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Koller CR, Greenberg JW, Natale C, Krane LS. Assessing the safety of bladder-preserving therapy as an alternative to surgical intervention in elderly patients with muscle invasive bladder cancer. Urologia 2024; 91:701-708. [PMID: 39058262 DOI: 10.1177/03915603241265828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
Abstract
BACKGROUND There is interest in using bladder-preserving therapy as an alternative definitive therapy for muscle invasive bladder cancer in certain high-risk groups such as the elderly. OBJECTIVE To determine if bladder-preserving therapy represents a safer alternative to surgical intervention in elderly patients with muscle invasive bladder cancer. METHODS We surveyed the Surveillance, Epidemiology and End Results database (SEER) for cases of non-metastasized malignant bladder cancer in patients aged 80+. Survival outcomes with radical cystectomy (RC) with or without chemotherapy were compared to those after chemotherapy and radiation without cystectomy. We performed log-rank tests and Kaplan-Meier and cox regression and hazard analyses before and after propensity score matching. RESULTS A total of 2995 patients were identified, with 49.98% treated with RC only, 8.65% treated with RC/chemotherapy, and 41.37% treated with chemotherapy and radiation without RC. Median overall survival for the RC only, RC/chemotherapy and chemotherapy/radiation groups were 31.4, 44.1, and 24.6 months, respectively. On multivariate analysis, hazard ratios (reference: RC/chemotherapy group) were RC Only (HR = 1.408 (95% CI 1.188-1.669), p < 0.0001) and chemotherapy/radiation (HR = 1.650 (95% CI 1.390-1.959), p < 0.0001). After matching the chemotherapy/radiation and RC/chemotherapy groups, the former continued to show survival hazard (HR = 1.744 (95% CI 1.414-2.155), p < 0.0001). CONCLUSIONS Octogenarians should be offered definitive local therapy for their localized bladder cancer including RC and chemotherapy. Bladder-sparing alternatives should be reserved for patients unfit for surgery.
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Affiliation(s)
- Christopher R Koller
- Tulane University School of Medicine, Department of Urology, New Orleans, LA, USA
| | - Jacob W Greenberg
- Tulane University School of Medicine, Department of Urology, New Orleans, LA, USA
| | - Caleb Natale
- Tulane University School of Medicine, Department of Urology, New Orleans, LA, USA
| | - L Spencer Krane
- Southeast Louisiana Veterans Health Care System, Department of Surgery, New Orleans, LA, USA
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Tholomier C, Souhami L, Kassouf W. Bladder-sparing protocols in the treatment of muscle-invasive bladder cancer. Transl Androl Urol 2020; 9:2920-2937. [PMID: 33457265 PMCID: PMC7807363 DOI: 10.21037/tau.2020.02.10] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 11/29/2019] [Indexed: 01/06/2023] Open
Abstract
Bladder-sparing protocols (BSP) have been gaining widespread popularity as an attractive alternative to radical cystectomy (RC) for muscle-invasive bladder cancer. Unimodal therapies are inferior to multimodal regimens. The most promising regimen is trimodal therapy (TMT), which is a combination of maximal transurethral resection of bladder tumor (TURBT), radiotherapy, and chemotherapy. In appropriately selected patients (low volume unifocal T2 disease, complete TURBT, no hydronephrosis and no carcinoma-in-situ), comparable oncological outcomes to RC have been reported in large retrospective studies, with a potential improvement in overall quality of life (QOL). TMT also offers the possibility for definitive therapy for patients who are not surgically fit to undergo RC. Routine biopsy of previous tumor resection is recommended to assess response. Prompt salvage RC is required in non-responders and for recurrent muscle-invasive disease, while non-muscle-invasive recurrence can be managed conservatively with TURBT +/- intravesical BCG. Long-term follow-up consisting of routine cystoscopy, urine cytology, and cross-section imaging is required. Further studies are warranted to better define the role of neoadjuvant or adjuvant chemotherapy in the setting of TMT. Finally, future research on predictive markers of response to TMT and on the integration of immunotherapy in bladder sparing protocols is ongoing and is highly promising.
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Affiliation(s)
- Côme Tholomier
- Department of Surgery, Division of Urology, McGill University, McGill University Health Centre, Montréal, Québec, Canada
| | - Luis Souhami
- Department of Radiation Oncology, McGill University, McGill University Health Centre, Montréal, Québec, Canada
| | - Wassim Kassouf
- Department of Surgery, Division of Urology, McGill University, McGill University Health Centre, Montréal, Québec, Canada
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Incidence and outcome of salvage cystectomy after bladder sparing therapy for muscle invasive bladder cancer: a systematic review and meta-analysis. World J Urol 2020; 39:1757-1768. [PMID: 32995918 PMCID: PMC8217031 DOI: 10.1007/s00345-020-03436-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 08/31/2020] [Indexed: 02/07/2023] Open
Abstract
Objective We conducted a systematic review and meta-analysis to assess the available literature regarding the surgical and oncologic outcomes of patients undergoing salvage radical cystectomy (SV-RC) for recurrence or failure of bladder sparing therapy (BST) for muscle-invasive bladder cancer (MIBC). Methods We searched MEDLINE (PubMed), EMBASE and Google Scholar databases in May 2020. We included all studies of patients with ≥ cT2N0/xM0 bladder cancer that were eligible for all treatment modalities at the time of treatment decision who underwent BST including radiotherapy (RTX). A meta-analysis was conducted to calculate the pooled rate of several variables associated with an increased need for SV-RC. Study quality and risk of bias were assessed using MINORS criteria. Results 73 studies comprising 9110 patients were eligible for the meta-analysis. Weighted mean follow-up time was 61.1 months (range 12–144). The pooled rate of non-response to BST and local recurrence after BST, the two primary reasons for SV-RC, was 15.5% and 28.7%, respectively. The pooled rate of SV-RC was 19.2% for studies with a follow-up longer than 5 years. Only three studies provided a thorough report of complication rates after SV-RC. The overall complication rate ranged between 67 and 72% with a 30-day mortality rate of 0–8.8%. The pooled rates of 5 and 10-year disease-free survival after SV-RC were 54.3% and 45.6%, respectively. Conclusion Approximately one-fifth of patients treated with BST with a curative intent eventually require SV-RC. This procedure carries a proportionally high rate of complications and is usually accompanied by an incontinent urinary diversion. Electronic supplementary material The online version of this article (10.1007/s00345-020-03436-0) contains supplementary material, which is available to authorized users.
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Lian F, Chen W, Liu Y, Shen L, Fan W, Cui W, Zhao Y, Li J, Wang Y. Intra-arterial chemotherapy combined with intravesical chemotherapy is effective in preventing recurrence in non-muscle invasive bladder cancer. J Cancer Res Clin Oncol 2019; 145:1625-1633. [DOI: 10.1007/s00432-019-02900-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 03/18/2019] [Indexed: 11/24/2022]
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Whole Versus Partial Bladder Radiation: Use of an Image-guided Hypofractionated IMRT Bladder-preservation Protocol. Am J Clin Oncol 2019; 41:107-114. [PMID: 26535994 DOI: 10.1097/coc.0000000000000237] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To report our institutional experience using definitive chemoradiation via whole bladder (WB) and partial bladder (PB) treatment in muscle-invasive bladder cancer. Combining intensity-modulated radiation therapy with image-guidance can improve the therapeutic ratio. MATERIALS AND METHODS Retrospective analysis of 26 patients with clinical stage T2-4 N0-2 M0 urothelial cancer treated in 2009 to 2012; 16 received WB radiation and 10 received PB radiation. PB/tumor boost volume included visibly thickened bladder wall or tumor localized on cystoscopy. WB radiation delivered 45 to 50.4 Gy to bladder/lymph nodes, then sequential 19.8 to 21.6 Gy tumor boost (1.8 Gy/fx). PB radiation was 45 to 50 Gy to lymph nodes (1.8 to 2 Gy/fx) and simultaneous integrated boost to 55 to 62.5 Gy to tumor only (2.2 to 2.5 Gy/fx). The primary endpoint was local control, defined as no muscle-invasive recurrence. Secondary endpoints were overall survival, toxicity, and cost. RESULTS Mean age was 77 and median follow-up was 20 months. Freedom from local recurrence was 86% at 2 years (PB 100%, WB 77%). Overall survival was 80% at 1 year (PB 88%, WB 75%), and 55% at 2 years (PB 70%, WB 48%, P=0.38). Failure was predominantly distant. Toxicities were minimal (3 late grade 3 ureteral, 1 acute grade 4 renal), and all resolved. No cystectomies were performed for toxicity. Hypofractionation reduces treatment time and costs by one third. CONCLUSIONS Image-guided hypofractionated PB radiation provides local control with similar survival to WB therapy, with minimal toxicity. Hypofractionation also offers time and cost advantages. Our results need to be validated in a larger, multi-institutional cohort.
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Neoadjuvant Chemotherapy Before Bladder-Sparing Chemoradiotherapy in Patients With Nonmetastatic Muscle-Invasive Bladder Cancer. Clin Genitourin Cancer 2018; 17:38-45. [PMID: 30686350 DOI: 10.1016/j.clgc.2018.09.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 09/25/2018] [Accepted: 09/27/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Cisplatin-based neoadjuvant chemotherapy (NAC) before cystectomy improves survival in muscle-invasive urothelial bladder cancer (MIBC). The use of NAC before chemoradiation (CRT) has been limited, as these patients are often elderly, frail, and ineligible for cisplatin. However, the role of NAC in fit, cisplatin-eligible patients who opt for bladder preservation warrants further evaluation. PATIENTS AND METHODS Patients with MIBC treated with NAC followed by CRT at the Princess Margaret and Durham Regional cancer centers from 2008 to 2017 were retrospectively reviewed. Gemcitabine-cisplatin NAC was given for 2 to 4 cycles, followed by reassessment for CRT. External-beam radiotherapy (60-66 Gy) over 6 weeks was given with concurrent weekly cisplatin at 40 mg/m2. Kaplan-Meier method was used for survival analyses. RESULTS We identified 57 consecutive patients. Median age was 72 (range 45-87), and all had an Eastern Cooperative Oncology Group performance status of 0 (60%) or 1 (40%). Stage II disease (65%), stage III disease (25%), and regional nodal metastases (11%) were included. Most completed planned NAC (95%). All patients completed external-beam radiotherapy, and 84% completed at least 60% of the planned concurrent weekly cisplatin doses. Median (range) follow-up was 19.3 (4.8-96.1) months. Median overall survival (OS) was not reached. Two-year OS and disease-specific survival rates were 74% (95% confidence interval, 57.7-84.9) and 88% (95% confidence interval, 78.5-98.1), respectively. Two-year bladder-intact disease-free survival was 64%. Salvage cystectomy was performed in 14%. Distant relapse occurred in 11%, and 9% died of metastatic disease. OS was associated with baseline hydronephrosis and with bladder-intact disease-free survival with residual disease on cystoscopy. CONCLUSION NAC followed by CRT can result in encouraging outcomes and tolerability in cisplatin-eligible patients.
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Tselis N, Prott FJ, Ott O, Weiss C, Rödel C. [Radiochemotherapy for invasive bladder cancer : An update]. Urologe A 2018; 57:679-685. [PMID: 29651707 DOI: 10.1007/s00120-018-0628-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The standard treatment for muscle-invasive bladder cancer is radical cystectomy with pelvic lymphadenectomy. Primary organ-preservation by means of multimodal therapy, however, can be a viable alternative to radical surgery. OBJECTIVES The concept and results of multimodal therapy, consisting of initial transurethral resection of the bladder tumor (TUR-B), followed by simultaneous radiochemotherapy (RCT), are presented. MATERIALS AND METHODS Evaluation of retrospective cohorts and prospective therapy optimization studies on organ-preservation treatment regimens. Comparative meta-analyses comparing cystectomy with multimodal treatment are presented. RESULTS Complete TUR-B, including bladder mapping and tumor biopsy, should precede simultaneous RCT. Radiosensitization should be cisplatin-based or consist of a combination of 5‑fluorouracil and mitomycin C. Complete response rates after TUR-B plus RCT are generated in 60-90% of patients along with 5‑year survival rates of 40-75% and preservation of the bladder in approximately 80% of surviving patients. CONCLUSIONS Multimodal therapy by means of TUR-B followed by simultaneous RCT is a viable alternative to radical cystectomy for patients with muscle-invasive urinary bladder carcinoma. Patients with early tumors (cT2/3N0) are particularly suitable in whom initial TUR-B leads to complete tumor resection (R0).
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Affiliation(s)
- N Tselis
- Klinik für Strahlentherapie und Onkologie, Universitätsklinikum Frankfurt, Goethe Universität Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Deutschland.
| | | | - O Ott
- Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - C Weiss
- Klinikum Darmstadt, Darmstadt, Deutschland
| | - C Rödel
- Universitätsklinikum Frankfurt, Frankfurt, Deutschland
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Ha YS, Kim TH. The Surveillance for Muscle-Invasive Bladder Cancer (MIBC). Bladder Cancer 2018. [DOI: 10.1016/b978-0-12-809939-1.00030-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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9
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Rödel C, Tselis N. Radiation Therapy in Bladder Cancer. Radiat Oncol 2018. [DOI: 10.1007/978-3-319-52619-5_39-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Inamoto T, Ibuki N, Komura K, Juri H, Yamamoto K, Yamamoto K, Fujita K, Nonomura N, Narumi Y, Azuma H. Can bladder preservation therapy come to the center stage? Int J Urol 2017; 25:134-140. [PMID: 29171098 DOI: 10.1111/iju.13495] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 10/23/2017] [Indexed: 12/17/2022]
Abstract
Decision-making in urological cancer care requires a multidisciplinary approach for refinement, but its impact on urothelial carcinoma of the bladder has not been fully addressed for the past three decades, except for the latest immunological checkpoint inhibitor approved by the U.S. Food and Drug Administration for metastatic muscle-invasive bladder cancer that is resistant to platinum-based chemotherapy. For the time being, radical cystectomy is the gold standard of curative therapy for muscle-invasive bladder cancer. Trimodal therapy that combines chemotherapy for the purpose of radiation sensitization, external beam radiotherapy and transurethral resection of bladder tumor has emerged as a potential alternative treatment option that preserves the bladder. In lack of randomized studies for bladder preservation therapy compared with surgery, the principles of management of urothelial carcinoma of the bladder have evolved in recent times, with an emphasis on bladder preservation. A number of bladder preservation techniques are available to the surgeon; however, appropriately selected patients with muscle-invasive bladder cancer should be offered the opportunity to discuss various treatment options, including organ-sparing trimodal therapy. The aim of the present study was to compare the primary outcomes of the available treatment methods and identify the sources of variance among studies. A review of various bladder preservation techniques in vogue for the management of urothelial carcinoma of the bladder is discussed.
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Affiliation(s)
- Teruo Inamoto
- Department of Urology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Naokazu Ibuki
- Department of Urology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Kazumasa Komura
- Department of Urology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Hiroshi Juri
- Department of Radiology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Kiyohito Yamamoto
- Department of Radiology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Kazuhiro Yamamoto
- Department of Radiology, Osaka Medical College, Takatsuki, Osaka, Japan
| | | | - Norio Nonomura
- Department of Urology, Osaka University, Suita, Osaka, Japan
| | - Yoshifumi Narumi
- Department of Radiology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Haruhito Azuma
- Department of Urology, Osaka Medical College, Takatsuki, Osaka, Japan
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Fahmy O, Khairul-Asri MG, Schubert T, Renninger M, Malek R, Kübler H, Stenzl A, Gakis G. A systematic review and meta-analysis on the oncological long-term outcomes after trimodality therapy and radical cystectomy with or without neoadjuvant chemotherapy for muscle-invasive bladder cancer. Urol Oncol 2017; 36:43-53. [PMID: 29102254 DOI: 10.1016/j.urolonc.2017.10.002] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 09/19/2017] [Accepted: 10/02/2017] [Indexed: 01/02/2023]
Abstract
OBJECTIVE This study aimed to comprehensively analyze the oncological long-term outcomes of trimodal therapy (TMT) and radical cystectomy (RC) for the treatment of muscle-invasive bladder cancer (BC) with or without neoadjuvant chemotherapy (NAC). PATIENTS AND METHODS A systematic search was conducted according to the PRISMA guidelines for studies reporting on outcomes after TMT and RC. A total of 57 studies including 30,293 patients were included. The 10-year overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) rates for TMT and RC were assessed. RESULTS The mean 10-year OS was 30.9% for TMT and 35.1% for RC (P = 0.32). The mean 10-year DSS was 50.9% for TMT and 57.8% for RC (P = 0.26). NAC was administered before therapy to 453 (13.3%) of 3,402 patients treated with TMT and 812 (3.0%) of 27,867 patients treated with RC (P<0.001). Complete response (CR) was achieved in 1,545 (75.3%) of 2,051 evaluable patients treated with TMT. A 5-year OS, DSS, and RFS after CR were 66.9%, 78.3%, and 52.5%, respectively. Downstaging after transurethral bladder tumor resection or NAC to stage ≤pT1 at RC was reported in 2,416 (29.1%) of 8,311 patients. NAC significantly increased the rate of pT0 from 20.2% to 34.3% (P = 0.007) in cT2 and from 3.8% to 23.9% (P<0.001) in cT3-4. A 5-year OS, DSS, and RFS in downstaged patients (≤pT1) at RC were 75.7%, 88.3%, and 75.8%, respectively. CONCLUSION In this analysis, the survival outcomes of patients after TMT and RC for MIBC were comparable. Patients who experienced downstaging after NAC and RC exhibited improved survival compared to patients treated with RC only. Best survival outcomes after TMT are associated with CR to this approach.
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Affiliation(s)
- Omar Fahmy
- Department of Urology, Universiti Putra Malaysia (UPM), Selangor, Malaysia.
| | | | - Tina Schubert
- Department of Urology, University Hospital Würzburg, Würzburg, Germany
| | - Markus Renninger
- Department of Urology, Eberhard-Karls University, Tübingen, Germany
| | - Rohan Malek
- Department of Urology, Hospital Selayang, Selangor, Malaysia
| | - Hubert Kübler
- Department of Urology, University Hospital Würzburg, Würzburg, Germany
| | - Arnulf Stenzl
- Department of Urology, Eberhard-Karls University, Tübingen, Germany
| | - Georgios Gakis
- Department of Urology, University Hospital Würzburg, Würzburg, Germany
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A prospective comparison of intra-arterial chemotherapy combined with intravesical chemotherapy and intravesical chemotherapy alone after transurethral resection with a thulium laser in high-risk non-muscle invasive bladder cancer. Cancer Chemother Pharmacol 2017; 79:1099-1107. [PMID: 28421294 DOI: 10.1007/s00280-017-3305-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 04/11/2017] [Indexed: 01/03/2023]
Abstract
Objective To compare intra-arterial chemotherapy combined with intravesical chemotherapy with intravesical chemotherapy alone in the treatment of high-risk non-muscle invasive bladder cancer (HRBC) after thulium laser resection of a bladder tumor (TmLRBT). MATERIALS AND METHODS From January 2009 to December 2013, 283 patients with HRBC were randomly assigned to the combined group (group A, n = 141) or intravesical chemotherapy-alone group (group B, n = 142) after TmLRBT. Intra-arterial chemotherapy was administered after initial TmLRBT, with 3 courses at 4-week intervals. Each course consisted of cisplatin (50 mg/m2) and epirubicin (30 mg/m2). Intravesical chemotherapy was administered in both groups, including an immediate 50 mg of epirubicin instillation after TmLRBT and weekly maintenance for 8 weeks, followed by monthly maintenance for 1 year. RESULTS The recurrence rate was 29.1% (41/141) in group A and 42.9% (61/142) in group B, with a significant difference (p = 0.01). The progression rate was 15.6% (22/141) in group A and 25.3% (36/142) in group B, with a significant difference (p = 0.039). Patients with concomitant carcinoma in situ (CIS) also had a lower recurrence rate and progression rate in group A compared to those in group B (p = 0.006 and p = 0.03, respectively). On univariate and multivariate logistic regression analyses, patients with low-grade histology had a higher reccurrence-free rate. Multivariate COX analysis of tumor-related factors suggested that concomitant CIS was the only significant prognostic factor associated with poorer recurrence-free survival and progression-free survival. CONCLUSIONS Intra-arterial chemotherapy combined with intravesical chemotherapy could reduce the risk of recurrence and progression compared to intravesical chemotherapy alone in HRBC.
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McPherson VA, Rodrigues G, Bauman G, Winquist E, Chin J, Izawa J, Potvin K, Ernst S, Venkatesan V, Sexton T, Ahmad B, Power N. Chemoradiotherapy in octogenarians as primary treatment for muscle-invasive bladder cancer. Can Urol Assoc J 2017; 11:24-30. [PMID: 28443140 DOI: 10.5489/cuaj.4008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION While radical cystectomy is the gold standard for muscle-invasive bladder cancer (MIBC), in octogenarians cystectomy results in a higher perioperative mortality rate (6.8-11.1%) than in younger patients (2.2%). Trimodality therapy is a bladder-sparing regimen composed of transurethral resection of bladder tumour (TURBT) and chemoradiotherapy, with intent for salvage cystectomy, and has a 62.5-90% initial complete response rate. In this study, we evaluate TURBT and chemoradiotherapy without salvage cystectomy in medically inoperable octogenarian patients. METHODS We identified a retrospective cohort of patients aged 80-89 years with invasive urothelial carcinoma who received combination chemoradiotherapy between 2008 and June 2014. Outcomes were evaluated by Kaplan-Meier (KM) and Cox regression. RESULTS In 40 patients, the mean age was 84.5 years (interquartile range [IQR] 83-86). Seventeen patients received hypofractionated, low-dose radiotherapy (LD) (37.5-40 Gy), while 23 received conventionally fractionated radiotherapy (high-dose [HD]) (50-65 Gy). Mean overall survival (OS) was 20.7 months (IQR 12.75-23.25), while mean recurrence-free survival (RFS) was 13.75 months (IQR 3.75-16.5). Patients receiving HD radiotherapy showed improved OS and local RFS (LRFS) without significant differences in Grade 3-4 toxicities. Univariate Cox regression identified hydronephrosis as a predictor of worse OS and local recurrence and HD radiotherapy as a predictor of improved OS and local recurrence rates. Multivariate Cox regression identified hydronephrosis to be a significant predictor of LRFS. CONCLUSIONS Primary chemoradiotherapy for inoperable patients with MIBC resulted in a three-year OS of 54.9% (comparable to cystectomy) and three-year RFS of 42.3%. Superior outcomes were associated with more aggressive chemoradiotherapy treatment. The results of the local control subanalyses in this study are hypothesis-generating due to the limited patient numbers in the cohort.
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Affiliation(s)
| | | | | | - Eric Winquist
- Division of Medical Oncology; Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | | | | | - Kylea Potvin
- Division of Medical Oncology; Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Scott Ernst
- Division of Medical Oncology; Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
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Russell CM, Lebastchi AH, Borza T, Spratt DE, Morgan TM. The Role of Transurethral Resection in Trimodal Therapy for Muscle-Invasive Bladder Cancer. Bladder Cancer 2016; 2:381-394. [PMID: 28035319 PMCID: PMC5181666 DOI: 10.3233/blc-160076] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
While radical cystectomy (RC) with pelvic lymph node dissection (PLND) represents the accepted gold standard for the treatment of muscle-invasive bladder cancer, this treatment approach is associated with significant morbidity. As such, bladder preservation strategies are often utilized in patients who are either deemed medically unfit due to significant comorbidities or whom decline management with RC and PLND secondary to its associated morbidity. In a select group of patients, meeting strict criteria, bladder preservation approaches may be employed with curative intent. Trimodal therapy, consisting of complete transurethral resection of bladder tumor (TURBT), chemotherapy, and radiation therapy has demonstrated durable oncologic control and long-term survival in a number of studies. The review presented here provides a description of trimodal therapy and the role of TURBT in bladder preservation for patients with muscle-invasive bladder cancer.
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Affiliation(s)
| | - Amir H Lebastchi
- Department of Urology, University of Michigan , Ann Arbor, MI, USA
| | - Tudor Borza
- Department of Urology, University of Michigan , Ann Arbor, MI, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan , Ann Arbor, MI, USA
| | - Todd M Morgan
- Department of Urology, University of Michigan , Ann Arbor, MI, USA
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15
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Arcangeli G, Strigari L, Arcangeli S. Radical cystectomy versus organ-sparing trimodality treatment in muscle-invasive bladder cancer: A systematic review of clinical trials. Crit Rev Oncol Hematol 2015; 95:387-96. [PMID: 25934521 DOI: 10.1016/j.critrevonc.2015.04.006] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 03/23/2015] [Accepted: 04/07/2015] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Radical cystectomy (RC) represents the mainstay of treatment in patients with muscle-invasive urinary bladder cancer but how it compares with the best organ preservation approach is not known. MATERIALS AND METHODS The objective of our review is to compare the 5-year overall survival (OS) rates from retrospective and prospective studies of RC and trimodality treatment (TMT), i.e. concurrent delivery of chemotherapy and radiotherapy after a transurethral resection of bladder tumor (TURBT), involving a total of 10,265 and 3131 patients, respectively. We used random-effect models to pool outcomes across studies and compared event rates of combined outcomes for TMT and RC using an interaction test. RESULTS The median 5-year OS rate was 57% in the TMT group, when compared with 52% (P=0.04), 51% (P=0.02) and 53% (P=0.38) in the whole group receiving RC or the group treated with RC alone or RC+chemotherapy, respectively. The hazard risk (HR) of mortality of patients treated with TMT or RC was 1.22 (95% CI=1.13-1.32) with an absolute benefit of 5% in favor of the former. The HR of mortality from TMT persisted significantly better not only versus the group treated with RC alone (HR=1.22; 95% CI=1.12-1.32), but also versus the group receiving RC+chemotherapy (HR=1.22; 95% CI=1.09-1.36). Multivariate analysis confirmed TMT as a significant prognostic variable for both RC alone and RC+chemotherapy. CONCLUSION Compared with RC, TMT seems to be associated with a better outcome for patients with muscle-invasive bladder cancer (MIBC). The addition of chemotherapy may improve the RC outcome in some subgroups of patients with a higher probability of micrometastases. Prospective randomized trials are urged to verify these findings and better define the role of organ preservation and radical treatment strategy in the management of patients with MIBC.
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Affiliation(s)
- G Arcangeli
- Medical Physics and Expert Systems Laboratory, Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy
| | - L Strigari
- Medical Physics and Expert Systems Laboratory, Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy.
| | - S Arcangeli
- Radiotherapy Department, Azienda Ospedaliera S. Camillo-Forlanini , Rome, Italy
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Efficacy and safety of systemic chemotherapy and intra-arterial chemotherapy with/without radiotherapy for bladder preservation or as neo-adjuvant therapy in patients with muscle-invasive bladder cancer: A single-centre study of 163 patients. Eur J Surg Oncol 2015; 41:361-7. [DOI: 10.1016/j.ejso.2014.07.043] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 06/21/2014] [Accepted: 07/21/2014] [Indexed: 11/20/2022] Open
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Matsumoto Y, Samma S, Fukui S, Nakai Y, Kagebayashi Y, Torimoto K. External beam radiation plus concurrent intra-arterial chemotherapy with low dose cisplatin for muscle invasive bladder cancer. Indian J Urol 2015; 31:52-6. [PMID: 25624577 PMCID: PMC4300573 DOI: 10.4103/0970-1591.139563] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Introduction: We aimed to investigate the long-term outcome of trimodality therapy consisting of transurethral resection of bladder tumor, external beam radiation therapy, and concurrent intra-arterial low dose cisplatin for patients with muscle invasive bladder cancer. Materials and Methods: We retrospectively reviewed the medical records of 37 consecutive patients (28 men and 9 women) who underwent trimodality therapy for T2-3N0M0 bladder cancer at our hospital between 1996 and 2011. A total of 60Gy of external beam radiation therapy was administered. A daily low dose of cisplatin was administered intra-arterially through a subcutaneously placed reservoir on the days of radiation therapy. Complete response was defined as no residual cancer in transurethral resection specimens and negative cytology. When a complete response could not be achieved, patients underwent additional intra-arterial chemotherapy. Results: Five-year cause specific, disease free, and overall survival rates were 86.4%, 69.7%, and 69.6%, respectively, with a mean follow-up period of 56.5 ± 6.1 months. Five-year cause specific survivals of the complete response group after the trimodality therapy, the complete response group after additional intra-arterial chemotherapy and the non-complete response group were 100% (n = 21), 85.9% (n = 9) and 0% (n = 7), respectively. Five-year overall survivals of the complete response group after the trimodality therapy, the complete response group after additional intra-arterial chemotherapy and the non-complete response group were 82.8%, 85.3% and 0%, respectively. Conclusions: This trimodality therapy for muscle invasive bladder cancer could achieve favorable survival rates with bladder preservation and minimal adverse events. This trimodality therapy can be one of the useful treatment options.
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Affiliation(s)
| | - Shoji Samma
- Department of Urology, Nara Prefectural Nara Hospital, Nara, Japan
| | - Shinji Fukui
- Department of Urology, Nara Prefectural Nara Hospital, Nara, Japan
| | - Yasushi Nakai
- Department of Urology, Nara Prefectural Nara Hospital, Nara, Japan
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Arcangeli G, Arcangeli S, Strigari L. A systematic review and meta-analysis of clinical trials of bladder-sparing trimodality treatment for muscle-invasive bladder cancer (MIBC). Crit Rev Oncol Hematol 2014; 94:105-15. [PMID: 25541350 DOI: 10.1016/j.critrevonc.2014.11.007] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 11/02/2014] [Accepted: 11/27/2014] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Despite the numerous prospective and retrospective studies published during the last 2 decades aiming at testing the safety and the efficacy of trimodality therapy (TMT) as a conservative treatment, an optimal therapeutic strategy has not yet been identified. We made a systematic overview of the 5-year outcomes from 31 trials of combined chemotherapy and radiation (CRT) after transurethral resection of muscle-infiltrating bladder tumours (TURBT), the so-called trimodality therapy. We took into consideration the results of each trial i.e. the rate of complete response (CR), local muscle-invasive local failure (LF), salvage cystectomy (SC), 5-year overall survival (OS) and 5-year bladder intact survival (BIS) from 3315 patients. RESULTS About half of the patients were treated with a preliminary induction followed by a consolidation CRT course in CR, or SC in non-CR patients (split treatment). The remaining half of the patients underwent an upfront full-dose CRT course (continuous treatment) with SC reserved to non-CR patients. Excellent results were obtained by trimodality therapy (TMT), with 78% CR, 28% muscle infiltrating LF and 21% SC in patients with MIBC. The 5-year OS and BIS rates were 56% and 42%, respectively. At univariate analysis, CR, and SC rates appeared to be significantly better in the continuous than in the split treatment group. Multivariate analysis confirmed the former regimen as a significant prognostic variables only for CR, while CP-based regimen was a significant prognostic factor for SC. The subgroup analysis revealed a significant improvement in 5-year OS rate of continuous over split treatment in later stage tumours. No relevant benefit was observed with the addition of other drugs to cisplatin (CP) or neo-adjuvant chemotherapy (NATC) to CRT, although, in patients receiving NACT, significantly better CR and OS rates were seen in the continuous than split treatment. CONCLUSIONS The results of this overview seem to indicate that TMT is able to produce excellent 5-year OS rates, no matter how it is done (continuous or split). No significant difference in 5-year OS rates could be observed between the two treatment regimens, although the continuous may offer some advantage compared to split treatment in terms of higher CR and, likely lower SC rates. The highest benefit might be achieved in later stage tumours, using a total radiation equivalent dose when delivered in 2Gy/fraction (EQD2) of more than 60Gy in combination with CP based regimes and preceded by 2-3 NACT cycles. Appropriate randomized trials should be addressed to confirm the results of the present review.
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Affiliation(s)
- Giorgio Arcangeli
- Laboratory of Medical Physics and Expert Systems, Regina Elena National Cancer Institute, Rome, Italy
| | - Stefano Arcangeli
- Department of Radiotherapy, Azienda Ospedaliera S. Camillo-Forlanini, Rome, Italy
| | - Lidia Strigari
- Laboratory of Medical Physics and Expert Systems, Regina Elena National Cancer Institute, Rome, Italy.
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Radical cystectomy vs. chemoradiation in T2-4aN0M0 bladder cancer: a case-control study. Urol Oncol 2014; 33:19.e1-19.e5. [PMID: 25445384 DOI: 10.1016/j.urolonc.2014.09.014] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Revised: 09/08/2014] [Accepted: 09/21/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND Muscle-invasive bladder cancer is most commonly treated by radical cystectomy. Patients who are too sick to go through this surgery or who are unwilling to accept the mutilation associated with it are referred to chemoradiation. We compared the results of these 2 modalities using age-matched populations. PARTICIPANTS AND METHODS Between 1998 and 2008, 33 patients were treated with chemoradiation for biopsy-proven T2-4aN0M0 urothelial bladder cancer. For every patient treated with chemoradiation, an age-matched patient who underwent radical cystectomy on the same year was selected for comparison. Mean radiotherapy dose was 62 Gy (standard deviation = 8.4) and median follow-up of both groups was approximately 36 months. RESULTS The groups were similar in age, proportion of men, and length of follow-up. However, the Charlson comorbidity index was significantly lower for operated patients (3.45 vs. 4.36, P = 0.01). Furthermore, 2 patients (6%) in the chemoradiation group had salvage cystectomy (one for disease recurrence and another for bladder shrinkage). The 2- and 5-year overall survival rates after surgery were 74.4% and 54.8%, respectively, and after chemoradiation were 70.2% and 56.6% (P = 0.8), respectively. The 2- and 5-year disease-free survival rates after surgery were 67.8% and 63.2%, respectively, and after chemoradiation were 63% and 54.3% (P = 0.89), respectively. Side effects were mild in both groups, with grade 3+toxicity seen in only 2 operated and 4 irradiated patients. CONCLUSIONS Despite having a significantly higher comorbidity index, patients treated with chemoradiation had similar overall and disease-free survival rates with low toxicity. Treatment with chemoradiation should be considered in patients with T2-4aN0M0 bladder cancer.
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Maebayashi T, Ishikawa H, Yorozu A, Yoshida D, Katoh H, Nemoto K, Ishihara S, Takemoto S, Ishibashi N, Tokumaru S, Akimoto T. Patterns of Practice in the Radiation Therapy for Bladder Cancer: Survey of the Japanese Radiation Oncology Study Group (JROSG). Jpn J Clin Oncol 2014; 44:1109-15. [DOI: 10.1093/jjco/hyu129] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Turgeon GA, Souhami L, Cury FL, Faria SL, Duclos M, Sturgeon J, Kassouf W. Hypofractionated intensity modulated radiation therapy in combined modality treatment for bladder preservation in elderly patients with invasive bladder cancer. Int J Radiat Oncol Biol Phys 2014; 88:326-31. [PMID: 24411604 DOI: 10.1016/j.ijrobp.2013.11.005] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 11/01/2013] [Accepted: 11/04/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE/OBJECTIVE(S) To review our experience with bladder-preserving trimodality treatment (TMT) using hypofractionated intensity modulated radiation therapy (IMRT) for the treatment of elderly patients with muscle-invasive bladder cancer. METHODS AND MATERIALS Retrospective study of elderly patients treated with TMT using hypofractionated IMRT (50 Gy in 20 fractions) with concomitant weekly radiosensitizing chemotherapy. Eligibility criteria were as follows: age ≥70 years, a proven diagnosis of muscle-invasive transitional cell bladder carcinoma, stage T2-T3N0M0 disease, and receipt of TMT with curative intent. Response rate was assessed by cystoscopic evaluation and bladder biopsy. RESULTS 24 patients with a median age of 79 years were eligible. A complete response was confirmed in 83% of the patients. Of the remaining patients, 1 of them underwent salvage cystectomy, and no disease was found in the bladder on histopathologic assessment. After a median follow-up time of 28 months, of the patients with a complete response, 2 patients had muscle-invasive recurrence, 1 experienced locoregional failure, and 3 experienced distant metastasis. The overall and cancer-specific survival rates at 3 years were 61% and 71%, respectively. Of the surviving patients, 75% have a disease-free and functioning bladder. All patients completed hypofractionated IMRT, and 19 patients tolerated all 4 cycles of chemotherapy. Acute grade 3 gastrointestinal or genitourinary toxicities occurred in only 4% of the patients, and acute grade 3 or 4 hematologic toxicities, liver toxicities, or both were experienced by 17% of the cohort. No patient experienced grade 4 gastrointestinal or genitourinary toxicity. CONCLUSIONS Hypofractionated IMRT with concurrent radiosensitizing chemotherapy appears to be an effective and well-tolerated curative treatment strategy in the elderly population and should be considered for patients who are not candidates for cystectomy or who wish to avoid cystectomy.
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Affiliation(s)
- Guy-Anne Turgeon
- Department of Oncology, Division of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Luis Souhami
- Department of Oncology, Division of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada.
| | - Fabio L Cury
- Department of Oncology, Division of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sergio L Faria
- Department of Oncology, Division of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Marie Duclos
- Department of Oncology, Division of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jeremy Sturgeon
- Department of Medical Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Wassim Kassouf
- Department of Urology, McGill University Health Centre, Montreal, Quebec, Canada
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Trimodality bladder-sparing approach versus radical cystectomy for invasive bladder cancer. JOURNAL OF RADIOTHERAPY IN PRACTICE 2014. [DOI: 10.1017/s1460396914000107] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractPurposeTo compare the outcome among patients with invasive bladder cancer treated with cystectomy alone with outcome among those treated with combined-modality treatment in a randomised phase III trial.Patients and methodsPatients with histologically confirmed invasive non-metastatic bladder cancer T2-3, N0 and M0 were randomly assigned to two arms: Arm 1: of which all patients underwent radical cystectomy (RC) alone; and Arm 2, of which all patients were subjected to maximal transurethral resection of bladder tumour, followed 2 weeks later by combined chemoradiotherapy. The whole pelvis received 46 Gy in 23 fractions over 4·5 weeks. Chemotherapy was administered concomitantly with radiotherapy with: cisplatin 70 mg/m2 q. 3 weeks and Gemcitabine 300 mg/m2 D 1, 8 and 15 q. 3 weeks for two cycles. Patients who had complete response were shifted to phase II treatment: 20 Gy/10 fractions/2 weeks to the bladder. Patients with residual tumour underwent RC.ResultsOf the 80 patients assigned Arm 2, a visibly completed transurethral resection of the bladder tumour was possible in 48 patients (60%). Phase I of combined chemoradiotherapy (CCRT) was accomplished in 74 patients. Post-induction urologic evaluation revealed no evidence of disease in 62 patients (83·8%) and residual disease in 12 patients (16·2%). Phase II of CCRT was completed in 58 of the 62 patients. The median follow-up for all patients is 27 months (range: 4–49). The 3-year overall survival (OS) for the combined-modality group and for the surgery group were 61 and 63%, respectively (p = 0·425), whereas the disease-specific survival (DSS) for each group was 69 and 73%, respectively (p = 0·714). The 3-year OS with bladder preservation for Arm 2 patients was 50%.Multivariate analysis for the whole series showed that tumour stage and performance status (PS) were the only factors independently associated with DSS, although PS was the only factor independently associated with OS. In addition, residual disease after transurethral resection of the bladder tumour in Arm 2 patients was independently associated with both DSS and OS.Acute toxicity was moderate and most of the late toxicities were grade 2 with no grade 4 toxicity and no treatment-related deaths, none required cystectomy for bladder contraction.ConclusionThis study demonstrates that trimodality bladder-preserving approach represents a valid alternative for suitable patients. The OS and DSS rates of patients treated with trimodality bladder-preserving protocol are comparable to the results reported on patients treated with immediate radical cystectomy.
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Ploussard G, Daneshmand S, Efstathiou JA, Herr HW, James ND, Rödel CM, Shariat SF, Shipley WU, Sternberg CN, Thalmann GN, Kassouf W. Critical analysis of bladder sparing with trimodal therapy in muscle-invasive bladder cancer: a systematic review. Eur Urol 2014; 66:120-37. [PMID: 24613684 DOI: 10.1016/j.eururo.2014.02.038] [Citation(s) in RCA: 227] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 02/14/2014] [Indexed: 12/17/2022]
Abstract
CONTEXT Aims of bladder preservation in muscle-invasive bladder cancer (MIBC) are to offer a quality-of-life advantage and avoid potential morbidity or mortality of radical cystectomy (RC) without compromising oncologic outcomes. Because of the lack of a completed randomised controlled trial, oncologic equivalence of bladder preservation modality treatments compared with RC remains unknown. OBJECTIVE This systematic review sought to assess the modern bladder-preservation treatment modalities, focusing on trimodal therapy (TMT) in MIBC. EVIDENCE ACQUISITION A systematic literature search in the PubMed and Cochrane databases was performed from 1980 to July 2013. EVIDENCE SYNTHESIS Optimal bladder-preservation treatment includes a safe transurethral resection of the bladder tumour as complete as possible followed by radiation therapy (RT) with concurrent radiosensitising chemotherapy. A standard radiation schedule includes external-beam RT to the bladder and limited pelvic lymph nodes to an initial dose of 40 Gy, with a boost to the whole bladder to 54 Gy and a further tumour boost to a total dose of 64-65 Gy. Radiosensitising chemotherapy with phase 3 trial evidence in support exists for cisplatin and mitomycin C plus 5-fluorouracil. A cystoscopic assessment with systematic rebiopsy should be performed at TMT completion or early after TMT induction. Thus, nonresponders are identified early to promptly offer salvage RC. The 5-yr cancer-specific survival and overall survival rates range from 50% to 82% and from 36% to 74%, respectively, with salvage cystectomy rates of 25-30%. There are no definitive data to support the benefit of using of neoadjuvant or adjuvant chemotherapy. Critical to good outcomes is proper patient selection. The best cancers eligible for bladder preservation are those with low-volume T2 disease without hydronephrosis or extensive carcinoma in situ. CONCLUSIONS A growing body of accumulated data suggests that bladder preservation with TMT leads to acceptable outcomes and therefore may be considered a reasonable treatment option in well-selected patients. PATIENT SUMMARY Treatment based on a combination of resection, chemotherapy, and radiotherapy as bladder-sparing strategies may be considered as a reasonable treatment option in properly selected patients.
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Affiliation(s)
- Guillaume Ploussard
- Department of Surgery, Division of Urology, McGill University, Montreal, Quebec, Canada; Department of Urology, Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Siamak Daneshmand
- University of Southern California Institute of Urology, University of Southern California/Norris Comprehensive Cancer Center, Los Angeles, CA, USA
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Harry W Herr
- Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Nicholas D James
- University of Birmingham, School of Cancer Sciences, Edgbaston, Birmingham, UK
| | - Claus M Rödel
- Department of Radiotherapy and Oncology, University of Frankfurt, Frankfurt, Germany
| | | | - William U Shipley
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Cora N Sternberg
- Department of Medical Oncology, San Camillo Forlanini Hospital, Rome, Italy
| | | | - Wassim Kassouf
- Department of Surgery, Division of Urology, McGill University, Montreal, Quebec, Canada.
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The role of radiotherapy in bladder cancer. Urologia 2014; 80:202-6. [PMID: 24526596 DOI: 10.5301/ru.2013.11554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2013] [Indexed: 11/20/2022]
Abstract
In this article we report on the current role of radiotherapy in the management of non-muscle invasive as well as in muscle invasive bladder cancer.
Radiotherapy seems to have no role in non-muscle invasive bladder cancer.
In muscle invasive bladder tumors, the role of radiotherapy is under investigation in view of new radiotherapy techniques and novel cytotoxic and biological agents.
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[Radiation therapy in locally advanced and/or relapsed urological tumors]. Urologia 2014; 80:212-24. [PMID: 24526598 DOI: 10.5301/ru.2013.11501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2013] [Indexed: 11/20/2022]
Abstract
Radiation therapy (RT) plays a fundamental role in the treatment of locally advanced and/or relapsed urological tumors, as well as in palliation, or as definitive treatment, and even where integrated into a multi-modal approach. In operated renal tumors, positive margins or extracapsular extension show a positive impact of postoperative RT, with a reduction of relapses between 100% and 30%, while, in the case of palliation, treatments with RT at high doses are preferred. In advanced cancers of the upper urinary tract, RT plays a limited role, even if it seems to increase the level of disease control locally and, with the combination of cisplatin, survival rates too. An important reduction in the recurrence is also observed in locally advanced tumors of the urethra, with a recurrence of 60% after surgery, 36% after RT and 25% after pairing of the two. In locally advanced tumors of the penis, RT shows poorer results than surgery, and the addition of postoperative RT does not seem to add any further outcome, except where, in the presence of a positive inguinal dissection, the postoperative RT reduces lymph node recurrences by 60%-11%. Interesting data for the preservation of the organ are reported with reference to the combination with chemotherapy. In the tumors of the testis, it is still disputable whether the treatment of residual masses after chemotherapy may be appropriate, with a view to a possible salvage radiotherapy. In the treatment of the prostate, the role of RT is consolidated and evolving with the progress of dose escalation, the association with hormonal therapy, new technologies, new possibilities of IMRT and proton therapy and various studies on multi-modal approaches (hormone therapy, surgery, radiotherapy, chemotherapy). Cystectomy is the gold standard for the treatment of locally advanced bladder cancer, even though there is a revived interest in multimodal treatments (transurethral resection, chemotherapy, RT) that may allow the organ preservation. Postoperative radiotherapy, which can reduce by 50% to 20%-5% local recurrences that are highly correlated with distance failure and with survival, should be revised in the light of modern RT techniques that can further increase local control levels and reduce the toxicity significantly.
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Sandler HM, Mirhadi AJ. Current status of radiation therapy for bladder cancer. Expert Rev Anticancer Ther 2014; 10:895-901. [DOI: 10.1586/era.10.34] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Plataniotis GA, Dale RG. Radio-chemotherapy for bladder cancer: Contribution of chemotherapy on local control. World J Radiol 2013; 5:267-274. [PMID: 24003352 PMCID: PMC3758494 DOI: 10.4329/wjr.v5.i8.267] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Revised: 06/26/2013] [Accepted: 08/06/2013] [Indexed: 02/06/2023] Open
Abstract
The purpose of this study was to review the magnitude of contribution of chemotherapy (CT) in the local control of muscle invasive bladder carcinoma in the studies where a combined radio-chemotherapy (RCT) was used (how much higher local control rates are obtained with RCT compared to RT alone). Studies on radiotherapy (RT) and combined RCT, neo-adjuvant, concurrent, adjuvant or combinations, reported after 1990 were reviewed. The mean complete response (CR) rates were significantly higher for the RCT studies compared to RT-alone studies: 75.9% vs 64.4% (Wilcoxon rank-sum test, P = 0.001). Eleven of the included RCT studies involved 2-3 cycles of neo-adjuvant CT, in addition to concurrent RCT. The RCT studies included the one-phase type (where a full dose of RCT was given and then assessment of response and cystectomy for non-responders followed) and the two-phase types (where an assessment of response was undertaken after an initial RCT course, followed 6 wk later by a consolidation RCT for those patients with a CR). CR rates between the two subgroups of RCT studies were 79.6% (one phase) vs 71.6% (two-phase) (P = 0.015). The average achievable tumour control rates, with an acceptable rate of side effects have been around 70%, which may represent a plateau. Further increase in CR response rates demands for new chemotherapeutic agents, targeted therapies, or modified fractionation in various combinations. Quantification of RT and CT contribution to local control using radiobiological modelling in trial designs would enhance the potential for both improved outcomes and the estimation of the potential gain.
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Khurana KK, Garcia JA, Tendulkar RD, Stephenson AJ. Multidisciplinary Management of Patients with Localized Bladder Cancer. Surg Oncol Clin N Am 2013; 22:357-73. [DOI: 10.1016/j.soc.2012.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Zapatero A, Martin De Vidales C, Arellano R, Ibañez Y, Bocardo G, Perez M, Rabadan M, García Vicente F, Cruz Conde JA, Olivier C. Long-term Results of Two Prospective Bladder-sparing Trimodality Approaches for Invasive Bladder Cancer: Neoadjuvant Chemotherapy and Concurrent Radio-chemotherapy. Urology 2012; 80:1056-62. [DOI: 10.1016/j.urology.2012.07.045] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 07/27/2012] [Accepted: 07/30/2012] [Indexed: 01/27/2023]
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Trimodality treatment in the conservative management of infiltrating bladder cancer: a critical review of the literature. Crit Rev Oncol Hematol 2012; 86:176-90. [PMID: 23088957 DOI: 10.1016/j.critrevonc.2012.09.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 08/21/2012] [Accepted: 09/26/2012] [Indexed: 11/23/2022] Open
Abstract
Although radical cystectomy is still the treatment of choice for patients with infiltrating bladder cancer, there is growing evidence of the effectiveness of a conservative approach. Developed as a treatment of need for elderly or unfit patients unable to undergo radical cystectomy, conservative therapy is becoming a true alternative to surgery for highly selected patients. Although transurethral bladder resection, external radiotherapy and systemic chemotherapy can control the disease as single treatments, the best results have been observed when they are combined. Moreover, new irradiation techniques and new-generation drugs are now being tested in an attempt to improve disease control further. Conservative management requires the multidisciplinary involvement of different specialties in order to give patients a real alternative to surgical treatment.
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Koga F, Kihara K. Selective bladder preservation with curative intent for muscle-invasive bladder cancer: a contemporary review. Int J Urol 2012; 19:388-401. [PMID: 22409269 DOI: 10.1111/j.1442-2042.2012.02974.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Radical cystectomy plus urinary diversion, the reference standard treatment for muscle-invasive bladder cancer, associates with high complication rates and compromises quality of life as a result of long-term effects on urinary, gastrointestinal and sexual function, and changes in body image. As a society ages, the number of elderly patients unfit for radical cystectomy as a result of comorbidity will increase, and thus the demand for bladder-sparing approaches for muscle-invasive bladder cancer will also inevitably increase. Trimodality bladder-sparing approaches consisting of transurethral resection, chemotherapy and radiotherapy (Σ 55-65 Gy) yield overall survival rates comparable with those of radical cystectomy series (50-70% at 5 years), while preserving the native bladder in 40-60% of muscle-invasive bladder cancer patients, contributing to an improvement in quality of life for such patients. Limitations of the trimodality therapy include (i) muscle-invasive bladder cancer recurrence in the preserved bladder, which most often arises in the original muscle-invasive bladder cancer site; (ii) potential lack of curative intervention for regional lymph nodes; and (iii) increased morbidity in the event of salvage radical cystectomy for remaining or recurrent disease as a result of high-dose pelvic irradiation. Consolidative partial cystectomy with pelvic lymph node dissection followed by induction chemoradiotherapy at lower dose (e.g. 40 Gy) is a rational strategy for overcoming such limitations by strengthening locoregional control and reducing radiation dosage. Molecular profiling of the tumor and functional imaging might play important roles in optimal patient selection for bladder preservation. Refinement of radiation techniques, intensified concurrent or adjuvant chemotherapy, and novel sensitizers, including molecular targeting agent, are also expected to improve outcomes and consequently provide more muscle-invasive bladder cancer patients with favorable quality of life.
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Affiliation(s)
- Fumitaka Koga
- Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan.
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Wood DP. Re: Bladder Preservation Multimodality Therapy as an Alternative to Radical Cystectomy for Treatment of Muscle Invasive Bladder Cancer. J Urol 2012; 187:473-4. [DOI: 10.1016/j.juro.2011.10.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Quintens H, Roupret M, Larré S, Neuzillet Y, Pignot G, Compérat E, Wallerand H, Houédé N, Roy C, Soulié M, Pfister C. Radiochimiothérapie pour le traitement des cancers de vessie infiltrant le muscle : modalités, surveillance et résultats. Mise au point du comité de cancérologie de l’Association française d’urologie. Prog Urol 2012; 22:13-6. [DOI: 10.1016/j.purol.2011.09.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Revised: 09/28/2011] [Accepted: 09/28/2011] [Indexed: 10/15/2022]
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Abstract
Management of muscle-invasive bladder cancer (MIBC) has changed little in the last twenty years. The gold standard treatment is still cystectomy, but it has a significant negative impact on quality of life. Bladder-preservation strategies can be used in some cases but patient selection for this approach remains unclear. New chemotherapy and biologic agents in combination with surgery or radiotherapy could improve results and these possibilities are currently under investigation.
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Balar A, Bajorin DF, Milowsky MI. Management of invasive bladder cancer in patients who are not candidates for or decline cystectomy. Ther Adv Urol 2011; 3:107-17. [PMID: 21904567 DOI: 10.1177/1756287211407543] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Bladder cancer is a common malignancy seen in older adults with coexisting medical illnesses. The management of patients with muscle invasive disease includes perioperative chemotherapy and radical cystectomy; however, patients may decline surgery and older patients with comorbid conditions may not be candidates for surgery and thus alternative treatment strategies are needed. Trimodality bladder preservation protocols for muscle invasive bladder cancer have generally included only those patients who are candidates for a salvage cystectomy. In this review, we discuss the current status of bladder preservation treatment options for patients with muscle-invasive disease who are not candidates for cystectomy or who decline surgery and highlight the need for clinical trials investigating novel treatment approaches in this older patient population.
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Affiliation(s)
- Arjun Balar
- Genitourinary Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
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Abstract
The concept of organ-preserving therapies is a trend in modern oncology, and several tumour types are now treated in this fashion. Trimodality therapy consisting of as thorough a transurethral resection of the bladder tumour as is judged safe, followed by concomitant chemoradiation therapy, is emerging as an attractive alternative for bladder preservation in selected patients with muscle-invasive bladder cancer. Long-term data from multiple institutional and cooperative group studies have shown that this approach is safe and effective and that it provides patients with the opportunity to maintain an intact and functional bladder with a survival rate similar to that for modern radical cystectomy.
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Affiliation(s)
- N J Rene
- Department of Radiation Oncology, McGill University Health Centre, Montreal, QC
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Choudhury A, Swindell R, Logue JP, Elliott PA, Livsey JE, Wise M, Symonds P, Wylie JP, Ramani V, Sangar V, Lyons J, Bottomley I, McCaul D, Clarke NW, Kiltie AE, Cowan RA. Phase II study of conformal hypofractionated radiotherapy with concurrent gemcitabine in muscle-invasive bladder cancer. J Clin Oncol 2011; 29:733-8. [PMID: 21205754 DOI: 10.1200/jco.2010.31.5721] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE The aim of this prospective, phase II trial was to determine the response of muscle-invasive bladder cancer (MIBC) to concurrent chemoradiotherapy of weekly gemcitabine with 4 weeks of radiotherapy (RT; GemX). PATIENTS AND METHODS Fifty patients with transitional cell carcinoma, stage T2-3, N0, M0 after transurethral resection and magnetic resonance imaging, were recruited. Gemcitabine was given intravenously at 100 mg/m(2) on days 1, 8, 15, and 22 of a 28-day RT schedule that delivered 52.5 Gy in 20 fractions. Chemotherapy was stopped for Radiation Therapy Oncology Group (RTOG) grade 3 bladder or bowel toxicity. The primary end points were tumor response, toxicity, and survival. RESULTS All patients completed RT; 46 tolerated all four cycles of gemcitabine. Two patients stopped after two cycles, and two stopped after three cycles, because of bowel toxicity. Forty-seven patients had a post-treatment cystoscopy; 44 (88%) achieved a complete endoscopic response. At a median follow-up of 36 months (range, 15 to 62 months), 36 patients were alive, and 32 of these had a functional and intact bladder. Fourteen patients died; seven died as a result of metastatic MIBC, five died as a result of intercurrent disease, and two died as a result of treatment-associated deaths. Four patients underwent cystectomy; three because of recurrent disease and one because of toxicity. One patient required a bowel resection for late toxicity. By using Kaplan-Meier analyses, 3-year cancer-specific survival was 82%, and overall survival was 75%. CONCLUSION Concurrent gemcitabine-based chemoradiotherapy (ie, GemX) produces a high response rate in MIBC and has durable local control and acceptable toxicity, which allows patients to preserve their own bladder. This treatment modality warrants additional investigation in a phase III setting.
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Affiliation(s)
- Ananya Choudhury
- The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX United Kingdom
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Maarouf AM, Khalil S, Salem EA, ElAdl M, Nawar N, Zaiton F. Bladder preservation multimodality therapy as an alternative to radical cystectomy for treatment of muscle invasive bladder cancer. BJU Int 2010; 107:1605-10. [DOI: 10.1111/j.1464-410x.2010.09564.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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39
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Treatment Results of Radiation Therapy for Muscle-Invasive Bladder Cancer. Strahlenther Onkol 2010; 186:203-9. [DOI: 10.1007/s00066-010-2053-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2009] [Accepted: 11/26/2009] [Indexed: 10/19/2022]
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Puppo P, Conti G, Francesca F, Mandressi A, Naselli A. New Italian guidelines on bladder cancer, based on the World Health Organization 2004 classification. BJU Int 2010; 106:168-79. [PMID: 20346041 DOI: 10.1111/j.1464-410x.2010.09324.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To provide evidence-based recommendations on bladder cancer management METHODS A multidisciplinary guideline panel composed of urologists, medical oncologists, radiotherapists, general practitioners, radiologists, epidemiologists and methodologists conducted a structured review of previous reports, searching the Medline database from 1 January 2004 to 31 December 2008. The milestone papers published before January 2004 were accepted for analysis. The level of evidence and the grade of the recommendations were established using the GRADE system. RESULTS In all, 15 806 references were identified, 1940 retrieved, 1712 eliminated (specifying the reason for their elimination) and 971 included in the analysis, as well as 241 milestone reports. A consensus conference held to discuss the discrepancies between the scientific evidence and the clinical practice was then attended by 122 delegates of various specialities. CONCLUSION Recommendations on bladder cancer management are provided.
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Abstract
PURPOSE OF REVIEW To review the diagnosis and management of all stages of bladder cancer with an emphasis on studies and developments within the last year. RECENT FINDINGS Cystoscopy remains the mainstay in the detection and surveillance of bladder cancer, though fluorescent light may enhance detection as well as prolong recurrence-free survival. Urine cytology remains the gold standard for diagnosis and surveillance of bladder cancer; however, there are continued efforts in the development of urinary bladder cancer markers. Transurethral resection and instillation of perioperative chemotherapy remains the treatment of choice for superficial bladder cancer in most patients. Data supports the use of intravesical Bacillus Calmette-Guerin (including a maintenance regimen) for those at high risk for disease progression. Radical cystectomy with thorough pelvic lymphadenectomy remains the gold standard for management of muscle invasive disease. Research on the use of laparoscopy, robot-assisted laparoscopy, the effect on patient's health-related quality of life, and the potential role for bladder preservation strategies is ongoing. The value of neoadjuvant versus adjuvant chemotherapy around the time of cystectomy is still debated, though the best level-one evidence supports the use of neoadjuvant methotrexate, vinblastine, doxorubicin, and cisplatin followed by cystectomy. Platinum-based chemotherapeutic agents are most commonly used in the community setting. Work is ongoing to develop new regimens, especially in patients who cannot take cisplatin. Research in the development of targeted therapies alone or in combination with chemotherapeutic regimens continues and will hopefully broaden our treatment strategy for patients with advanced/metastatic disease. SUMMARY We are encouraged by the progress in bladder cancer diagnosis and management; however, continued research is needed in order to improve the lives of our patients with this disease.
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Sutherland DE, Wagner KR, Compton JB, Rezaei MK, Schwartz AM, Jarrett TW. Bladder cryoablation in a porcine model: evaluation of three surgical approaches and cryolesion predictability. J Endourol 2009; 23:515-8. [PMID: 19322940 DOI: 10.1089/end.2008.0200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To determine the feasibility of bladder cryoablation (BC) applied laparoscopically, percutaneously, and transurethrally in a porcine survival study. The expected and observed area of cell death after BC was also examined. MATERIALS AND METHODS Nine pigs were divided equally into the three treatment groups. Cryoablation was performed with two freeze-thaw cycles after the bladder had been insufflated with CO2. Each animal was observed for 7 days after the procedure for treatment-related complications. After cystectomy, each specimen was examined pathologically to determine the degree and dimension of cell death achieved. RESULTS BC applied via the laparoscopic and percutaneous approach is feasible and safe. No BC-related complications occurred in these two groups. A complication resulting from BC developed in all three animals that were treated cystoscopically, including two intraperitoneal bladder perforations at the time of BC necessitating immediate sacrifice, and one enterovesical fistula discovered at cystectomy. Transmural necrosis was demonstrated in seven of seven animal specimens that survived to the end of the protocol. The observed diameter of tissue necrosis was highly predictable based on the reported cryoprobe isotherms given by the manufacturer. CONCLUSION All locations within the bladder can be successfully and predictably treated with cryoablation. Of the three approaches, laparoscopically administered BC appears to be the most safe and consistent method. Transurethral BC was not safe with the equipment available without laparoscopic assistance to prevent bowel complications.
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Affiliation(s)
- Douglas E Sutherland
- Department of Urology, The George Washington University Hospital, Washington, D.C. 20037, USA
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Cobo M, Delgado R, Gil S, Herruzo I, Baena V, Carabante F, Moreno P, Ruiz JL, Bretón JJ, Del Rosal JM, Fuentes C, Moreno P, García E, Villar E, Contreras J, Alés I, Benavides M. Conservative treatment with transurethral resection, neoadjuvant chemotherapy followed by radiochemotherapy in stage T2-3 transitional bladder cancer. Clin Transl Oncol 2009; 8:903-11. [PMID: 17169764 DOI: 10.1007/s12094-006-0154-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE Organ preservation has been investigated in patients (p) with infiltrating transitional cell carcinoma (TCC) of the bladder over the past decade as an alternative to radical cystectomy. This is a trimodal schedule study, including transurethral resection of bladder tumor (TURB), neoadjuvant chemotherapy and concomitant radiochemotherapy (RTC). PATIENTS AND METHODS From April 1996 until August 2005, 29 evaluable patients (p) with T2-T3NXM0 bladder cancer were enrolled. After a transurethral resection of bladder tumor (TURB), we administered 2 cycles of induction chemotherapy with CMV (15 p) or Gemcitabine-Cisplatin (14 p) followed by radiotherapy 45 Gy 1.8 Gy/fraction and two cycles of concomitant cisplatin 70 mg/m(2). 2-3 weeks later, a cystoscopy with tumor-site biopsy was performed. If complete histological response, p were treated with consolidation radiotherapy until 64.8 Gy. For p with residual or recurrent tumor, cystectomy was performed. RESULTS We included 28 men and 1 women (median age 63, range 39-72 years) with PS (ECOG) 0-1. The stage was: 21 p T2; 6 p T3a; and 2 p T3b. Toxicity was higher in CMV compared with Gem- Cis: grade (3/4) neutropenia 4/15 (26%) vs 1/14 (7%); febrile neutropenia 3/15 (20%) vs 1/14 (7%); grade (3/4) trombocytopenia 2/15 (13%) vs 1/14 (7%). Toxicities with concomitant RCT were low-moderate: urocystitis (26%) and enteritis (18%). RESPONSE microscopically complete TURB was obtained in 20 p (69%), but not in 9 p (31%) (7 microscopic, and 2 macroscopic residual tumor). We found a complete histologic response after induction RCT in 25 p (86%). After a median follow-up of 69.4 months (m) (range: 8-97.7), there were 8 deaths, with a overall survival of 72%. Furthermore 14 of 29 p (48%) were alive with intact bladder, and median survival time with intact bladder was 63.6 m (50.1-77.2); were predictive of best outcome T2 stage vs T3 (p < 0.0001), and complete histologic resection in initial TURB vs residual tumor (p = 0.0004). CONCLUSIONS Combined treatment provide high response rates and can be offered as an alternative option to radical cystectomy in selected patients with TCC. Patients with T2 stage and complete histologic resection in initial TURB had the best outcome.
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Affiliation(s)
- M Cobo
- Medical Oncology Section, Hospital Regional Universitario Carlos Haya, Málaga, Spain.
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64-detector row CT cystography with virtual cystoscopy in the detection of bladder carcinoma: preliminary experience in selected patients. Radiol Med 2008; 114:52-69. [DOI: 10.1007/s11547-008-0350-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2007] [Accepted: 04/10/2008] [Indexed: 10/21/2022]
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Troiano M, Corsa P, Raguso A, Cossa S, Piombino M, Guglielmi G, Parisi S. Radiation therapy in urinary cancer: state of the art and perspective. Radiol Med 2008; 114:70-82. [PMID: 19082788 DOI: 10.1007/s11547-008-0347-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Accepted: 04/10/2008] [Indexed: 12/19/2022]
Abstract
Invasive urinary tumours are relatively rare, and their treatment may cause important changes in urinary, sexual and social functions. A systematic review of external radiation therapy studies in urinary cancers was performed. This synthesis of the literature is based on data from meta-analyses, randomised and prospective trials and retrospective studies. There are few controlled clinical trials using adjuvant or radical radiotherapy with or without chemotherapy in cancer of the kidney, ureter and urethra. There are several reports on multimodality treatment in invasive bladder cancer: intravesical surgery and neoadjuvant chemotherapy to radiotherapy or concomitant radiochemotherapy with organ preservation. The conclusions reached for renal cancer are controversial, and data on cancers of the urethra and ureter are few and inconclusive. Sufficient data now exist in the literature to demonstrate that conservative management with organ preservation is a valuable alternative to radical cystectomy, the traditional gold standard, in invasive bladder cancer.
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Affiliation(s)
- M Troiano
- Department of Radiation Oncology, Scientific Institute Hospital Casa Sollievo della Sofferenza, and University of Foggia, Department of Radiology, San Giovanni Rotondo, 71013, Foggia, Italy
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Conservative treatment in patients with muscle-invasive bladder cancer by transurethral resection, neoadjuvant chemotherapy with gemcitabine and cisplatin, and accelerated radiotherapy with concomitant boost plus concurrent cisplatin – assessment of response and toxicity. Rep Pract Oncol Radiother 2008. [DOI: 10.1016/s1507-1367(10)60016-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Sabaa MA, El-Gamal OM, Abo-Elenen M, Khanam A. Combined modality treatment with bladder preservation for muscle invasive bladder cancer. Urol Oncol 2008; 28:14-20. [PMID: 18818110 DOI: 10.1016/j.urolonc.2008.07.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2008] [Revised: 06/30/2008] [Accepted: 07/02/2008] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To evaluate the 5-year results of the following trimodal therapy for treatment of some selected cases of muscle invasive bladder cancer. MATERIALS AND METHODS In this prospective study, we included 104 patients with transitional cell carcinoma (TCC) (T2 and T3a, N0, M0) who were amenable to complete transurethral resection. All patients received adjuvant chemo-radiotherapy (CRT) in the form of gemcitabine and cisplatin and conventional radiotherapy after the maximum resection of their tumors. Two weeks later, all cases had radiologic and cystoscopic evaluation. The patients who showed no evidence of the bladder tumors [complete response (CR)] went on to complete the CRT, while those with recurrent invasive tumors did not receive any more CRT and were assigned to have salvage cystectomy. Thereafter, all patients were subjected to a regular follow-up. RESULTS This trimodal therapy was well tolerated in most of cases with no severe acute toxicities. Complete response was achieved in 78.8% of cases after the initial CRT, and tumor grade was found to be the most significant risk factor to predict this response (P = 0.004). With a median follow-up of 71 months for patients with initial CR, 16.2% of cases showed muscle invasive recurrences, and multifocality was the only significant risk factor for their development (P = 0.003). Meanwhile, superficial recurrences were detected in 8.1% of cases with initial CR and were successfully treated with transurethral resection and intravesical bacillus Calmette-Guerin (BCG). On the other hand, we reported distant metastasis in 24.3% of patients with initial CR, and tumor grade, stage and multifocality were the most significant risk factors for this complication (P = 0.002, 0.031, 0.006). No cases of contracted bladder or late gastrointestinal complications were demonstrated in this series. The 5-year overall survival rate for patients with initial CR was 67.6%, and for all the patients in this study it was 59.4%. CONCLUSIONS This trimodal therapy can be considered as a treatment option for patients with localized muscle invasive TCC. The best candidates for such therapy are those with solitary T2, low grade tumors that are amenable to complete transurethral resection.
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Affiliation(s)
- Magdy A Sabaa
- Department of Urology, Tanta University Hospitals, Tanta, Egypt
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Joung JY, Han KS, Kim TS, Seo HK, Chung J, Lee KH. Single institutional experience of bladder-preserving trimodality treatment for muscle-invasive bladder cancer. J Korean Med Sci 2008; 23:598-603. [PMID: 18756044 PMCID: PMC2526414 DOI: 10.3346/jkms.2008.23.4.598] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The authors designed this study to determine the clinical effectiveness of trimodality treatment, i.e., transurethral resection of a bladder tumor (TURBT) and concurrent chemoradiotherapy (CRT). Twenty patients with a muscle-invasive bladder cancer were treated by TURBT followed by concurrent cisplatin (75 mg/m(2) day), administered on weeks 1 and 4 of radiotherapy. According to residual tumor status after TURBT, patients were classified into patients with a complete TURBT group and incomplete TURBT group. Response to treatment was evaluated by restaging TURBT at 4 weeks after completing CRT (post-CRT). Fifteen patients (75%) achieved complete remission (CR) at restaging; 10 patients (50%) remained continuously free of tumor recurrence. Disease-specific and overall survivals were 51.1% and 38.6% at 5 yr post-CRT, respectively. Of 16 patients in the complete TURBT group, 14 patients (87.5%) achieved CR, which was significantly different from that observed in the incomplete TURBT group, in which only 1 (25%) of 4 patients achieved CR (p=0.032). Five- year disease-specific and overall survivals were 71.6% and 53.5%, respectively. Ten patients (90.9%) maintained their own bladder among the 11 surviving patients. Trimodality treatment was found to be an effective treatment in patients who underwent complete TURBT for a muscle-invasive bladder cancer.
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Affiliation(s)
- Jae Young Joung
- Urologic Oncology Clinic, Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Kyung Seok Han
- Urologic Oncology Clinic, Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Taek Sang Kim
- Urologic Oncology Clinic, Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Ho Kyung Seo
- Urologic Oncology Clinic, Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jinsoo Chung
- Urologic Oncology Clinic, Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Kang Hyun Lee
- Urologic Oncology Clinic, Institute and Hospital, National Cancer Center, Goyang, Korea
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Pansadoro V, Emiliozzi P. Bladder-sparing therapy for muscle-infiltrating bladder cancer. ACTA ACUST UNITED AC 2008; 5:368-75. [PMID: 18560383 DOI: 10.1038/ncpuro1145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2007] [Accepted: 04/22/2008] [Indexed: 11/09/2022]
Abstract
Radical cystectomy is the treatment of choice for nonmetastatic, muscle-infiltrating bladder cancer. Several researchers have proposed the use of a bladder-sparing approach in carefully selected patients. Strict selection criteria and close follow-up are needed for bladder-preservation protocols. Although repeated transurethral resection of bladder tumors or partial cystectomy might be offered to high-risk patients, combined protocols with transurethral resection of bladder tumors and chemotherapy, with or without additional radiotherapy, seem to provide the best results, with 5-year survival rates of about 50%. Even if the chance of preserving the bladder is appealing, and despite evidence of some promising results, these protocols should still be considered investigative because, as yet, there are no randomized trials available that compare cystectomy with bladder-sparing surgery.
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Smaldone MC, Jacobs BL, Smaldone AM, Hrebinko RL. Long-term results of selective partial cystectomy for invasive urothelial bladder carcinoma. Urology 2008; 72:613-6. [PMID: 18554696 DOI: 10.1016/j.urology.2008.04.052] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2008] [Revised: 04/11/2008] [Accepted: 04/17/2008] [Indexed: 11/13/2022]
Abstract
OBJECTIVES We reviewed our experience with partial cystectomy to assess local control and survival rates, and to identify pathologic predictors for recurrence. METHODS From 1995 to 2005, 25 patients with urothelial carcinoma underwent partial cystectomy with curative intent. As protocol, patients with primary solitary muscle-invasive bladder tumors underwent preoperative localized radiotherapy, administration of a single dose of intravesical chemotherapy at the time of partial cystectomy, and postoperative intravesical Bacillus Calmette-Guérin therapy. We reviewed clinical and pathologic data to identify variables associated with disease recurrence. RESULTS We analyzed data from 25 patient records meeting review criteria (72% male, mean age 65.1 +/- 9.8 years). At time of transurethral resection of a bladder tumor (TURBT), all had a solitary primary T2 (68%) or T1HG (32%) lesion with no evidence of carcinoma in situ. At follow-up (mean 45.3 +/- 30.7 months), 5-year recurrence-free, disease-specific, and overall survival rates were 64%, 84%, and 70%, respectively. At a mean of 18.0 +/- 15.6 months, 8% of patients experienced intravesical non-muscle-invasive tumor recurrences and were treated with TURBT and intravesical chemotherapy. Twenty percent recurred with locally advanced tumors or visceral metastasis and were treated with systemic chemotherapy, local resection or cystectomy, or both. On univariate analysis, only tumor size at time of partial cystectomy (P = .03) was significantly associated with tumor recurrence. CONCLUSIONS Partial cystectomy offers adequate control of localized invasive urothelial carcinoma in carefully selected patients with solitary primary tumors. Lifelong follow-up with cystoscopy and abdominal imaging is recommended to detect recurrence.
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Affiliation(s)
- Marc C Smaldone
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA.
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