Background
Retrospective single-institution series from Massachusetts General Hospital (MGH). 348 patients with cT2–T4a muscle-invasive bladder cancer treated with selective bladder-preserving trimodality therapy (TMT): maximal TURBT followed by concurrent chemoradiotherapy (cisplatin-based, 40 Gy induction + consolidation to 64–65 Gy). Largest single-institution bladder-preservation series at the time of publication. Median follow-up 7.7 years.
Interventions and follow up
Arm A: Trimodality therapy (TURBT + concurrent cisplatin-based CRT) — bladder preservation with cystectomy reserved for incomplete response or recurrence
Arm B: N/A (single-arm retrospective series)
Primary endpoint: Overall survival, bladder-intact survival, and disease-specific survival
mFollow up: 7.7 year
Arm B: N/A (single-arm retrospective series)
Primary endpoint: Overall survival, bladder-intact survival, and disease-specific survival
mFollow up: 7.7 year
Results
5-yr OS: 57%
10-yr OS: 36%
5-yr disease-specific survival: 69%
5-yr intact bladder survival: 47%
Complete response rate to CRT: ~75%
Radical cystectomy rate: 29% (17% for incomplete response; 12% for new tumor)
10-yr OS: 36%
5-yr disease-specific survival: 69%
5-yr intact bladder survival: 47%
Complete response rate to CRT: ~75%
Radical cystectomy rate: 29% (17% for incomplete response; 12% for new tumor)
Adverse events
Main adverse events: Late grade ≥3 GU toxicity: 8.4%. Late grade ≥3 GI toxicity: 3.4%. No treatment-related deaths. Patient quality of life with preserved bladder reported as satisfactory.
Conclusions
Long-term outcomes with TMT at MGH demonstrate 5-year OS comparable to radical cystectomy series, with approximately half of patients retaining their native bladder at 5 years. Complete response to induction CRT is the strongest predictor of intact bladder survival, supporting a response-adapted approach.
Key Limitations
Key Limitations: Retrospective single-institution series with inherent selection bias — patients received TMT based on clinical suitability (good performance status, solitary tumor, absence of hydronephrosis). No direct randomized comparison with radical cystectomy. T-stage migration over time makes historical comparisons difficult. Cisplatin-based regimens are not universally tolerated.
Clinical Context
This landmark series established that carefully selected patients with MIBC can achieve long-term bladder preservation with survival comparable to cystectomy. Selection criteria emphasized in this paper (solitary tumor, complete TURBT, no hydronephrosis, good performance status) form the basis for current TMT patient selection guidelines in NCCN and AUA/ASTRO/ASCO joint guidelines.
References