What is the typical management for a fit patient with T3N0 (T3, no lymph node involvement) urinary bladder cancer?

Management of T3N0 Urinary Bladder Cancer in Fit Patients

Radical cystectomy with bilateral pelvic lymphadenectomy preceded by neoadjuvant cisplatin-based combination chemotherapy is the standard of care for fit patients with T3N0 bladder cancer, providing the best survival outcomes. 1, 2

Primary Treatment Algorithm

Step 1: Neoadjuvant Chemotherapy (Category 1 Recommendation)

• Administer 2-3 cycles of cisplatin-based combination chemotherapy before surgery 1
• Preferred regimens include:
  • Gemcitabine and cisplatin (GC) 1
  • Dose-dense MVAC (methotrexate, vinblastine, doxorubicin, cisplatin) with G-CSF support 1
• The survival benefit is particularly strong for T3 disease, with randomized trials demonstrating improved outcomes specifically in patients with palpable masses or unequivocal masses on CT 1
• Neoadjuvant chemotherapy shows no apparent increase in postoperative morbidity or mortality 1

Step 2: Radical Cystectomy with Extended Lymphadenectomy

• Perform cystoprostatectomy in men or cystectomy with hysterectomy in women 1
• Extended pelvic lymph node dissection must include:
  • Common iliac nodes
  • Internal and external iliac nodes
  • Obturator nodes
  • Consider para-aortic or paracaval nodes 1
• More extensive lymphadenectomy yields better survival and lower pelvic recurrence rates 1
• Create urinary diversion via ileal conduit or continent reservoir 1

Step 3: Adjuvant Therapy Consideration

• If neoadjuvant chemotherapy was NOT given, consider adjuvant chemotherapy based on pathologic findings 1
• Indications for adjuvant treatment:
  • Pathologic T3 or T4 disease
  • Positive lymph nodes
  • Vascular invasion 1
• Adjuvant radiotherapy with or without chemotherapy is another option for high-risk pathologic features 1

Bladder Preservation Alternative (Highly Selected Cases Only)

Bladder preservation with maximal TURBT followed by concurrent chemoradiotherapy is an alternative, but patient selection is absolutely critical. 1, 2

Strict Selection Criteria (ALL Must Be Met)

• T3a disease only (T3b has poor outcomes) 1, 2
• Tumor <5 cm in size 1, 2
• Solitary lesion 1
• No carcinoma in situ elsewhere in bladder 1, 2
• No hydronephrosis (absolute contraindication) 1, 2
• Visibly complete or maximal TURBT achievable 1, 2
• Good performance status 1
• Adequate bladder capacity and function 1

Bladder Preservation Protocol

1. Maximal TURBT - achieve most complete endoscopic resection possible 2
2. Concurrent chemoradiotherapy:
   • Deliver 40-50 Gy induction radiation 1, 2
   • Concurrent cisplatin (days 1 and 21) OR 5-fluorouracil with mitomycin C 1, 2
3. Mandatory restaging at 40-50 Gy:
   • Cystoscopy with tumor site rebiopsy
   • Cytology
   • Imaging of abdomen/pelvis 1
4. If complete response: consolidation radiation up to 64-66 Gy total 1, 2
5. If incomplete response: immediate radical cystectomy 1, 3

Expected Outcomes with Bladder Preservation

• Complete response rate: 65-80% 3
• 5-year overall survival: 50% 1, 3
• Bladder-intact survival at 5 years: 40-45% 3
• 75-85% of complete responders remain free of invasive recurrence 3

Follow-Up Protocol

After Radical Cystectomy

• First 2 years:
  • Urine cytology, liver function tests, creatinine, electrolytes every 3-6 months 1, 2
  • CT chest/abdomen/pelvis every 3-12 months based on recurrence risk 2
• After 2 years: annual imaging as clinically indicated 1

After Bladder Preservation

• Intensive monitoring mandatory:
  • Cystoscopy with cytology every 3 months for 2 years, then every 6 months 2
  • Upper tract imaging every 1-2 years for high-grade tumors 2
  • Any invasive recurrence requires immediate cystectomy 1

Critical Pitfalls to Avoid

• Never attempt bladder preservation in patients with hydronephrosis - this is an absolute contraindication 1, 2
• Do not delay cystectomy beyond 3 months from diagnosis - delays negatively impact outcomes 4
• Never give adjuvant chemotherapy if neoadjuvant chemotherapy was already administered 2
• Avoid bladder preservation in T3b disease - deeply invasive lesions (T3b-T4) are usually not candidates for bladder preservation 5
• Do not perform inadequate lymphadenectomy - extended dissection is associated with better survival 1
• Partial cystectomy is NOT an option for T3 disease - only appropriate for <5% of cases with dome lesions and no CIS 1

Special Considerations for Cisplatin-Ineligible Patients

For patients with extensive comorbid disease or poor performance status who cannot tolerate standard treatment 1:

• TURBT alone
• Radiotherapy with chemotherapy
• Chemotherapy alone
• Consider carboplatin-based regimens instead of cisplatin 1