Occult Residual Malignancy Despite Normal Surveillance Cystoscopy in Trimodalilty Therapy Patients for Bladder Cancer
Jillian Egan Kelly, M.D.1, Affan Zafar, M.D.1, Linda V. Nguyen, B.S.2, Alexandra E. Hunter, B.S.3, William U. Shipley, M.D.3, Niall M. Heney, M.D.3, Anthony L. Zietman, M.D.3, Matthew F. Wszolek, M.D.3, Jason, Efstathiou, M.D., DPhil3, Adam S. Feldman, M.D., MPH3.
1Massachusetts General Hospital/Brigham and Women's Hospital, Boston, MA, USA, 2UMass Chan Medical School, Worcesster, MA, USA, 3Massachusetts General Hospital, Boston, MA, USA.
BACKGROUND: Trimodalilty therapy (TMT) has become a standard treatment option for patients with muscle-invasive bladder cancer. The clinical protocol followed by our institution has been to perform a surveillance biopsy of the resection site, either after consolidation chemotherapy or completion of full-chemoradiation. There is variation in biopsy protocols between centers across the United States and Europe with no evidence to guide providers on if and when surveillance biopsy should be performed. We sought to determine the rate of residual malignancy on initial surveillance biopsy when the cystoscopic visual examination is normal.
METHODS: The Massachusetts General Hospital's institutional trimodal therapy database was reviewed to obtain patients who had completed all three components of treatment. The electronic health record was utilized to obtain the operative report from the initial biopsy, either after consolidation chemotherapy and/or completion of chemoradiation. A determination was made from the operative report whether the bladder was visually normal or abnormal. Keywords for a visually abnormal cystoscopy were: papillary tumor, tumor of any kind, erythematous lesion, significant bullous edema, and suspicious for tumor. All other cystoscopies were considered visually normal. The rate of biopsies positive for malignancy was determined. Urine cytology data from the time of biopsy was also collected.
RESULTS: 211 patients underwent induction and consolidation chemotherapy and proceeded with an initial surveillance biopsy at that time. 24 patients completed full-chemoradiation and had a surveillance biopsy at that time. Biopsy after consolidation chemotherapy was performed by cold cup forceps in 147 patients (69.66%) and transurethral resection in 64 patients (30.33%). Biopsy after completion of full-chemoradiation was performed by cold cup forceps in 11 patients (45.83%) and transurethral resection in 13 patients (54.16%). For patients whose initial surveillance biopsy was after consolidation chemotherapy, 166 (78.67%) had a visually normal bladder on cystoscopy. The rate of positive biopsy for bladder cancer was 5.42%. For patients who completed full-chemoradiation and then had a surveillance biopsy, 21 (87.5%) had a visually normal bladder. The rate of positive biopsy for bladder cancer was 4.76%. The sensitivity of urine cytology immediately after completion of chemoradiation was 27%. The specificity was 86%.
CONCLUSIONS: After completion of chemoradiation for trimodality therapy, when the bladder is visually normal the risk of underlying malignancy is low but remains clinically significant. Furthermore, cytology data shows low sensitivity early after trimodality therapy. Based on these findings, we recommend routine biopsy at the first cystoscopy after chemoradiation.
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