[Neoadjuvant chemotherapy MVAC in the treatment of infiltrating bladder carcinoma]. / Quimioterapia neoadyuvante MVAC en el tratamiento del carcinoma vesical infiltrante.

INTRODUCTION: Aiming to preserve the bladder in patients with infiltrative carcinoma of the bladder and to offer patients improved quality of life with no detriment for survival, a therapeutical protocol was set up. MATERIAL AND METHODS: Between August 1988 and January 1997 63 patients with stage T2 and T3a infiltrative carcinoma of the bladder, with no metastasis or node extension detectable with imaging techniques were treated in our unit. 45 of these patients met all protocol criteria and were given 3 neoadjuvant chemotherapy courses with MVAC (methotrexate, vincristine, adriamycin, cisplatin). INCLUSION CRITERIA: age under 75 years, Karnofsky greater than 50%, leucocytes greater than 2,500 cell/mL and platelet greater than 100,000/mL. Following chemotherapy, re-assessment was performed through lab tests, chest X-rays, abdomino-pelvic CT, bone scanning, cystoscopy, multiple randomized biopsies, tumoral bed scar resection and resection of relapsed urothelioma. Patients with complete remission were given radiotherapy. Those showing stabilisation of progression were proposed to undergo cystectomy. Fisher's test or chi 2 test were used for the comparison of qualitative variables. The survival analysis was performed using the Kaplan-Meier method. The curves comparison was done with Breslow's exact test. A Cox's proportional risk method allowed to calculate the relative risks together with their 95% confidence interval. RESULTS: 53.7% patients included in this protocol showed complete remission, 41.5% stable disease and 4.9% progression. 62.2% of patients were given radiotherapy versus 17.8% who underwent cystectomy. 20% received other therapies after rejecting both cystectomy or radiotherapy. Median follow-up was 43.38 months. Overall median survival was 96 months. The accumulate probability of survival at 4 years was 79%. 50% patients with complete clinical response relapsed during follow-up. Tumoral stage of those who relapsed was lower than the initial one in 63.7% cases, remained the same in 18.2%, and higher in 18.2%. With regards to grading, 66.7% patients had lower grading at relapse if tumour was initially grade 2. For those with initial tumour grade 3, only 20% had a lower grade. CONCLUSION: 64.4% patients retained their bladder. In 26.7% there was demonstrable metastatic disease. No differences were seen in the distribution or survival time based on the different treatment given after chemotherapy (p = 0.22). Patients with complete remission after chemotherapy have greater actuarial survival which is statistically significant (p = 0.04).