Management of local recurrences in the irradiated bladder: a systematic review

Objective: • To review and report the management and outcomes of patients with recurrence of bladder cancer (BC) who initially had complete response to bladder conservation therapy.

Methods: • A comprehensive review of all published literature reporting outcomes in bladder-sparing treatments for muscle-invasive BC (MIBC) was conducted in a systematic fashion by two independent authors across several databases including PubMed and Medline using the following keywords, alone or in combination: bladder cancer, radiotherapy, recurrence, outcome, cystoscopy, follow up, combined modality therapy, and organ preservation. • In all, 17 studies reporting prevalence and management of local recurrences were included in final analysis.

Results: • Complete response rates to CRT ranged from 56 to 100%. • Local recurrence rates ranged from 13 to 40%. Initial BC recurrences were equally likely to be non-muscle-invasive (NMI) or muscle invasive (MI). Average time to local recurrence from RT was 18-36 months but can extend to 10 years. • For first NMIBC recurrences, transurethral resection of bladder tumour (TURBT) with or without intravesical therapy was most commonly used with cystectomy and TURBT used equally for subsequent recurrences. Cystectomy was advocated most commonly for MIBC recurrences. • In most studies, the 5-year cancer-specific survival for patients with NMIBC recurrences was 50-70%, with that for MIBC recurrences being much less at 16-40%. Patients with recurrences have a lower probability of surviving with an intact bladder compared with those who do not have a recurrence. • Age, resection status, T-stage and presence of carcinoma in situ at time of RT were adversely associated with local control and overall survival.

Conclusion: • In patients with MIBC managed with CRT, who have a complete response at initial cystoscopy, survival after NMIBC recurrence is comparable with those without any recurrence but with a smaller chance of surviving with an intact bladder. However, prognosis for patients with MIBC recurrences remains poor. • Cystoscopic follow-up to 10 years is mandated.