Less Is More: Evaluation of Gross Examination Protocol for Cystectomy Specimens Following Neoadjuvant Chemotherapy

Neoadjuvant chemotherapy (NAC) confers a survival advantage for muscle-invasive bladder cancer and is now recommended for chemotherapy-eligible patients. NAC may result in absent gross tumor, and current cystectomy gross examination protocols do not specify approach for these cases.

We included cystectomies performed from 2010 to 2018, capturing a period pre- and post-NAC recommendations. Gross descriptions were reviewed and slides of patients who received NAC were evaluated for microscopic tumor, number of blocks with tumor, and location of those blocks.

We identified 239 radical cystectomies for bladder cancer (147 NAC, 92 non-NAC). Gross lesions were not identified for 91 cases. NAC cases had more total blocks submitted (mean, 17.5) compared with non-NAC cases (mean, 16.6). More NAC cases had additional blocks submitted (20 cases) compared with non-NAC cases (2), which were more frequently additional random sections. Of 108 NAC cases with residual carcinoma, only 2 (1.9%) were upstaged on additional random sections.

At our institution, NAC and non-NAC cases are grossed with similar numbers of initial blocks; however, NAC cases are more likely to submit additional sections of gross lesions and random bladder without significant changes in stage. Our data suggest current gross examination protocols are sufficient for NAC cystectomies.