病灶,明确病理分期,然后接受3~4个周期吉西他滨联合顺铂方案(吉西他滨1000 mg/m^(2),第1天和第8天静脉滴注;顺铂75 mg/m^(2),第1天静脉滴注;每21天为1个周期)化疗。22例化疗后再次行TURBT,根据病理结果分别采用同步放化疗或主动监测。治疗后6个月采用膀胱过度活动症症状评分(OABSS)评估患者膀胱功能。结果本研究22例中,mTURBT+全身化疗后临床完全缓解(pT0期)12例,降期达pTa~T1期10例。14例行同步放化疗,其中4例发生>Ⅲ度化疗不良反应;8例行主动监测,其中3例全身化疗后发生>Ⅲ度不良反应。22例中位随访36.7个月,保留膀胱成功率为90.9%(20/22),其中9例发生肿瘤复发,2例死亡;5年无复发生存率(RFS)为52.2%,5年总生存率(OS)为86.1%。mTURBT+全身化疗后降期为pT0期的12例中,3例复发,5年RFS为66.7%,OS为100.0%;mTURBT+全身化疗后降期为pTa~T1期的10例中,6例复发,其中2例死亡,5年RFS为40.0%,OS为72.0%。20例成功保留膀胱患者治疗后6个月OABSS为(1.00±1.03)分。结论以mTURBT+全身化疗后明显病理降期作为判断标准,联合同步化放疗,对MIBC患者保留膀胱是可行的,化疗后病理降期为pT0期患者的预后更好,长期不良反应少见。

Objective To investigate the long-term survival and safety in patients with muscle-invasive bladder cancer(MIBC)who experienced a noninvasive down-staging(≤pT1)after transurethral resection of bladder tumor(TURBT)plus systemic chemotherapy and received bladder-sparing treatment.Methods The records of patients with MIBC who underwent maximal TURBT plus systemic chemotherapy-guided bladder-sparing treatment were reviewed retrospectively from Dec 2013 to Dec 2020.Eventually,22 patients who achieved noninvasive down-staging underwent conservative management.The total patient cohort contained 10 males and 12 females.A majority of patients had single lesion and stage T2 disease.The median age of the patients was 66 years and the median tumor size was 3.0 cm.All patients underwent maximal TURBT to resect all visible diseases and followed by 3-4 cycles platinum-based systemic chemotherapy.After achieving noninvasive down-staging,14 patients received concurrent chemoradiotherapy,and the other 8 patients underwent surveillance.Overactive bladder symptom score(OABSS)was used to assess the bladder function after treatment.Results Twelve patients achieved pT0 and 10 patients were down-staged to cTa-T1.At a median follow-up of 36.7 months,90.9%(20/22)patients retained their bladder function successfully.Among the 14 patients who received concurrent chemoradiotherapy,4 had grade 3 or 4 adverse events.Among the 8 patients who underwent surveillance,3 had grade 3 or 4 adverse events after systemic chemotherapy.Nine patients experienced tumor recurrence in the bladder,and 2 patients died of bladder cancer.Seven(31.8%)patients experiencedⅢ/Ⅳgrade complications.The 5-year recurrence-free survival(RFS)and overall survival(OS)in patients achieved pT0 were 66.7%and 100.0%,respectively.The 5-year RFS and OS in patients achieved cTa-T1 were 40%and 72%,respectively.The OABSS score of 20 patients who retained their bladder successfully was(1.00±1.03).Conclusions MIBC patients who achieved noninvasive down-staging might be candidates for the bladder-sparing treatment with maximum TURBT followed by systemic chemotherapy.The patients who achieved pT0 might have better prognosis with functional bladder.