Sarcopenia, loss of skeletal muscle mass, reflects frailty and low performance status and is associated with poor prognosis in patients with muscle-invasive bladder cancer (MIBC). Sarcopenic patients can be unfit for radical cystectomy, the gold standard treatment for MIBC, because of its significant morbidity rates. Bladder sparing treatment based on chemoradiotherapy (CRT) may be a less-invasive alternative treatment for sarcopenic patients. We have developed a tetra-modality bladder sparing therapy (TeMT) consisting of maximal transurethral resection (TUR), CRT and consolidative partial cystectomy (PC) (Koga et al. BJU Int 2012). This study aims to evaluate the feasibility and oncological outcomes of TeMT in sarcopenic patients.
This study included 126 cT2-3N0M0 MIBC patients who entered TeMT protocol. After TUR and CRT (40Gy+cisplatin), response was evaluated by cytology, imaging and tumor-site rebiopsy. Complete responders proceeded to consolidative PC, while RC was recommended for others. The skeletal muscle index (SMI) was calculated using diagnostic CT images. Sarcopenia was defined as SMI <43 cm2/m2 for males with body mass index (BMI) <25 kg/m2, <53 cm2/m2 for males with BMI ≥25 kg/m2, and <41 cm2/m2 for females (J Clin Oncol 2013). Response rate to CRT, MIBC recurrence-free survival (MIBC-RFS) and cancer-specific survival (CSS) were compared between sarcopenic and non-sarcopenic patients.
Sarcopenia was found in 68 (54%) patients. All patients completed CRT according to the protocol without any grade 3-4 adverse events. There were no differences in the complete response rate to CRT (75% vs 72%, p=0.74) and in the completion rate of PC according to the protocol (72% vs 71%, p=0.87) between sarcopenic and non-sarcopenic patients. Among the patients who underwent PC, 5-yr MIBC-RFS rates were 97% in both (p=0.57; Fig. A), 5-yr CSS rates were 94% in both (p=0.96; Fig. B) and major complication rates after PC (Clavien grade ≥3b) were not different between sarcopenic and non-sarcopenic patients (6% vs 2%; p=0.42). On an intent-to-treat basis, 5-yr CSS rates were 83% and 79% in sarcopenic and non-sarcopenic patients, respectively (p=0.47; Fig. C).
Tetra-modality bladder sparing therapy can be feasible and yield favorable local control and survival for muscle invasive bladder cancer patients with sarcopenia.