in 2014 , it is estimated that there are 608,620 bladder cancer survivors living in the united states , and an additional 74,690 cases will be diagnosed .
neoadjuvant chemotherapy ( nc ) followed by radical cystectomy ( rc ) is now considered the standard of care for muscle - invasive bladder cancer after numerous trials demonstrated a survival benefit , most notably in patients with advanced pathologic stage disease [ 24 ] . for highly selected patients , bladder - sparing surgery such as transurethral resection of bladder tumor ( turbt ) [ 5 , 6 ] or partial cystectomy ( pc ) [ 710 ] may provide similar oncologic outcomes to rc while maintaining bladder and sexual functions .
of the two bladder - sparing options , pc has advantages over turbt as a third of patients are understaged with turbt   and pc allows for full thickness examination of the bladder wall and concurrent lymphadenectomy resulting in more accurate staging and prognosis .
our institution previously reported on 111 patients who received neoadjuvant methotrexate - vinblastine - doxorubicin - cisplatinum ( m - vac ) chemotherapy followed by turbt .
of the 60 patients achieving ct0 , 15 subsequently underwent pc and 17 underwent rc .
ten - year metastasis - free survival for the 15 patients who underwent pc was 73% with 53% of patients having their bladders intact , compared to the 65% 10-year metastasis - free survival for patients undergoing rc . similarly in a prospective trial conducted by sternberg et al .
, 104 patients with muscle - invasive bladder cancer underwent turbt after 3 cycles of m - vac chemotherapy and 49% of the cohort achieved ct0 after nc .
of these 104 patients , 13 patients with a solitary lesion underwent pc , while 39 patients underwent rc . for patients undergoing
pc , 5-year survival was 69% with 4 patients alive after a median follow - up of 88 months ( range 16158 ) compared to 5-year survival of 46% with 15 patients alive after a median follow - up of 45 months ( range 4172 ) for patients undergoing rc .
we herein report our contemporary experience with a highly select cohort of patients who received neoadjuvant chemotherapy followed by pc performed for curative intent at a single tertiary institution .
in this institutional review board - approved retrospective study , we identified patients who underwent pc at memorial sloan kettering cancer center from 1995 to 2013 ( n = 331 ) .
only patients who underwent nc for urothelial cell carcinoma of the bladder followed by pc with curative intent were included in our study ( n = 36 ) .
these were not consecutive cases and all patients underwent restaging turbt at our institution prior to and after nc with cystoscopic mapping of bladder tumor / scar .
all patients were followed up postoperatively with imaging and cystoscopy every 3 months for 2 years with widening of surveillance interval after .
we recorded data for clinical and pathologic variables including age , gender , race , tumor size and focality , histology , presence of carcinoma in situ ( cis ) , cross - sectional imaging , type and duration of nc , clinical and pathologic stages according to american joint committee on cancer 2010 tnm staging 7th edition , surgical margin ( sm ) , disease status , and cause of death .
survival outcomes included recurrence - free survival ( rfs ) which was defined as freedom from recurrence after pc , advanced recurrence - free survival ( arfs ) which was defined as freedom from recurrence after pc beyond salvage with intravesical therapy or rc , and overall survival ( os ) .
kaplan - meier survival estimates were generated with time measured from the date of pc to the date of event ( recurrence , advanced recurrence , and death ) or last follow - up .
using univariate cox regression for continuous and log - rank text for categorical variables , we analyzed variables for association with rfs , arfs , and os .
all probabilities were two - sided , and a p value < 0.05 was considered significant for all analyses .
all data were analyzed using stata version 12.0 ( statacorp , college station , tx , usa ) .
median age for the cohort was 70 years old ( interquartile range ( iqr ) 58.876.8 ) .
all tumors were solitary , less than 5  cm in diameter , and 22 ( 61% ) had a variant histology .
six tumors were located in the anterior wall , 19 in the lateral wall , 5 in the posterior wall , 3 in the base / trigone , and 3 in a diverticulum .
chemotherapy characteristics are described in table 1 ; most patients received platinum - based chemotherapy with 20 patients ( 56% ) having received gemcitabine and cisplatin combination .
unilateral ureteral reimplantation was performed in 7 patients at the time of pc to achieve sm in all cases .
margin status was evaluated by intraoperative frozen sections at pc in all patients . as shown in table 1 , prior to nc , 22 ( 61% ) patients had ct2 disease , 21 ( 58% )
all patients were clinically restaged after nc ( tables 1 and 2 ) with 21 ( 58% ) patients achieving ct0 , 3 ( 8% ) having ctis , and 4 ( 11% ) having cn+ .
of the 4 patients with cn+ after nc , 3 had cn+ before nc , and information prior to nc was unavailable for 1 patient .
as shown in tables 1 and 3 , pc pathologic findings were pt0 in 18 ( 50% ) patients , ptis in 6 ( 17% ) , pn+ in 4 ( 11% ) , and sm+ in 3 ( 8% ) .
the sm+ was perivesical in 1 patient with pt3 disease and ptis at margin in 2 patients with pt3 disease and pt2 disease .
all 3 patients with sm+ experienced recurrence and died of disease ( dod ) at 5 , 10 , and 43 months .
of the 21 patients who were ct0 after nc , 7 ( 33% ) had residual bladder disease in the pc specimen ( table 3 ) . at last follow - up , 19 ( 53% )
patients had recurrence , 15 ( 42% ) had advanced recurrences , 10 ( 28% ) died of disease , and 1 died of another cause .
twenty ( 56% ) patients were with no evidence of disease ( ned ) after median follow - up of 17 months ( iqr 9.438.2 ) , with 15 having had no recurrences .
two of these 4 patients underwent intravesical bacillus calmette - guerin ( bcg ) treatment at 8 and 23 months after pc and the other 2 patients underwent rc at 23 and 43 months after pc .
four were alive with disease ( awd ) : 2 patients having disease in the pelvis and 2 patients having disease in retroperitoneum .
of the 19 ( 53% ) patients who experienced recurrence ( table 4 ) 9 had recurrence in the bladder with 6 in the bladder only .
of the 9 patients with bladder cancer recurrences , 5 were at the resection site and 2 had sm+ at pc .
of the 6 patients with bladder - only recurrences , 2 patients had ctis , received bcg therapy , and have been ned to date ; 2 patients had ct2 and ct1/ctis tumors , underwent rc , and remained disease free ; 1 patient had ctis and received bcg but developed distant metastases ( lung and adrenal ) without further bladder recurrences 7 years after pc and eventually died of disease . another patient developed persistent ct1/ctis disease that was managed with repeating turbt and bcg before a failed attempt at rc and later died of disease .
as shown in table 5 , median time to recurrence was 23 months ( iqr 5.966.2 ) , median time to advanced recurrences was 66 months ( 7.2not reached ) , and median time to death was 79 months ( 20.6not reached ) .
kaplan - meier survival estimates for 2- and 5-year rfs , arfs , and os were 37% and 28% , 58% and 51% , and 71% and 63% , respectively ( figure 1 ) .
clinical stage > ct2 was associated with both worse rfs ( p = 0.03 ) and arfs ( p < 0.01 ) .
after nc , the presence of cis was associated with worse os ( p = 0.04 ) and cn+ was associated with worse rfs ( p < 0.01 ) , arfs ( p < 0.01 ) , and os ( p < 0.01 ) . following pc , presence of pt2 disease
was associated with worse rfs ( p = 0.02 ) and arfs ( p = 0.01 ) , pn+ was associated with worse rfs ( p = 0.04 ) , and sm+ on final pathology was associated with worse rfs ( p = 0.01 ) , arfs ( p = 0.04 ) , and os ( p < 0.01 ) .
our findings have been consistent with those of the literature with regard to oncologic outcomes in patients undergoing pc after nc . in our series ,
74% of patients were downstaged after nc with 58% having a complete clinical response . of the patients who achieved ct0 after nc , 7 ( 33% ) had evidence of residual disease within the resected specimen at pc , which is close to 30% of understaging with turbt alone reported by our institution 's herr and scher study .
two- and 5-year overall survival were 71% and 63% , respectively , which were comparable to oncologic outcomes of other studies involving pc after nc [ 5 , 11 , 12 ] and rc . in our study , at
last follow - up 19 patients ( 53% ) had experienced recurrence and 24 ( 67% ) were alive with 22 patients ( 61% ) having retained an intact bladder .
nine patients had recurrence in the bladder with 5 at the suture line . in rc series by stein et al .
, local pelvic recurrence only occurred in 6%13% of cases depending on radical cystectomy pathology and in our series 5 ( 14% ) patients had recurrence in the pelvis with only 2 having isolated pelvic recurrences .
both of these patients with pelvic - only recurrences had negative surgical margins at pc with only 1 patient having recurrence on the ipsilateral side of the previous tumor .
for our study , advanced recurrence was defined as presence of disease that can not be treated with salvage intravesical therapy or rc , which differs from previous reports of disease recurring in the bladder muscle and beyond [ 7 , 8 ] .
we believe that , with the improved quality of surveillance cross - sectional imaging and follow - up cystoscopies , disease control can still be achieved despite recurrences .
this was evident in the 6 patients with isolated bladder recurrence as only 1 patient experienced disease progression and died of disease .
we also noted that 53% of patients who experienced recurrence had no disease in bladder and hence it is unclear whether a rc would have altered their disease course . in our previous report by holzbeierlein et al . , the authors noted that presence of cis preoperatively
was associated with local recurrence and sm+ and pn+ were associated with advanced recurrence , as defined by muscle invasion and beyond .
though this series differs for lack of association of cis with recurrence , we noted similar findings with sm+ and pn+ .
all 3 patients with sm+ on final pathology experienced recurrence and died of diseasewith sm+ being associated with worse rfs , arfs , and os on univariable analysis . similarly , 4 patients had cn+ after nc with 2 eventually having pn+ at pc .
of those 2 patients with pn+ , one was awd at 7.3 months of follow - up and the other died of disease at 16.8 months of follow - up .
cn+ after nc was associated with worse rfs , arfs , and os on univariable analysis . unlike in kassouf
anderson cancer center series , the need for ureteral reimplantation is not an exclusion criterion for pc at our institution . in this series
, we performed 7 unilateral ureteral cases of reimplantation and we were able to achieve sm in 4 patients and the rest had pt0 disease . in terms of the concerning voiding dysfunction after pc ,
none of the patients in this series underwent any additional procedures for diminished bladder capacity .
our study is limited by its small size , retrospective nature , surgical selection bias , and relatively short follow - up .
additionally , patients did not receive a uniform nc regimen ; 4 ( 11% ) patients had evidence of clinical nodal involvement after nc , and 22 patients ( 61% ) had a variant histology including some with recognized aggressive nature such as small cell ( 25% ) and micropapillary ( 14% ) .
also though none of our patients underwent any additional procedures for voiding dysfunction , we do not have long - term quality of life or medication usage data .
in this contemporary institutional series , pc after nc in highly selected patients with muscle - invasive bladder cancer provides acceptable oncologic outcomes comparable to those in previously published reports .
 
 objective . to report our contemporary experience with partial cystectomy after neoadjuvant chemotherapy . 
 patients and methods . retrospective review of patients who underwent neoadjuvant chemotherapy and partial cystectomy for urothelial cell carcinoma of the bladder at memorial sloan kettering cancer center from 1995 to 2013 . 
 log - rank test and cox regression models were used to analyze variables possibly associated with recurrence - free , advanced recurrence - free ( free from recurrence beyond salvage with intravesical therapy or radical cystectomy ) , and overall survival . 
 results . 
 all 36 patients had a solitary tumor < 5  cm in size . 
 twenty - one patients ( 58% ) achieved ct0 following neoadjuvant chemotherapy with 7 ( 33% ) having residual disease at pc . at last follow - up , 19 ( 53% ) patients had recurrence , 15 ( 42% ) had advanced recurrence , 10 ( 28% ) died of disease , and 22 ( 61% ) maintained an intact bladder . 
 median follow - up of those who were with no evidence of disease was 17 months . 
 on univariable analysis , after neoadjuvant chemotherapy positive nodes on imaging and positive surgical margin at partial cystectomy were both associated with worse recurrence - free , advanced recurrence - free , and overall survival . 
 five - year recurrence - free , advanced recurrence - free , and overall survival were 28% , 51% , and 63% , respectively . 
 conclusion . 
 partial cystectomy following neoadjuvant chemotherapy provides acceptable oncologic outcomes in highly selected patients with muscle - invasive bladder cancer . 