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Stecca C, Mitin T, Sridhar SS. The Role of Neoadjuvant Chemotherapy in Bladder Preservation Approaches in Muscle-Invasive Bladder Cancer. Semin Radiat Oncol 2023; 33:51-55. [PMID: 36517193 DOI: 10.1016/j.semradonc.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Neoadjuvant chemotherapy (NAC), which aims to eliminate micrometastatic disease, has been established as the standard of care for patients with muscle-invasive bladder cancer (MIBC) undergoing radical cystectomy (RC). This is based on randomized controlled trials showing a survival benefit of NAC prior to RC compared to RC alone. It was anticipated that a similar survival benefit would also be seen when NAC was given prior to bladder preserving approaches, but the e phase III RTOG 8903 study which explored this concept was reported to be a negative study. However, there are a number of important caveats to be considered. First, the profile of patients opting for bladder preservation has changed from the older, frailer non-surgical candidates, to now also include younger, fitter patients opting for bladder preservation and who are also more likely to tolerate NAC. In recent years, there have also been important advances in systemic chemotherapy, immunotherapy, radiation techniques, and supportive care. As such revisitng the role of NAC prior to bladder preserving approaches in MIBC appears warranted.
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Affiliation(s)
- Carlos Stecca
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Timur Mitin
- Department of Radiation Medicine, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Srikala S Sridhar
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada.
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2
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Bladder-Sparing Approaches to Treatment of Muscle-Invasive Bladder Cancer. Urol Oncol 2022. [DOI: 10.1007/978-3-030-89891-5_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Agrawal C, Bansal S, Biswas M, Gupta M, Nautiyal V, Ahmed M. Bladder Preservation with Neoadjuvant Chemotherapy Followed by Concurrent Chemoradiation for the Treatment of Muscle-invasive Carcinoma of the Bladder: A Single-Center Experience. South Asian J Cancer 2021; 9:121-125. [PMID: 33937132 PMCID: PMC8075628 DOI: 10.1055/s-0041-1723076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose
The purpose of the study was to evaluate the short-term response and acute toxicities in muscle-invasive carcinoma urinary bladder treated with neoadjuvant chemotherapy followed by concurrent chemoradiation.
Materials and Methods
Thirty patients with muscle-invasive bladder cancer were treated with three cycles of neoadjuvant chemotherapy every 3 weeks. Response assessment was done after 4 weeks with repeat cystoscopy and imaging. Responders were treated with concurrent chemoradiation 60 Gy/30# at 2 Gy/# along with weekly injection cisplatin 35 mg/m
2
. Response assessment was done by new response evaluation criteria in solid tumors (version 1.1). Treatment-related acute toxicities were scored using common terminology criteria for adverse events version 4.0.
Results
Of the 30 patients, 25 patients responded to neoadjuvant chemotherapy with complete response in 17 patients (56.67%) and partial response in eight patients (26.66%). Five patients (16.66%) showed poor response and were advised radical cystectomy, of which four underwent radical cystectomy and one patient opted for concurrent chemoradiation. Of 26 patients who completed chemoradiation, complete response was seen in 21 patients (80.76%) and partial response was seen in four patients (15.38%). Only one patient developed progression of disease in the form of lung metastasis. All the patients with residual disease were advised to undergo salvage cystectomy. Among the patients receiving chemoradiation, grade 2 cystitis and diarrhea was seen in 10 patients (38.46%) and four patients (15.38%), respectively. Only one patient developed grade 3 diarrhea.
Conclusion
Bladder preservation treatment is an effective, safe, and convenient option for patients presenting with muscle-invasive carcinoma bladder. Neoadjuvant chemotherapy followed by chemoradiation was well-tolerated with an acceptable rate of complications.
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Affiliation(s)
- Chinmayee Agrawal
- Department of Radiation Oncology, Cancer Research Institute, SRHU, Dehradun, Uttarakhand, India
| | - Saurabh Bansal
- Department of Radiation Oncology, Cancer Research Institute, SRHU, Dehradun, Uttarakhand, India
| | - Manoj Biswas
- Department of General Surgery, HIMS, SRHU, Dehradun, Uttarakhand, India
| | - Meenu Gupta
- Department of Radiation Oncology, Cancer Research Institute, SRHU, Dehradun, Uttarakhand, India
| | - Vipul Nautiyal
- Department of Radiation Oncology, Cancer Research Institute, SRHU, Dehradun, Uttarakhand, India
| | - Mushtaq Ahmed
- Department of Radiation Oncology, Cancer Research Institute, SRHU, Dehradun, Uttarakhand, India
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Surgical challenges and considerations in Tri-modal therapy for muscle invasive bladder cancer. Urol Oncol 2021; 40:442-450. [PMID: 33642229 DOI: 10.1016/j.urolonc.2021.01.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 12/13/2020] [Accepted: 01/08/2021] [Indexed: 01/20/2023]
Abstract
Trimodal therapy (TMT) for muscle invasive bladder cancer has become an accepted alternative to radical cystectomy and has become integrated into national guidelines as standard a treatment option. The urologist plays a critical role in proper patient selection, thorough transurethral resection, ongoing cystoscopic surveillance and management of local recurrences. There exists multiple patient related and tumor related factors, which contribute to the selection of TMT vs. radical cystectomy for a patient with muscle invasive bladder cancer. Although the ideal patient for TMT has a tumor which can undergo a visibly complete resection, has no associated hydronephrosis, does not invade the prostatic urethra and is not associated with diffuse carcinoma in situ throughout the bladder, select patients who do not meet all these criteria can still be successfully treated with this approach. A multidisciplinary approach including urology, radiation oncology and medical oncology is paramount with clear communication of tumor location, timing of chemoradiation and repeat cystoscopic resection followed by surveillance. Nonmuscle invasive bladder cancer recurrences can occur in up to 26% of patients after completion of TMT, with many being treated by routine and standard therapy for non-muscle invasive bladder cancer. However, in this population after TMT, early salvage cystectomy should be considered in those with adverse features, including T1 disease, tumor greater than 3 cm, CIS, or lymphovascular invasion. Salvage cystectomy can be performed for local recurrences with acceptable oncologic control and no clear evidence of any greater risk of early complications; however, there may be a slightly increased risk for late complications, namely small bowel obstruction, ureteral stricture, and parastomal hernia. An understanding of these surgical considerations is of utmost importance to the treating urologist in selecting and managing a patient through TMT.
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Polo-Alonso E, Kuk C, Guruli G, Paul AK, Thalmann G, Kamat A, Solsona E, Thalmann G, Urdaneta AI, Zlotta AR, Mir MC. Trimodal therapy in muscle invasive bladder cancer management. MINERVA UROL NEFROL 2020; 72:650-662. [PMID: 33263367 DOI: 10.23736/s0393-2249.20.04018-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Radical cystectomy (RC) is the current mainstay for muscle-invasive bladder cancer (MIBC). Concerns regarding morbidity, mortality and quality of life have favored the introduction of bladder sparing strategies. Trimodal therapy, combining transurethral resection, chemotherapy and radiotherapy is the current standard of care for bladder preservation strategies in selected patients with MIBC. EVIDENCE ACQUISITION A comprehensive search of the Medline and Embase databases was performed. A total of 19 studies were included in a systematic review of bladder sparing strategies in MIBC management was carried out following the preferred reporting items for systematic reviews and meta-analysis (PRISMA). EVIDENCE SYNTHESIS The overall median complete response rate after trimodal therapy (TMT) was 77% (55-93). Salvage cystectomy rate with TMT was 17% on average (8-30). For TMT, the 5-year cancer-specific survival and overall survival rates range from 42-82% and 32-74%, respectively. Currently data supporting neoadjuvant or adjuvant chemotherapy in bladder sparing approaches are emerging, but robust definitive conclusions are still lacking. Gastrointestinal toxicity rates are low around 4% (0.5-16), whereas genitourinary toxicity rates reached 8% (1-24). Quality of life outcomes are still underreported. CONCLUSIONS Published data and clinical experience strongly support trimodal therapy as an acceptable bladder sparing strategy in terms of oncological outcomes and quality of life in selected patients with MIBC. A strong need exists for specialized centers, to increase awareness among urologists, to discuss these options with patients and to stress the increased participation of patients and their families in treatment path decision-making.
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Affiliation(s)
- Elvira Polo-Alonso
- Department of Urology, Instituto Valenciano de Oncologia (IVO), Valencia, Spain
| | - Cynthia Kuk
- Division of Urology, Departments of Surgical Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada.,Division of Urology, Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada
| | - Georgi Guruli
- Division of Urology, Virginia Commonwealth University, Richmond, VA, USA
| | - Asit K Paul
- Division of Hematology, Oncology and Palliative Care Unit, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - George Thalmann
- Division of Hematology, Oncology and Palliative Care Unit, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Ashish Kamat
- Department of Urology, Anderson Cancer Center, Houston, TX, USA
| | - Eduardo Solsona
- Department of Urology, Instituto Valenciano de Oncologia (IVO), Valencia, Spain
| | - George Thalmann
- Department of Urology, University Hospital of Bern, Bern, Switzerland
| | - Alfredo I Urdaneta
- Division of Hematology, Oncology and Palliative Care Unit, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Alexandre R Zlotta
- Division of Urology, Departments of Surgical Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada.,Division of Urology, Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada
| | - Maria C Mir
- Department of Urology, Instituto Valenciano de Oncologia (IVO), Valencia, Spain -
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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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Kimura T, Ishikawa H, Kojima T, Kandori S, Kawahara T, Sekino Y, Sakurai H, Nishiyama H. Bladder preservation therapy for muscle invasive bladder cancer: the past, present and future. Jpn J Clin Oncol 2020; 50:1097-1107. [PMID: 32895714 DOI: 10.1093/jjco/hyaa155] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/26/2020] [Indexed: 12/24/2022] Open
Abstract
Radical cystectomy is the gold standard treatment for muscle invasive bladder cancer, but some patients have medically inoperable disease or refuse cystectomy to preserve their bladder function. Bladder preservation therapy with transurethral resection of the bladder tumor and concurrent chemoradiotherapy, known as trimodal treatment, is regarded to be a curative-intent alternative to radical cystectomy for patients with muscle invasive bladder cancer during the past decade. After the development of immune checkpoint inhibitors, a world-changing breakthrough occurred in the field of metastatic urothelial carcinoma and many clinical trials have been conducted against non-muscle invasive bladder cancer. Interestingly, preclinical and clinical studies against other malignancies have shown that immune checkpoint inhibitors interact with the radiation-induced immune reaction. As half of the patients with muscle invasive bladder cancer are elderly, and some have renal dysfunction, not only as comorbidity but also because of hydronephrosis caused by their tumors, immune checkpoint inhibitors are expected to become part of a new therapeutic approach for combination treatment with radiotherapy. Accordingly, clinical trials testing immune checkpoint inhibitors have been initiated to preserve bladder for muscle invasive bladder cancer patients using radiation and immune checkpoint inhibitors with/without chemotherapy. The objective of this review is to summarize the evidence of trimodal therapy for muscle invasive bladder cancer during the past decade and to discuss the future directions of bladder preservation therapy in immuno-oncology era.
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Affiliation(s)
- Tomokazu Kimura
- Department of Urology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Hitoshi Ishikawa
- Department of Radiation Oncology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Takahiro Kojima
- Department of Urology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Shuya Kandori
- Department of Urology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Takashi Kawahara
- Department of Urology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yuta Sekino
- Department of Radiation Oncology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Hideyuki Sakurai
- Department of Radiation Oncology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Hiroyuki Nishiyama
- Department of Urology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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Dinh TKT, Mitin T, Bagshaw HP, Hoffman KE, Hwang C, Jeffrey Karnes R, Kishan AU, Liauw SL, Lloyd S, Potters L, Showalter TN, Taira AV, Vapiwala N, Zaorsky NG, D'Amico AV, Nguyen PL, Davis BJ. Executive Summary of the American Radium Society Appropriate Use Criteria for Radiation Treatment of Node-Negative Muscle Invasive Bladder Cancer. Int J Radiat Oncol Biol Phys 2020; 109:953-963. [PMID: 33127490 DOI: 10.1016/j.ijrobp.2020.10.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/19/2020] [Accepted: 10/22/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Definitive radiation therapy (RT), with or without concurrent chemotherapy, is an alternative to radical cystectomy for patients with localized, muscle-invasive bladder cancer (MIBC) who are either not surgical candidates or prefer organ preservation. We aim to synthesize an evidence-based guideline regarding the appropriate use of RT. METHODS AND MATERIALS We performed a Preferred Reporting Items for Systematic Reviews and Meta-analyses literature review using the PubMed and Embase databases. Based on the literature review, critical management topics were identified and reformulated into consensus questions. An expert panel was assembled to address key areas of both consensus and controversy using the modified Delphi framework. RESULTS A total of 761 articles were screened, of which 61 were published between 1975 and 2019 and included for full review. There were 7 well-designed studies, 20 good quality studies, 28 quality studies with design limitations, and 6 references not suited as primary evidence. Adjuvant radiation therapy after cystectomy was not included owing to lack of high-quality data or clinical use. An expert panel consisting of 14 radiation oncologists, 1 medical oncologist, and 1 urologist was assembled. We identified 4 clinical variants of MIBC: surgically fit patients who wish to pursue organ preservation, patients surgically unfit for cystectomy, patients medically unfit for cisplatin-based chemotherapy, and borderline cystectomy candidates based on age with unilateral hydronephrosis and normal renal function. We identified key areas of controversy, including use of definitive radiation therapy for patients with negative prognostic factors, appropriate radiation therapy dose, fractionation, fields and technique when used, and chemotherapy sequencing and choice of agent. CONCLUSIONS There is limited level-one evidence to guide appropriate treatment of MIBC. Studies vary significantly with regards to patient selection, chemotherapy use, and radiation therapy technique. A consensus guideline on the appropriateness of RT for MIBC may aid practicing oncologists in bridging the gap between data and clinical practice.
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Affiliation(s)
- Tru-Khang T Dinh
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Timur Mitin
- Department of Radiation Medicine, Oregon Health Sciences University, Portland, Oregon.
| | - Hilary P Bagshaw
- Department of Radiation Oncology, Stanford University Clinics, Palo Alto, California
| | - Karen E Hoffman
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Clara Hwang
- Department of Hematology/Oncology, Henry Ford Health System, Detroit, Michigan
| | | | - Amar U Kishan
- Department of Radiation Oncology, University of California at Los Angeles Medical Center, Los Angeles, California
| | - Stanley L Liauw
- Department of Radiation Oncology, University of Chicago, Chicago, Illinois
| | - Shane Lloyd
- Department of Radiation Oncology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Louis Potters
- Department of Radiation Oncology, Northwell Health, New Hyde Park, New York
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia
| | - Al V Taira
- Sutter Health Radiation Oncology, San Mateo, California
| | - Neha Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State University Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Anthony V D'Amico
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana Farber Cancer, Institute, Boston, Massachusetts
| | - Paul L Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana Farber Cancer, Institute, Boston, Massachusetts
| | - Brian J Davis
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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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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Jiang DM, North SA, Canil C, Kolinsky M, Wood LA, Gray S, Eigl BJ, Basappa NS, Blais N, Winquist E, Mukherjee SD, Booth CM, Alimohamed NS, Czaykowski P, Kulkarni GS, Black PC, Chung PW, Kassouf W, van der Kwast T, Sridhar SS. Current Management of Localized Muscle-Invasive Bladder Cancer: A Consensus Guideline from the Genitourinary Medical Oncologists of Canada. Bladder Cancer 2020. [DOI: 10.3233/blc-200291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND: Despite recent advances in the management of muscle-invasive bladder cancer (MIBC), treatment outcomes remain suboptimal, and variability exists across current practice patterns. OBJECTIVE: To promote standardization of care for MIBC in Canada by developing a consensus guidelines using a multidisciplinary, evidence-based, patient-centered approach who specialize in bladder cancer. METHODS: A comprehensive literature search of PubMed, Medline, and Embase was performed; and most recent guidelines from national and international organizations were reviewed. Recommendations were made based on best available evidence, and strength of recommendations were graded based on quality of the evidence. RESULTS: Overall, 17 recommendations were made covering a broad range of topics including pathology review, staging investigations, systemic therapy, local definitive therapy and surveillance. Of these, 10 (59% ) were level 1 or 2, 7 (41% ) were level 3 or 4 recommendations. There were 2 recommendations which did not reach full consensus, and were based on majority opinion. This guideline also provides guidance for the management of cisplatin-ineligible patients, variant histologies, and bladder-sparing trimodality therapy. Potential biomarkers, ongoing clinical trials, and future directions are highlighted. CONCLUSIONS: This guideline embodies the collaborative expertise from all disciplines involved, and provides guidance to further optimize and standardize the management of MIBC.
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Affiliation(s)
- Di Maria Jiang
- Department of Medicine, Division of Medical Oncology and Hematology, University Health Network, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Scott A. North
- Department of Oncology, Division of Medical Oncology, Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - Christina Canil
- Department of Internal Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre, University of Ottawa, Ottawa, ON, Canada
| | - Michael Kolinsky
- Department of Oncology, Division of Medical Oncology, Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - Lori A. Wood
- Department of Medicine, Division of Medical Oncology, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, NS, Canada
| | - Samantha Gray
- Department of Oncology, Saint John Regional Hospital, Department of Medicine, Dalhousie University, Saint John, NB, Canada
| | - Bernhard J. Eigl
- Department of Medicine, Division of Medical Oncology, BC Cancer - Vancouver, University of British Columbia, Vancouver, BC, Canada
| | - Naveen S. Basappa
- Department of Oncology, Division of Medical Oncology, Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - Normand Blais
- Department of Medicine, Division of Medical Oncology and Hematology, Centre Hospitalier de l’Université de Montréal; Université de Montréal, Montreal, QC, Canada
| | - Eric Winquist
- Department of Oncology, London Health Sciences Centre, University of Western Ontario, London, ON, Canada
| | - Som D. Mukherjee
- Department of Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | | | - Nimira S. Alimohamed
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | - Piotr Czaykowski
- Department of Medical Oncology and Hematology, Cancer Care Manitoba, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Girish S. Kulkarni
- Departments of Surgery and Surgical Oncology, Division of Urology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Peter C. Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Peter W. Chung
- Department of Radiation Oncology, Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Wassim Kassouf
- Department of Urology, McGill University Health Centre, Montreal, QC, Canada
| | | | - Srikala S. Sridhar
- Department of Medicine, Division of Medical Oncology and Hematology, University Health Network, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
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Jiang DM, Chung P, Kulkarni GS, Sridhar SS. Trimodality Therapy for Muscle-Invasive Bladder Cancer: Recent Advances and Unanswered Questions. Curr Oncol Rep 2020; 22:14. [PMID: 32008105 DOI: 10.1007/s11912-020-0880-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE OF REVIEW Bladder-sparing trimodality therapy (TMT) has become an accepted alternative to cystectomy for selected muscle invasive bladder cancer (MIBC) patients unfit for cystectomy or opting for bladder preservation. This review will summarize recent advances in TMT for MIBC. RECENT FINDINGS A growing body of literature has emerged which supports the use of TMT. However, its delivery is yet to be standardized. The role of chemotherapy and predictive biomarkers remain to be elucidated. Novel bladder-sparing approaches, drug combinations including immunotherapy and targeted therapies are under investigation in clinical trials, with the goal of ultimately enhancing survival and quality of life outcomes. Recent advances in TMT have made bladder preservation possible for MIBC patients seeking an alternative local therapy to cystectomy. With careful patient selection, TMT offers comparable survival outcomes to cystectomy, and improved quality of life as patients are able to successfully retain their bladder.
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Affiliation(s)
- Di Maria Jiang
- Department of Medicine, Division of Medical Oncology, Princess Margaret Cancer Center, University Health Network, University of Toronto, Canada, 700 University Avenue, Toronto, ON, Canada
| | - Peter Chung
- Department of Radiation Oncology, Radiation Medicine Program, Princess Margaret Cancer Center, University Health Network, University of Toronto, Canada, 700 University Ave, Toronto, ON, Canada
| | - Girish S Kulkarni
- Departments of Surgery and Surgical Oncology, Division of Urology, Princess Margaret Cancer Center, University Health Network, University of Toronto, Canada, 6-824, 700 University Avenue, Toronto, ON, Canada
| | - Srikala S Sridhar
- Department of Medicine, Division of Medical Oncology, Princess Margaret Cancer Center, University Health Network, University of Toronto, Canada, 700 University Avenue, Toronto, ON, Canada.
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12
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El-Achkar A, Souhami L, Kassouf W. Bladder Preservation Therapy: Review of Literature and Future Directions of Trimodal Therapy. Curr Urol Rep 2018; 19:108. [PMID: 30392150 DOI: 10.1007/s11934-018-0859-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF THE REVIEW This review targets the latest literature on bladder preservation therapy with emphasis on trimodal therapy (TMT), highlighting its role in the management of muscle invasive bladder cancer (MIBC) and outlining future directions in bladder preservation research. RECENT FINDINGS TMT is the most promising bladder preservation treatment modality. Comparable results to contemporary radical cystectomy series are seen in properly selected patients. A multidisciplinary team approach is critical in the management of these patients. Future research is directed at the integration of immunotherapy into the treatment protocol. TMT, involving maximal transurethral resection followed by chemoradiation, is an attractive alternative to radical cystectomy with urinary diversion in carefully selected patients with muscle invasive disease. In the absence of randomized trial (RCT), comparison between TMT and cystectomy, based on retrospective data from large centers, suggests comparable oncological outcomes, with a favorable impact on quality of life.
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Affiliation(s)
- Adnan El-Achkar
- Experimental surgery, McGill University Health Center, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Luis Souhami
- Department of Radiation Oncology, McGill University Health Center, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Wassim Kassouf
- Department of Surgery, McGill University Health Center, McGill University, 1001 Decarie Blvd, D02.7210, Montreal, QC, H4A 3J1, Canada.
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Mathes J, Rausch S, Todenhöfer T, Stenzl A. Trimodal therapy for muscle-invasive bladder cancer. Expert Rev Anticancer Ther 2018; 18:1219-1229. [DOI: 10.1080/14737140.2018.1535314] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Joachim Mathes
- Department of Urology, University of Tübingen, Tübingen, Germany
| | - Steffen Rausch
- Department of Urology, University of Tübingen, Tübingen, Germany
| | | | - Arnulf Stenzl
- Department of Urology, University of Tübingen, Tübingen, Germany
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Olbert P, Goebell PJ, Hegele A. [Follow-up of bladder cancer : The right examinations at the right time]. Urologe A 2018; 57:693-701. [PMID: 29663062 DOI: 10.1007/s00120-018-0641-3] [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: 11/24/2022]
Abstract
Schedules for the follow-up (FU) of bladder cancer patients are predominantly based on studies with low level of evidence and the resulting guidelines' recommendations that are often founded on expert consensus. FU of non-muscle invasive bladder cancer (NMIBC) includes cystoscopy and cytology as standard, and imaging modalities to a lower extent. FU of muscle-invasive bladder cancer (MIBC) depends primarily on the therapeutic modality chosen and on the stage of disease. In this scenario, FU is complemented by functional and quality of life related aspects. These apply even more for FU in palliative situations. Here, the individual focus is on examinations that might have a consequence in terms of survival and/or symptom relief.
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Affiliation(s)
- P Olbert
- Praxis und Belegabteilung für Urologie und Andrologie, Brixsana Private Clinic, Julius Durst Str. 28, 39042, Brixen, Italien.
| | - P J Goebell
- Urologische und Kinderurologische Klinik, Friedrich-Alexander Universität, Erlangen, Deutschland
| | - A Hegele
- Klinik für Urologie und Kinderurologie, Universitätsklinikum Marburg UKGM, Marburg, Deutschland
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15
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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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16
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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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17
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Korpics M, Block AM, Altoos B, Martin B, Carey K, Welsh J, Harkenrider MM, Solanki AA. Maximizing survival in patients with muscle-invasive bladder cancer undergoing curative bladder-preserving radiotherapy: the impact of radiotherapy dose escalation. ACTA ACUST UNITED AC 2017. [DOI: 10.1007/s13566-017-0319-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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18
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Nishioka K, Shimizu S, Shinohara N, Ito YM, Abe T, Maruyama S, Katoh N, Kinoshita R, Hashimoto T, Miyamoto N, Onimaru R, Shirato H. Analysis of inter- and intra fractional partial bladder wall movement using implanted fiducial markers. Radiat Oncol 2017; 12:44. [PMID: 28249609 PMCID: PMC5333467 DOI: 10.1186/s13014-017-0778-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 02/08/2017] [Indexed: 11/13/2022] Open
Abstract
Background Current adaptive and dose escalating radiotherapy for muscle invasive bladder cancer requires knowledge of both inter-fractional and intra-fractional motion of the bladder wall involved. The purpose of this study is to characterize inter- and intra-fractional movement of the partial bladder wall using implanted fiducial markers and a real-time tumor-tracking radiotherapy system. Methods Two hundred fifty one sessions with 29 patients were analysed. After maximal transurethral bladder tumor resection and 40 Gy of whole bladder irradiation, up to six gold markers were implanted transurethrally into the bladder wall around the tumor bed and used for positional registration. We compared the systematic and random uncertainty of positions between cranial vs. caudal, left vs. right, and anterior vs. posterior tumor groups. The variance in intrafractional movement and the percentage of sessions where 3 mm and 5 mm or more of intrafractional wall movement occurring at 2, 4, 6, 8, 10, and at more than 10 min until the end of a session were determined. Results The cranial and anterior tumor group showed larger interfractional uncertainties in the position than the opposite side tumor group in the CC and AP directions respectively, but these differences did not reach significance. Among the intrafractional uncertainty of position, the cranial and anterior tumor group showed significantly larger systematic uncertainty of position than the groups on the opposite side in the CC direction. The variance of intrafractional movement increased over time; the percentage of sessions where intrafractional wall movement was larger than 3 mm within 2 min of the start of a radiation session or larger than 5 mm within 10 min was less than 5%, but this percentage was increasing further during the session, especially in the cranial and anterior tumor group. Conclusions More attention for intrafractional uncertainty of position is required in the treatment of cranial and anterior bladder tumors especially in the CC direction. The optimal internal margins in each direction should be chosen or a precise intrafractional target localization system is required depending on the tumor location and treatment delivery time in the setting of partial bladder radiotherapy.
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Affiliation(s)
- Kentaro Nishioka
- Department of Radiation Oncology, Hokkaido University Graduate School of Medicine / School of Medicine, Sapporo, Japan
| | - Shinichi Shimizu
- Department of Radiation Oncology, Hokkaido University Graduate School of Medicine / School of Medicine, Sapporo, Japan. .,Global Station for Quantum Medical Science and Engineering, Global Institution for Collaborative Research and Education (GI-CoRE), Hokkaido University, Sapporo, Japan.
| | - Nobuo Shinohara
- Department of Renal and Genitourinary Surgery, Hokkaido University Graduate School of Medicine / School of Medicine, Sapporo, Japan
| | - Yoichi M Ito
- Department of Biostatistics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takashige Abe
- Department of Renal and Genitourinary Surgery, Hokkaido University Graduate School of Medicine / School of Medicine, Sapporo, Japan
| | - Satoru Maruyama
- Department of Renal and Genitourinary Surgery, Hokkaido University Graduate School of Medicine / School of Medicine, Sapporo, Japan
| | - Norio Katoh
- Department of Radiation Medicine, Hokkaido University Graduate School of Medicine / School of Medicine, Sapporo, Japan
| | - Rumiko Kinoshita
- Department of Radiation Oncology, Hokkaido University Hospital, Sapporo, Japan
| | - Takayuki Hashimoto
- Department of Radiation Medicine, Hokkaido University Graduate School of Medicine / School of Medicine, Sapporo, Japan
| | - Naoki Miyamoto
- Department of Medical Physics, Hokkaido University Graduate School of Medicine / School of Medicine, Sapporo, Japan
| | - Rikiya Onimaru
- Department of Radiation Medicine, Hokkaido University Graduate School of Medicine / School of Medicine, Sapporo, Japan
| | - Hiroki Shirato
- Department of Radiation Medicine, Hokkaido University Graduate School of Medicine / School of Medicine, Sapporo, Japan.,Global Station for Quantum Medical Science and Engineering, Global Institution for Collaborative Research and Education (GI-CoRE), Hokkaido University, Sapporo, Japan
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Desai NB, Scott SN, Zabor EC, Cha EK, Hreiki J, Sfakianos JP, Ramirez R, Bagrodia A, Rosenberg JE, Bajorin DF, Berger MF, Bochner BH, Zelefsky MJ, Kollmeier MA, Ostrovnaya I, Al-Ahmadie HA, Solit DB, Iyer G. Genomic characterization of response to chemoradiation in urothelial bladder cancer. Cancer 2016; 122:3715-3723. [PMID: 27479538 PMCID: PMC5115929 DOI: 10.1002/cncr.30219] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 05/25/2016] [Accepted: 05/26/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND The authors characterized the genetic landscape of chemoradiation-treated urothelial carcinoma of the bladder (UCB) with the objective of identifying potential correlates of response. METHODS Primary tumors with (n = 8) or without (n = 40) matched recurrent tumors from 48 patients who had non-metastatic, high-grade UCB and received treatment primarily with chemoradiation were analyzed using a next-generation sequencing assay enriched for cancer-related and canonical DNA damage response (DDR) genes. Protein expression of meiotic recombination 11 homolog (MRE11), a previously suggested biomarker, was assessed in 44 patients. Recurrent tumors were compared with primary tumors, and the clinical impact of likely deleterious DDR gene alterations was evaluated. RESULTS The profile of alterations approximated that of prior UCB cohorts. Within 5 pairs of matched primary-recurrent tumors, a median of 92% of somatic mutations were shared. A median 33% of mutations were shared between 3 matched bladder-metastasis pairs. Of 26 patients (54%) who had DDR gene alterations, 12 (25%) harbored likely deleterious alterations. In multivariable analysis, these patients displayed a trend toward reduced bladder recurrence (hazard ratio, 0.32; P = .070) or any recurrence (hazard ratio, 0.37; P = .070). The most common of these alterations, ERCC2 (excision repair cross-complementation group 2) mutations, were associated with significantly lower 2-year metastatic recurrence (0% vs 43%; log-rank P = .044). No impact of MRE11 protein expression on outcome was detected. CONCLUSIONS A similar mutation profile between primary and recurrent tumors suggests that pre-existing, resistant clonal populations represent the primary mechanism of chemoradiation treatment failure. Deleterious DDR genetic alterations, particularly recurrent alterations in ERCC2, may be associated with improved chemoradiation outcomes in patients with UCB. A small sample size necessitates independent validation of these observations. Cancer 2016;122:3715-23. © 2016 American Cancer Society.
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Affiliation(s)
- Neil B Desai
- Department of Radiation Oncology, University of Texas Southwestern, Dallas, Texas
| | - Sasinya N Scott
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Emily C Zabor
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eugene K Cha
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, Cornell University, New York, New York
| | - Joseph Hreiki
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ricardo Ramirez
- Weill Cornell Graduate School of Medical Science, Cornell University, New York, New York
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Aditya Bagrodia
- Weill Cornell Medical College, Cornell University, New York, New York
| | - Jonathan E Rosenberg
- Weill Cornell Medical College, Cornell University, New York, New York
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Dean F Bajorin
- Weill Cornell Medical College, Cornell University, New York, New York
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael F Berger
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bernard H Bochner
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, Cornell University, New York, New York
| | - Michael J Zelefsky
- Weill Cornell Medical College, Cornell University, New York, New York
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marisa A Kollmeier
- Weill Cornell Medical College, Cornell University, New York, New York
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Irina Ostrovnaya
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hikmat A Al-Ahmadie
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, Cornell University, New York, New York
| | - David B Solit
- Weill Cornell Medical College, Cornell University, New York, New York
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Gopa Iyer
- Weill Cornell Medical College, Cornell University, New York, New York
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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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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21
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Pino Villarreal LE. Terapia trimodal en cáncer urotelial de vejiga. Rev Urol 2015. [DOI: 10.1016/j.uroco.2015.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Muscle-invasive bladder cancer treated with TURB followed by concomitant boost with small reduction of radiotherapy field with or without of chemotherapy. Rep Pract Oncol Radiother 2015; 21:31-6. [PMID: 26900355 DOI: 10.1016/j.rpor.2015.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 06/15/2015] [Accepted: 09/02/2015] [Indexed: 11/21/2022] Open
Abstract
AIM To evaluate the clinical outcome and toxicity of the treatment of muscle-invasive bladder cancer (MIBC) that combined transurethral resection of bladder tumor (TURB) with "concomitant boost" radiotherapy delivered over a shortened overall treatment time of 5 weeks, with or without concurrent chemotherapy. BACKGROUND Local control of MIBC by bladder-sparing approach is unsatisfactory. In order to improve the effectiveness of radiotherapy, we have designed a protocol that combines TURB with a non-conventionally fractionated radiotherapy "concomitant boost". MATERIALS AND METHODS Between 2004 and 2010, 73 patients with MIBC cT2-4aN0M0, were treated with "concomitant boost" radiotherapy. The whole bladder with a 2-3 cm margin was irradiated with fractions of 1.8 Gy to a dose of 45 Gy, with a "concomitant boost" to the bladder with 1-1.5 cm margin, during the last two weeks of treatment, as a second fraction of 1.5 Gy, to a total dose of 60 Gy. Radiochemotherapy using mostly cisplatin was delivered in 42/73(58%) patients, 31/73(42%) patients received radiotherapy alone. RESULTS Acute genitourinary toxicity of G3 was scored in 3/73(4%) patients. Late gastrointestinal toxicity higher than G2 and genitourinary higher than G3 were not reported. Complete remission was achieved in 48/73(66%), partial remission in 17/73(23%), and stabilization disease in 8/73(11%) patients. Three- and five-year overall, disease specific and invasive locoregional disease-free survival rates were 65% and 52%, 70% and 59%, 52% and 43%, respectively. CONCLUSIONS An organ-sparing approach using TURB followed by radio(chemo)therapy with "concomitant boost" in patients with MIBC allows to obtain long-term survival with acceptable toxicity.
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Braunstein LZ, Shipley WU, James ND, Apolo AB, Efstathiou JA. Integrating chemotherapy and radiotherapy for bladder cancer. Bladder Cancer 2015. [DOI: 10.1002/9781118674826.ch20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Premo C, Apolo AB, Agarwal PK, Citrin D. Trimodality therapy in bladder cancer: who, what, and when? Urol Clin North Am 2015; 42:169-80, vii. [PMID: 25882559 PMCID: PMC4465095 DOI: 10.1016/j.ucl.2015.02.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Radical cystectomy is a standard treatment of nonmetastatic, muscle-invasive bladder cancer. Treatment with trimodality therapy consisting of maximal transurethral resection of the bladder tumor followed by concurrent chemotherapy and radiation has emerged as a method to preserve the native bladder in highly motivated patients. Several factors can affect the likelihood of long-term bladder preservation after trimodality therapy and therefore should be taken into account when selecting patients. New radiation techniques such as intensity modulated radiation therapy and image-guided radiation therapy may decrease the toxicity of radiotherapy in this setting. Novel chemotherapy regimens may improve response rates and minimize toxicity.
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Affiliation(s)
- Christopher Premo
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, 10 CRC, B2-3500, Bethesda, MD 20892, , Phone: (301) 496-5457, Fax (301) 480-5439
| | - Andrea B. Apolo
- Bladder Cancer Section, Genitourinary Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, 10 Center Dr.12N226, MSC 1906, Bethesda, MD 20892, Tel: 301-451-1984, Fax: 301-402-0172,
| | - Piyush K. Agarwal
- Bladder Cancer Section, Urologic Oncology Branch, National Cancer Institute, NIH, Building 10, Room 2W-5940, Bethesda, MD 20892-1210, Office: 301-496-6353, Fax: 301-480-5626,
| | - Deborah Citrin
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, 10 CRC, B2-3500, Bethesda, MD 20892, , Phone: (301) 496-5457, Fax (301) 480-5439
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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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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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Bellefqih S, Khalil J, Mezouri I, ElKacemi H, Kebdani T, Hadadi K, Benjaafar N. [Concomitant chemoradiotherapy for muscle-invasive bladder cancer: current knowledge, controversies and future directions]. Cancer Radiother 2014; 18:779-89. [PMID: 25454383 DOI: 10.1016/j.canrad.2014.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 07/23/2014] [Accepted: 08/06/2014] [Indexed: 01/04/2023]
Abstract
Radical cystectomy with lymphadenectomy is currently the standard of care for muscle-invasive urothelial bladder cancer; however and because of its morbidity and its impact on quality of life, there is a growing tendency for bladder-sparing strategies. Initially reserved for elderly or unfit patients unable to undergo radical cystectomy, chemoradiotherapy became a true alternative to surgery for highly selected patients. Although there are no randomized trials comparing radical cystectomy with bladder preserving approaches, surgery remains the preferred treatment for many clinicians. Furthermore, comparison is even more difficult as modalities of radiotherapy are not consensual and differ between centers with a variability of protocols, volume of irradiation and type of chemotherapy. Several ongoing trials are attempting to optimize chemoradiotherapy and limit its toxicity, especially through techniques of adaptive radiotherapy or targeted therapies.
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Affiliation(s)
- S Bellefqih
- Service de radiothérapie, Institut national d'oncologie, université Mohammed-V Souissi, avenue Allal-El Fassi, 10100 Rabat, Maroc.
| | - J Khalil
- Service de radiothérapie, Institut national d'oncologie, université Mohammed-V Souissi, avenue Allal-El Fassi, 10100 Rabat, Maroc
| | - I Mezouri
- Service de radiothérapie, Institut national d'oncologie, université Mohammed-V Souissi, avenue Allal-El Fassi, 10100 Rabat, Maroc
| | - H ElKacemi
- Service de radiothérapie, Institut national d'oncologie, université Mohammed-V Souissi, avenue Allal-El Fassi, 10100 Rabat, Maroc
| | - T Kebdani
- Service de radiothérapie, Institut national d'oncologie, université Mohammed-V Souissi, avenue Allal-El Fassi, 10100 Rabat, Maroc
| | - K Hadadi
- Service de radiothérapie, hôpital militaire d'instruction Mohamed-V, 10100 Rabat, Maroc
| | - N Benjaafar
- Service de radiothérapie, Institut national d'oncologie, université Mohammed-V Souissi, avenue Allal-El Fassi, 10100 Rabat, Maroc
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Li J, Wang Q, Xiao B, Zhang X. Effect of internal iliac artery chemotherapy after transurethral resection of bladder tumor for muscle invasive bladder cancer. Chin J Cancer Res 2014; 26:558-63. [PMID: 25400421 DOI: 10.3978/j.issn.1000-9604.2014.10.05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 10/09/2014] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To evaluate the clinical effect of transurethral resection of bladder tumor (TUR-BT) combined with internal iliac artery chemotherapy and intravesical instillation therapy for muscle invasive bladder cancer (MIBC). METHODS From February 2007 to April 2014, 62 patients with MIBC were treated with TUR-BT combined with intravesical instillation therapy, with or without internal iliac artery chemotherapy, and the chemotherapy regimen is gemcitabine and cisplatin (GC). The bladder preservation and survival rate as well as cancer-specific survival (CSS) rate and overall survival (OS) rate of the two groups were compared. RESULTS Sixty-two patients were followed-up for 26-102 months with an average of 58.4±3.1 months. Recurrence-free survival (RFS) at 2-year for TUR + GC group and TUR group were 77.8% and 53.8%, respectively. Bladder preserved rate (BPR) at 3-year for TUR + GC group and TUR group were 94.4% and 80.8%. CSS rate at 2-year for TUR + GC group and TUR group were 94.4% and 84.6%. The disease-free survival (DFS) at 1-year for TUR + GC group and TUR group were 83.3% and 61.5%, and 77.8% and 53.8% for the 2(nd) year. OS at 2-year for TUR + GC group and TUR group were 88.9% and 92.3%. CONCLUSIONS TUR-BT and intravesical instillation therapy combined with internal iliac artery chemotherapy for MIBC had a better outcome at RFS, BPR and DFS than the treatment without internal iliac artery chemotherapy, and no difference in OS and CSS.
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Affiliation(s)
- Jianxing Li
- 1 Department of Urology, Beijing Tsinghua Changgung Hospital, Medical Centre, Tsinghua University, Beijing 102218, China ; 2 Department of Urology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Qi Wang
- 1 Department of Urology, Beijing Tsinghua Changgung Hospital, Medical Centre, Tsinghua University, Beijing 102218, China ; 2 Department of Urology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Bo Xiao
- 1 Department of Urology, Beijing Tsinghua Changgung Hospital, Medical Centre, Tsinghua University, Beijing 102218, China ; 2 Department of Urology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Xin Zhang
- 1 Department of Urology, Beijing Tsinghua Changgung Hospital, Medical Centre, Tsinghua University, Beijing 102218, China ; 2 Department of Urology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
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Yoshida S, Koga F, Kobayashi S, Tanaka H, Satoh S, Fujii Y, Kihara K. Diffusion-weighted magnetic resonance imaging in management of bladder cancer, particularly with multimodal bladder-sparing strategy. World J Radiol 2014; 6:344-354. [PMID: 24976935 PMCID: PMC4072819 DOI: 10.4329/wjr.v6.i6.344] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Accepted: 05/14/2014] [Indexed: 02/07/2023] Open
Abstract
Bladder-sparing strategy for muscle-invasive bladder cancer (MIBC) is increasingly demanded instead of radical cystectomy plus urinary diversion. Multimodal therapeutic approaches consisting of transurethral resection, chemotherapy, radiotherapy and/or partial cystectomy improve patients’ quality of life by preserving their native bladder and sexual function without compromising oncological outcomes. Because a favorable response to chemoradiotherapy (CRT) is a prerequisite for successful bladder preservation, predicting and monitoring therapeutic response is an essential part of this approach. Diffusion-weighted magnetic resonance imaging (DW-MRI) is a functional imaging technique increasingly applied to various types of cancers. Contrast in this imaging technique derives from differences in the motion of water molecules among tissues and this information is useful in assessing the biological behavior of cancers. Promising results in predicting and monitoring the response to CRT have been reported in several types of cancers. Recently, growing evidence has emerged showing that DW-MRI can serve as an imaging biomarker in the management of bladder cancer. The qualitative analysis of DW-MRI can be applied to detecting cancerous lesion and monitoring the response to CRT. Furthermore, the potential role of quantitative analysis by evaluating apparent diffusion coefficient values has been shown in characterizing bladder cancer for biological aggressiveness and sensitivity to CRT. DW-MRI is a potentially useful tool for the management of bladder cancer, particularly in multimodal bladder-sparing approaches for MIBC.
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Affiliation(s)
- Jong Chul Park
- Lombardi Comprehensive Cancer Center, Georgetown University Hospital, Washington, DC
| | - Deborah E. Citrin
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Piyush K. Agarwal
- Urologic Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Andrea B. Apolo
- Genitourinary Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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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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Biancia CD, Yorke E, Kollmeier MA. Image guided radiation therapy for bladder cancer: Assessment of bladder motion using implanted fiducial markers. Pract Radiat Oncol 2014; 4:108-115. [DOI: 10.1016/j.prro.2013.07.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 07/03/2013] [Accepted: 07/08/2013] [Indexed: 10/26/2022]
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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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Nishioka K, Shimizu S, Shinohara N, Ito YM, Abe T, Maruyama S, Kinoshita R, Harada K, Nishikawa N, Miyamoto N, Onimaru R, Shirato H. Prospective phase II study of image-guided local boost using a real-time tumor-tracking radiotherapy (RTRT) system for locally advanced bladder cancer. Jpn J Clin Oncol 2013; 44:28-35. [PMID: 24302759 PMCID: PMC3880146 DOI: 10.1093/jjco/hyt182] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The real-time tumor-tracking radiotherapy system with fiducial markers has the advantage that it can be used to verify the localization of the markers during radiation delivery in real-time. We conducted a prospective Phase II study of image-guided local-boost radiotherapy for locally advanced bladder cancer using a real-time tumor-tracking radiotherapy system for positioning, and here we report the results regarding the safety and efficacy of the technique. METHODS Twenty patients with a T2-T4N0M0 urothelial carcinoma of the bladder who were clinically inoperable or refused surgery were enrolled. Transurethral tumor resection and 40 Gy irradiation to the whole bladder was followed by the transurethral endoscopic implantation of gold markers in the bladder wall around the primary tumor. A boost of 25 Gy in 10 fractions was made to the primary tumor while maintaining the displacement from the planned position at less than ±2 mm during radiation delivery using a real-time tumor-tracking radiotherapy system. The toxicity, local control and survival were evaluated. RESULTS Among the 20 patients, 14 were treated with concurrent chemoradiotherapy. The median follow-up period was 55.5 months. Urethral and bowel late toxicity (Grade 3) were each observed in one patient. The local-control rate, overall survival and cause-specific survival with the native bladder after 5 years were 64, 61 and 65%. CONCLUSIONS Image-guided local-boost radiotherapy using a real-time tumor-tracking radiotherapy system can be safely accomplished, and the clinical outcome is encouraging. A larger prospective multi-institutional study is warranted for more precise evaluations of the technological efficacy and patients' quality of life.
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Affiliation(s)
- Kentaro Nishioka
- *Department of Radiation Medicine, Hokkaido University Graduate School of Medicine/School of Medicine, Sapporo, Japan.
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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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Marta GN, Hanna SA, Gadia R, Correa SFM, Silva JLFD, Carvalho HDA. The role of radiotherapy in urinary bladder cancer: current status. Int Braz J Urol 2013; 38:144-53; discussion 153-4. [PMID: 22555038 DOI: 10.1590/s1677-55382012000200002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2011] [Indexed: 11/21/2022] Open
Abstract
The role of radiotherapy (RT) in the treatment of urinary bladder cancer has undergone several modifications along the last decades. In the beginning, definitive RT was used as treatment in an attempt to preserve the urinary bladder; however, the results were poor compared to those of radical surgery. Recently, many protocols have been developed supporting the use of multi-modality therapy, and the concept of organ preservation began to be reconsidered. Although phase III randomized clinical studies comparing radical cystectomy with bladder preservation therapies do not exist, the conservative treatment may present low toxicity and high indexes of complete response for selected patients. The aim of this study was to review the literature on the subject in order to situate RT in the current treatment of urinary bladder cancer.
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Affiliation(s)
- Gustavo Nader Marta
- Department of Radiation Oncology-Oncology Center, Hospital Sirio-Libanes, Sao Paulo, Brazil.
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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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Transurethral resection, neoadjuvant chemotherapy and accelerated hyperfractionated radiotherapy (concomitant boost), with or without concurrent cisplatin, for patients with invasive bladder cancer - clinical outcome. Contemp Oncol (Pozn) 2013; 17:302-6. [PMID: 24596519 PMCID: PMC3934068 DOI: 10.5114/wo.2013.35276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Revised: 11/25/2012] [Accepted: 01/10/2013] [Indexed: 11/17/2022] Open
Abstract
AIM OF THE STUDY To evaluate the toxicity, clinical effectiveness and survival rate of transurethral resection, neoadjuvant chemotherapy and accelerated hyperfractionated radiotherapy (concomitant boost), with or without concurrent cisplatin in patients with muscle invasive bladder cancer. MATERIAL AND METHODS Between March 2004 and December 2009, 35 patients with histologically proven invasive carcinoma of the bladder (T2-4a, N0-1, M0), who were fit for combined radiochemotherapy and refused radical surgery or were medically or surgically inoperable, were selected for the bladder-sparing protocol. RESULTS In this study, twenty-five patients (25/35; 72%) received two cycles of neoadjuvant chemotherapy, and ten of them (10/35; 28%) only one, because of treatment-related toxicity. In twenty-one patients (21/35; 60%) chemotherapy consisting of gemcitabine with cisplatin and in fourteen patients (14/35; 40%) gemcitabine with carboplatin were applied. Only 13 patients (13/35; 37%) received combined irradiation with cisplatin. All patients completed their planned course of radiation therapy. Complete response (CR) occurred in 26/35 (74%) patients, partial response (PR) in 2/35(6%), and stable disease (SD) in 7/35 (20%). The overall actuarial survival rates at 3 and 5 years were 75% and 66%, respectively. Disease-specific actuarial survival rates at 3 and 5 years were 81% and 71%, respectively. CONCLUSIONS Conservative treatment of patients with muscle-invasive bladder cancer by transurethral resection, neoadjuvant chemotherapy, and accelerated hyperfractionated radiotherapy with concomitant boost, with or without concurrent cisplatin, provides a high probability of local and distal response with acceptable toxicity in properly selected patients.
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Sapre N, Anderson P, Foroudi F. Management of local recurrences in the irradiated bladder: a systematic review. BJU Int 2012. [DOI: 10.1111/j.1464-410x.2012.11476.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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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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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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Khosravi-Shahi P, Cabezón-Gutiérrez L. Selective organ preservation in muscle-invasive bladder cancer: review of the literature. Surg Oncol 2011; 21:e17-22. [PMID: 22088598 DOI: 10.1016/j.suronc.2011.10.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2011] [Revised: 10/27/2011] [Accepted: 10/30/2011] [Indexed: 11/19/2022]
Abstract
The standard of care for transitional-cell carcinoma of the bladder with invasion to the muscularis propria is radical cystectomy with bilateral pelvic lymph node dissection. However, currently there is a tendency for organ preservation in selected cases of muscle-invasive bladder cancer. Trimodality treatment, including transurethral resection of the bladder tumor (TURBT), radiation therapy and chemotherapy, has been shown to produce 5-year and 10-year overall survival rates comparable to those of radical cystectomy. The current 5-year overall survival rates range from 50 to 67% with trimodality treatment, and approximately 75% of the surviving patients maintains their bladder. After trimodality treatment complete response is obtained in more than 70% of patients with muscle-invasive bladder cancer. Clinical criteria helpful in determining patients for bladder preservation include such variables as small tumor size (<2 cm), early tumor stage (T2-T3 disease), a visibly and microscopically complete TURBT, absence of ureteral obstruction, no evidence of pelvic lymph node metastases, and absence of carcinoma in situ (Tis). The close collaboration of urologists, radiation oncologists and medical oncologists is of paramount importance in succeeding in bladder preservation.
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Affiliation(s)
- Parham Khosravi-Shahi
- Servicio de Oncología, Hospital de Torrejón, Calle Mateo Inurria, s/n, Torrejón de Ardoz, 28850 Madrid, Spain.
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Iwai A, Koga F, Fujii Y, Masuda H, Saito K, Numao N, Sakura M, Kawakami S, Kihara K. Perioperative complications of radical cystectomy after induction chemoradiotherapy in bladder-sparing protocol against muscle-invasive bladder cancer: a single institutional retrospective comparative study with primary radical cystectomy. Jpn J Clin Oncol 2011; 41:1373-9. [PMID: 21994208 DOI: 10.1093/jjco/hyr150] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To compare rates of early morbidity after radical cystectomy in patients treated with or without induction chemoradiotherapy (CRT) using a standardized reporting methodology. METHODS All 193 consecutive patients undergoing radical cystectomy for bladder cancer between 1989 and 2010 were retrospectively reviewed. Induction chemoradiotherapy consists of radiation at 40 Gy to the small pelvis and two cycles of concurrent cisplatin at 20 mg/day for 5 days. Deaths within 90 days after radical cystectomy and complications arising within 30 days were recorded and graded according to the Clavien-Dindo classification. Grades 1-2 were considered minor; Grades 3-5 were considered major. RESULTS Eighty-seven patients underwent radical cystectomy following chemoradiotherapy (chemoradiotherapy group) while the remaining 106 primarily underwent radical cystectomy (no chemoradiotherapy group). No Grade 4-5 complication was observed. Overall, 118 patients (61%) experienced 36 major and 122 minor complications. There was no significant difference in the incidence of overall complications between the chemoradiotherapy and no chemoradiotherapy groups (67 vs. 57%). Overall urinary anastomosis-related complications and major gastrointestinal complications, most of which were Grade 3 ileus, were more frequent in the chemoradiotherapy group than the no chemoradiotherapy group (11 vs. 2%, P = 0.007; and 14 vs. 4%, P = 0.02; respectively). Multivariate analysis identified induction chemoradiotherapy as an independent risk factor for overall urinary anastomosis-related complications (relative risk 6.0, P = 0.01) but not for major gastrointestinal complications. CONCLUSIONS Induction chemoradiotherapy at 40 Gy in bladder-sparing protocols against MIBC is unlikely to increase the rate of severe complications of radical cystectomy.
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Affiliation(s)
- Aki Iwai
- Department of Urology, Tokyo Medical and Dental University Graduate School, Yushima, Tokyo 113-8519, Japan
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Prasad SM, Decastro GJ, Steinberg GD. Urothelial carcinoma of the bladder: definition, treatment and future efforts. Nat Rev Urol 2011; 8:631-42. [PMID: 21989305 DOI: 10.1038/nrurol.2011.144] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The identification of patients with high-risk bladder cancer is important for the timely and appropriate treatment of this lethal disease. The understanding of the natural history of bladder cancer has improved; however, the criteria used to define high-risk disease and the relevant treatment strategies have remained the same for the past several decades, despite multiple large, randomized, prospective clinical trials that have evaluated the use of intravesical, surgical and systemic therapies. The genetic signature of high-risk bladder cancer has been a focus of investigation and has led to the discovery of potential molecular targets for disease identification, risk stratification and therapy. These advances, combined with a comprehensive risk assessment profile that incorporates available pathological and clinical characteristics, might improve the diagnosis and treatment of patients with bladder cancer.
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Affiliation(s)
- Sandip M Prasad
- Section of Urology, University of Chicago Medical Center, 5841 South Maryland Avenue, MC 6038, Chicago, IL 60637, 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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Hara T, Nishijima J, Miyachika Y, Yamamoto Y, Sakano S, Matsuyama H. Primary cT2 Bladder Cancer: A Good Candidate for Radiotherapy Combined with Cisplatin for Bladder Preservation. Jpn J Clin Oncol 2011; 41:902-7. [DOI: 10.1093/jjco/hyr064] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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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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