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Witjes JA, Bruins HM, Cathomas R, Compérat EM, Cowan NC, Gakis G, Hernández V, Linares Espinós E, Lorch A, Neuzillet Y, Rouanne M, Thalmann GN, Veskimäe E, Ribal MJ, van der Heijden AG. European Association of Urology Guidelines on Muscle-invasive and Metastatic Bladder Cancer: Summary of the 2020 Guidelines. Eur Urol 2020; 79:82-104. [PMID: 32360052 DOI: 10.1016/j.eururo.2020.03.055] [Citation(s) in RCA: 1076] [Impact Index Per Article: 269.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 03/31/2020] [Indexed: 01/11/2023]
Abstract
CONTEXT This overview presents the updated European Association of Urology (EAU) guidelines for muscle-invasive and metastatic bladder cancer (MMIBC). OBJECTIVE To provide practical evidence-based recommendations and consensus statements on the clinical management of MMIBC with a focus on diagnosis and treatment. EVIDENCE ACQUISITION A broad and comprehensive scoping exercise covering all areas of the MMIBC guideline has been performed annually since its 2017 publication (based on the 2016 guideline). Databases covered by the search included Medline, EMBASE, and the Cochrane Libraries, resulting in yearly guideline updates. A level of evidence and a grade of recommendation were assigned. Additionally, the results of a collaborative multistakeholder consensus project on advanced bladder cancer (BC) have been incorporated in the 2020 guidelines, addressing those areas where it is unlikely that prospective comparative studies will be conducted. EVIDENCE SYNTHESIS Variant histologies are increasingly reported in invasive BC and are relevant for treatment and prognosis. Staging is preferably done with (enhanced) computerised tomography scanning. Treatment decisions are still largely based on clinical factors. Radical cystectomy (RC) with lymph node dissection remains the recommended treatment in highest-risk non-muscle-invasive and muscle-invasive nonmetastatic BC, preceded by cisplatin-based neoadjuvant chemotherapy (NAC) for invasive tumours in "fit" patients. Selected men and women benefit from sexuality sparing RC, although this is not recommended as standard therapy. Open and robotic RC show comparable outcomes, provided the procedure is performed in experienced centres. For open RC 10, the minimum selected case load is 10 procedures per year. If bladder preservation is considered, chemoradiation is an alternative in well-selected patients without carcinoma in situ and after maximal resection. Adjuvant chemotherapy should be considered if no NAC was given. Perioperative immunotherapy can be offered in clinical trial setting. For fit metastatic patients, cisplatin-based chemotherapy remains the first choice. In cisplatin-ineligible patients, immunotherapy in Programmed Death Ligand 1 (PD-L1)-positive patients or carboplatin in PD-L1-negative patients is recommended. For second-line treatment in metastatic disease, pembrolizumab is recommended. Postchemotherapy surgery may prolong survival in responders. Quality of life should be monitored in all phases of treatment and follow-up. The extended version of the guidelines is available at the EAU website: https://uroweb.org/guideline/bladder-cancer-muscle-invasive-and-metastatic/. CONCLUSIONS This summary of the 2020 EAU MMIBC guideline provides updated information on the diagnosis and treatment of MMIBC for incorporation into clinical practice. PATIENT SUMMARY The European Association of Urology Muscle-invasive and Metastatic Bladder Cancer (MMIBC) Panel has released an updated version of their guideline, which contains information on histology, staging, prognostic factors, and treatment of MMIBC. The recommendations are based on the current literature (until the end of 2019), with emphasis on high-level data from randomised clinical trials and meta-analyses and on the findings of an international consensus meeting. Surgical removal of the bladder and bladder preservation are discussed, as well as the use of chemotherapy and immunotherapy in localised and metastatic disease.
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Affiliation(s)
- J Alfred Witjes
- Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
| | - Harman Max Bruins
- Department of Urology, Zuyderland Medical Center, Sittard-Geleen-Heerlen, The Netherlands
| | - Richard Cathomas
- Department of Medical Oncology, Kantonsspital Graubünden, Chur, Switzerland
| | - Eva M Compérat
- Department of Pathology, Sorbonne University, Assistance Publique-Hôpitaux de Paris, Hopital Tenon, Paris, France
| | - Nigel C Cowan
- Department of Radiology, The Queen Alexandra Hospital, Portsmouth, UK
| | - Georgios Gakis
- Department of Urology and Pediatric Urology, University of Würzburg, Würzburg, Germany
| | - Virginia Hernández
- Department of Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | | | - Anja Lorch
- Department of Medical Oncology and Hematology, University Hospital Zürich, Zürich, Switzerland
| | - Yann Neuzillet
- Department of Urology, Foch Hospital, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France
| | - Mathieu Rouanne
- Department of Urology, Foch Hospital, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France
| | - George N Thalmann
- Department of Urology, Inselspital, University Hospital Bern, Switzerland
| | - Erik Veskimäe
- Department of Urology, Tampere University Hospital, Tampere, Finland
| | - Maria J Ribal
- Department of Urology, Hospital Clinic, University of Barcelona, Barcelona, Spain
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Hermans TJN, Voskuilen CS, Deelen M, Mertens LS, Horenblas S, Meijer RP, Boormans JL, Aben KK, van der Heijden MS, Pos FJ, de Wit R, Beerepoot LV, Verhoeven RHA, van Rhijn BWG. Superior efficacy of neoadjuvant chemotherapy and radical cystectomy in cT3-4aN0M0 compared to cT2N0M0 bladder cancer. Int J Cancer 2018; 144:1453-1459. [PMID: 30155893 DOI: 10.1002/ijc.31833] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/09/2018] [Accepted: 07/26/2018] [Indexed: 11/09/2022]
Abstract
In this study, we compared complete pathological downstaging (pCD, ≤(y)pT1N0) and overall survival (OS) in patients with cT2 versus cT3-4aN0M0 UC of the bladder undergoing radical cystectomy (RC) with or without neoadjuvant chemo- (NAC) or radiotherapy (NAR). A population-based sample of 5,517 patients, who underwent upfront RC versus NAC + RC or NAR + RC for cT2-4aN0M0 UC between 1995-2013, was identified from the Netherlands Cancer Registry. Data were retrieved from individual patient files and pathology reports. pCD-rates were compared using Chi-square tests and OS was estimated by Kaplan-Meier analyses. Multivariable analyses were conducted to determine odds (OR) and hazard ratios (HR) for pCD-status and OS, respectively. We included 4,504 (82%) patients with cT2 and 1,013 (18%) with cT3-4a UC. Median follow-up was 9.2 years. In cT2 UC, pCD-rate was 25% after upfront RC versus 43% (p < 0.001) and 33% (p = 0.130) after NAC + RC and NAR + RC, respectively. In cT3-4a UC, pCD-rate was 8% after upfront RC versus 37% (p < 0.001) and 16% (p = 0.281) after NAC + RC and NAR + RC, respectively. In cT2 UC, 5-year OS was 57% and 51% for NAC + RC and upfront RC, respectively (p = 0.135), whereas in cT3-4a UC, 5-year OS was 55% for NAC + RC versus 36% for upfront RC (p < 0.001). In multivariable analysis for OS, NAC was beneficial in cT3-4a UC (HR: 0.67, 95%CI 0.51-0.89) but not in cT2 UC (HR: 0.91, 95%CI 0.72-1.15). NAR did not influence OS. In conclusion, NAC + RC was associated with superior pCD compared to RC alone and NAR + RC. Superior OS for NAC + RC compared to RC alone was especially evident in cT3-4a disease.
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Affiliation(s)
- T J N Hermans
- Department of Surgical Oncology, Division of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - C S Voskuilen
- Department of Surgical Oncology, Division of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - M Deelen
- Department of Surgical Oncology, Division of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - L S Mertens
- Department of Surgical Oncology, Division of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - S Horenblas
- Department of Surgical Oncology, Division of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - R P Meijer
- Department of Surgical Oncology, Division of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.,Department of Urology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J L Boormans
- Department of Urology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - K K Aben
- Department of Research, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands.,Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - M S van der Heijden
- Department of Medical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - F J Pos
- Department of Radiation Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - R de Wit
- Department of Medical Oncology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - L V Beerepoot
- Department of Medical Oncology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - R H A Verhoeven
- Department of Research, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands
| | - B W G van Rhijn
- Department of Surgical Oncology, Division of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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Hermans TJN, Voskuilen CS, van der Heijden MS, Schmitz-Dräger BJ, Kassouf W, Seiler R, Kamat AM, Grivas P, Kiltie AE, Black PC, van Rhijn BWG. Neoadjuvant treatment for muscle-invasive bladder cancer: The past, the present, and the future. Urol Oncol 2018; 36:413-422. [PMID: 29128420 DOI: 10.1016/j.urolonc.2017.10.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 10/01/2017] [Accepted: 10/16/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Approximately half of patients who undergo radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC) will succumb to metastatic disease. We summarize the evidence for neoadjuvant radiation (NAR), chemo (NAC), and immunotherapy (checkpoint inhibition) prior to RC for MIBC. MATERIALS AND METHODS Data were obtained by a search of PubMed, ClinicalTrials.gov, and Cochrane databases for English language articles published from 1925 up to 2017. RESULTS NAC usage has increased over the last decade, while NAR is rarely administered. Although NAR results in downstaging, its impact on survival is inconclusive. Based on level I evidence, cisplatin-based NAC (CB-NAC) is considered standard of care in cT2-4aN0M0 MIBC. NAC results in a 6% absolute 10-year overall survival (OS) benefit. In-depth analyses of key randomized controlled trials showed that failure to correct for uniform staging, surgical variation, and patient selection compromises the ability to identify factors predictive of response to NAC. The benefit appears to be restricted to patients downstaged to ypT1N0 or less. In these patients, 5-year OS is 80% to 90%. Regarding a number needed to treat of 17, most patients with cT2-4aN0M0 MIBC will be exposed to toxicity without benefit. Possible approaches to reduce overtreatment are suggested in this article and include patient selection, the chosen NAC regimen, and emerging molecular data to predict responsiveness to NAC. Neoadjuvant immunotherapy with checkpoint inhibitors is a promising future perspective currently under investigation. CONCLUSIONS Past studies on NAR show inconclusive results and NAR is rarely administered. Instead, CB-NAC is advised in eligible patients with cT2-4aN0M0 MIBC prior to RC. In the near future, predictive biomarkers will be the key to tailor the use of CB-NAC and reduce harm to nonresponders.
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Affiliation(s)
- Tom J N Hermans
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Charlotte S Voskuilen
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Michiel S van der Heijden
- Department of Medical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Bernd J Schmitz-Dräger
- Department of Urology, Friedrich-Alexander University, Erlangen, Germany; Department of Urology, Schön-Klinik, Nürnberg/Fürth, Germany
| | - Wassim Kassouf
- Department of Surgery, Division of Urology, McGill University Health Center, Montreal, Canada
| | - Roland Seiler
- Department of Urology, Inselspital, University of Bern, Bern, Switzerland
| | - Ashish M Kamat
- Department of Urology, The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Petros Grivas
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Anne E Kiltie
- Department of Radiation Oncology, CRUK/MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, United Kingdom
| | - Peter C Black
- Department of Urologic Sciences, Vancouver Prostate Centre, University of British Columbia, Vancouver, Canada
| | - Bas W G van Rhijn
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
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Alfred Witjes J, Lebret T, Compérat EM, Cowan NC, De Santis M, Bruins HM, Hernández V, Espinós EL, Dunn J, Rouanne M, Neuzillet Y, Veskimäe E, van der Heijden AG, Gakis G, Ribal MJ. Updated 2016 EAU Guidelines on Muscle-invasive and Metastatic Bladder Cancer. Eur Urol 2016; 71:462-475. [PMID: 27375033 DOI: 10.1016/j.eururo.2016.06.020] [Citation(s) in RCA: 1051] [Impact Index Per Article: 131.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 06/13/2016] [Indexed: 12/20/2022]
Abstract
CONTEXT Invasive bladder cancer is a frequently occurring disease with a high mortality rate despite optimal treatment. The European Association of Urology (EAU) Muscle-invasive and Metastatic Bladder Cancer (MIBC) Guidelines are updated yearly and provides information to optimise diagnosis, treatment, and follow-up of this patient population. OBJECTIVE To provide a summary of the EAU guidelines for physicians and patients confronted with muscle-invasive and metastatic bladder cancer. EVIDENCE ACQUISITION An international multidisciplinary panel of bladder cancer experts reviewed and discussed the results of a comprehensive literature search of several databases covering all sections of the guidelines. The panel defined levels of evidence and grades of recommendation according to an established classification system. EVIDENCE SYNTHESIS Epidemiology and aetiology of bladder cancer are discussed. The proper diagnostic pathway, including demands for pathology and imaging, is outlined. Several treatment options, including bladder-sparing treatments and combinations of treatment modalities (different forms of surgery, radiation therapy, and chemotherapy) are described. Sequencing of these modalities is discussed. Potential indications and contraindications, such as comorbidity, are related to treatment choice. There is a new paragraph on organ-sparing approaches, both in men and in women, and on minimal invasive surgery. Recommendations for chemotherapy in fit and unfit patients are provided including second-line options. Finally, a follow-up schedule is provided. CONCLUSIONS The current summary of the EAU Muscle-invasive and Metastatic Bladder Cancer Guidelines provides an up-to-date overview of the available literature and evidence dealing with diagnosis, treatment, and follow-up of patients with metastatic and muscle-invasive bladder cancer. PATIENT SUMMARY Bladder cancer is an important disease with a high mortality rate. These updated guidelines help clinicians refine the diagnosis and select the appropriate therapy and follow-up for patients with metastatic and muscle-invasive bladder cancer.
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Affiliation(s)
- J Alfred Witjes
- Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
| | - Thierry Lebret
- Hôpital Foch, Department of Urology, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France
| | - Eva M Compérat
- Department of Pathology, Hôpital La Pitié Salpetrière, UPMC, Paris, France
| | - Nigel C Cowan
- Radiology Department, Queen Alexandra Hospital, Portsmouth, UK
| | - Maria De Santis
- University of Warwick, Cancer Research Unit, Coventry, UK; Queen Elizabeth Hospital, Birmingham, UK
| | - Harman Maxim Bruins
- Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Virginia Hernández
- Department of Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | | | - James Dunn
- Department of Urology, Derriford Hospital, Plymouth, UK
| | - Mathieu Rouanne
- Hôpital Foch, Department of Urology, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France
| | - Yann Neuzillet
- Hôpital Foch, Department of Urology, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France
| | - Erik Veskimäe
- Department of Urology, Tampere University Hospital, Tampere, Finland
| | | | - Georgios Gakis
- Department of Urology, Eberhard-Karls University, Tübingen, Germany
| | - Maria J Ribal
- Department of Urology, Hospital Clinic, University of Barcelona, Barcelona, Spain
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Perioperative treatment and radical cystectomy for bladder cancer – a population based trend analysis of 10,338 patients in the Netherlands. Eur J Cancer 2016; 54:18-26. [DOI: 10.1016/j.ejca.2015.11.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Revised: 11/05/2015] [Accepted: 11/07/2015] [Indexed: 11/21/2022]
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Quinn DI, Sternberg CN. Neoadjuvant chemotherapy in the treatment of muscle-invasive bladder cancer. Bladder Cancer 2015. [DOI: 10.1002/9781118674826.ch25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Correlation of Pathologic Complete Response with Survival After Neoadjuvant Chemotherapy in Bladder Cancer Treated with Cystectomy: A Meta-analysis. Eur Urol 2014; 65:350-7. [DOI: 10.1016/j.eururo.2013.06.049] [Citation(s) in RCA: 200] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 06/25/2013] [Indexed: 11/17/2022]
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EAU guidelines on muscle-invasive and metastatic bladder cancer: summary of the 2013 guidelines. Eur Urol 2013; 65:778-92. [PMID: 24373477 DOI: 10.1016/j.eururo.2013.11.046] [Citation(s) in RCA: 739] [Impact Index Per Article: 67.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 11/29/2013] [Indexed: 01/08/2023]
Abstract
CONTEXT The European Association of Urology (EAU) guidelines panel on Muscle-invasive and Metastatic bladder cancer (BCa) updates its guidelines yearly. This updated summary provides a synthesis of the 2013 guidelines document, with emphasis on the latest developments. OBJECTIVE To provide graded recommendations on the diagnosis and treatment of patients with muscle-invasive BCa (MIBC), linked to a level of evidence. EVIDENCE ACQUISITION For each section of the guidelines, comprehensive literature searches covering the past 10 yr in several databases were conducted, scanned, reviewed, and discussed both within the panel and with external experts. The final results are reflected in the recommendations provided. EVIDENCE SYNTHESIS Smoking and work-related carcinogens remain the most important risk factors for BCa. Computed tomography (CT) and magnetic resonance imaging can be used for staging, although CT is preferred for pulmonary evaluation. Open radical cystectomy with an extended lymph node dissection (LND) remains the treatment of choice for treatment failures in non-MIBC and T2-T4aN0M0 BCa. For well-informed, well-selected, and compliant patients, however, multimodality treatment could be offered as an alternative, especially if cystectomy is not an option. Comorbidity, not age, should be used when deciding on radical cystectomy. Patients should be encouraged to actively participate in the decision-making process, and a continent urinary diversion should be offered to all patients unless there are specific contraindications. For fit patients, cisplatinum-based neoadjuvant chemotherapy should always be discussed, since it improves overall survival. For patients with metastatic disease, cisplatin-containing combination chemotherapy is recommended. For unfit patients, carboplatin combination chemotherapy or single agents can be used. CONCLUSIONS This 2013 EAU Muscle-invasive and Metastatic BCa guidelines updated summary aims to increase the quality of care and outcome for patients with muscle-invasive or metastatic BCa. PATIENT SUMMARY In this paper we update the EAU guidelines on Muscle-invasive and Metastatic bladder cancer. We recommend that chemotherapy be administered before radical treatment and that bladder removal be the standard of care for disease confined to the bladder.
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Hansel DE, Amin MB, Comperat E, Cote RJ, Knüchel R, Montironi R, Reuter VE, Soloway MS, Umar SA, Van der Kwast TH. A Contemporary Update on Pathology Standards for Bladder Cancer: Transurethral Resection and Radical Cystectomy Specimens. Eur Urol 2013; 63:321-32. [DOI: 10.1016/j.eururo.2012.10.008] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Accepted: 10/05/2012] [Indexed: 11/29/2022]
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Stenzl A, Cowan NC, De Santis M, Kuczyk MA, Merseburger AS, Ribal MJ, Sherif A, Witjes JA. [Treatment of muscle-invasive and metastatic bladder cancer: update of the EAU guidelines]. Actas Urol Esp 2012; 36:449-60. [PMID: 22386114 DOI: 10.1016/j.acuro.2011.11.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Accepted: 11/16/2011] [Indexed: 01/26/2023]
Abstract
CONTEXT New data regarding treatment of muscle-invasive and metastatic bladder cancer (MiM-BC) has emerged and led to an update of the European Association of Urology (EAU) guidelines for MiM-BC. OBJECTIVE To review the new EAU guidelines for MiM-BC with a specific focus on treatment. EVIDENCE ACQUISITION New literature published since the last update of the EAU guidelines in 2008 was obtained from Medline, the Cochrane Database of Systematic Reviews, and reference lists in publications and review articles and comprehensively screened by a group of urologists, oncologists, and a radiologist appointed by the EAU Guidelines Office. Previous recommendations based on the older literature on this subject were also taken into account. Levels of evidence (LEs) and grades of recommendations (GRs) were added based on a system modified from the Oxford Centre for Evidence-based Medicine Levels of Evidence. EVIDENCE SYNTHESIS Current data demonstrate that neoadjuvant chemotherapy in conjunction with radical cystectomy (RC) is recommended in certain constellations of MiM-BC. RC remains the basic treatment of choice in localised invasive disease for both sexes. An attempt has been made to define the extent of surgery under standard conditions in both sexes. An orthotopic bladder substitute should be offered to both male and female patients lacking any contraindications, such as no tumour at the level of urethral dissection. In contrast to neoadjuvant chemotherapy, current advice recommends the use of adjuvant chemotherapy only within clinical trials. Multimodality bladder-preserving treatment in localised disease is currently regarded only as an alternative in selected, well-informed, and compliant patients for whom cystectomy is not considered for medical or personal reasons. In metastatic disease, the first-line treatment for patients fit enough to sustain cisplatin remains cisplatin-containing combination chemotherapy. With the advent of vinflunine, second-line chemotherapy has become available. CONCLUSIONS In the treatment of localised invasive bladder cancer (BCa), the standard treatment remains radical surgical removal of the bladder within standard limits, including as-yet-unspecified regional lymph nodes. However, the addition of neoadjuvant chemotherapy must be considered for certain specific patient groups. A new drug for second-line chemotherapy (vinflunine) in metastatic disease has been approved and is recommended.
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Affiliation(s)
- A Stenzl
- Servicio de Urología, Universidad Eberhard-KarlsTuebingen, Alemania.
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Stenzl A, Cowan N, De Santis M, Kuczyk M, Merseburger A, Ribal M, Sherif A, Witjes J. Treatment of muscle-invasive and metastatic bladder cancer: Update of the EAU guidelines. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.acuroe.2011.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Pathologic downstaging is a surrogate marker for efficacy and increased survival following neoadjuvant chemotherapy and radical cystectomy for muscle-invasive urothelial bladder cancer. Eur Urol 2011; 61:1229-38. [PMID: 22189383 DOI: 10.1016/j.eururo.2011.12.010] [Citation(s) in RCA: 209] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Accepted: 12/05/2011] [Indexed: 11/23/2022]
Abstract
BACKGROUND Characterising responders to neoadjuvant chemotherapy (NAC) is important to minimise overtreatment and the unnecessary delay of definitive treatment of urothelial urinary bladder cancer. OBJECTIVE To assess the effect of NAC on tumour downstaging and overall survival. DESIGN, SETTING, AND PARTICIPANTS A total of 449 patients from the randomised prospective Nordic Cystectomy Trials 1 and 2 were analysed retrospectively. Eligible patients were defined as T2-T4aNXM0 preoperatively and pT0-pT4aN0-N+M0 postoperatively. The median follow-up time was 5 yr. INTERVENTION The experimental arm consisted of cisplatin-based NAC; the control arm consisted of cystectomy only. MEASUREMENTS The primary outcome was tumour downstaging defined as pathologic TNM less than clinical TNM. Different downstaging thresholds were applied: complete downstaging (CD) (pT0N0), noninvasive downstaging (NID) (pT0/pTis/pTaN0), and organ confinement (OC) (≤ pT3aN0). Downstaging rates and nodal status were compared between the study arms using the chi-square test. Secondary outcome was overall survival (OS) stratified by treatment arm, downstaging categories, and clinical stages, analysed by the Kaplan-Meier method. The following covariates were tested as prognostic factors in univariate and multivariate analyses using the Cox regression method: age, sex, clinical stage, pN status, NAC, CD, NID, and OC. RESULTS AND LIMITATIONS Downstaging rates increased significantly in the NAC arm independent of the downstaging threshold. The impact was more prominent in clinical T3 tumours, with a near threefold increase in CD tumours. The combination of CD and NAC showed an absolute risk reduction of 31.1% in OS at 5 yr compared with CD controls. The combination of NAC and CD revealed a hazard ratio of 0.32 compared with 1.0 for the combination of no NAC and no CD. Limitations were the retrospective approach and uncertain clinical TNM staging. CONCLUSIONS Survival benefits of NAC are reflected in downstaging of the primary tumour. Chemo-induced downstaging might be a potential surrogate marker for OS.
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Zhang H, Ye D. Re: Hassan Abol-Enein, Derya Tilki, Ahmed Mosbah, et al. Does the extent of lymphadenectomy in radical cystectomy for bladder cancer influence disease-free survival? A prospective single-center study. Eur Urol 2011;60:572-7. Eur Urol 2011; 60:e48. [PMID: 21807455 DOI: 10.1016/j.eururo.2011.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Accepted: 07/15/2011] [Indexed: 11/29/2022]
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Stenzl A, Cowan NC, De Santis M, Kuczyk MA, Merseburger AS, Ribal MJ, Sherif A, Witjes JA. Treatment of muscle-invasive and metastatic bladder cancer: update of the EAU guidelines. Eur Urol 2011; 59:1009-18. [PMID: 21454009 DOI: 10.1016/j.eururo.2011.03.023] [Citation(s) in RCA: 453] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2011] [Accepted: 03/15/2011] [Indexed: 01/05/2023]
Abstract
CONTEXT New data regarding treatment of muscle-invasive and metastatic bladder cancer (MiM-BC) has emerged and led to an update of the European Association of Urology (EAU) guidelines for MiM-BC. OBJECTIVE To review the new EAU guidelines for MiM-BC with a specific focus on treatment. EVIDENCE ACQUISITION New literature published since the last update of the EAU guidelines in 2008 was obtained from Medline, the Cochrane Database of Systematic Reviews, and reference lists in publications and review articles and comprehensively screened by a group of urologists, oncologists, and a radiologist appointed by the EAU Guidelines Office. Previous recommendations based on the older literature on this subject were also taken into account. Levels of evidence (LEs) and grades of recommendations (GRs) were added based on a system modified from the Oxford Centre for Evidence-based Medicine Levels of Evidence. EVIDENCE SYNTHESIS Current data demonstrate that neoadjuvant chemotherapy in conjunction with radical cystectomy (RC) is recommended in certain constellations of MiM-BC. RC remains the basic treatment of choice in localised invasive disease for both sexes. An attempt has been made to define the extent of surgery under standard conditions in both sexes. An orthotopic bladder substitute should be offered to both male and female patients lacking any contraindications, such as no tumour at the level of urethral dissection. In contrast to neoadjuvant chemotherapy, current advice recommends the use of adjuvant chemotherapy only within clinical trials. Multimodality bladder-preserving treatment in localised disease is currently regarded only as an alternative in selected, well-informed, and compliant patients for whom cystectomy is not considered for medical or personal reasons. In metastatic disease, the first-line treatment for patients fit enough to sustain cisplatin remains cisplatin-containing combination chemotherapy. With the advent of vinflunine, second-line chemotherapy has become available. CONCLUSIONS In the treatment of localised invasive bladder cancer (BCa), the standard treatment remains radical surgical removal of the bladder within standard limits, including as-yet-unspecified regional lymph nodes. However, the addition of neoadjuvant chemotherapy must be considered for certain specific patient groups. A new drug for second-line chemotherapy (vinflunine) in metastatic disease has been approved and is recommended.
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Affiliation(s)
- Arnulf Stenzl
- Department of Urology, Eberhard-Karls-University Tuebingen, Tuebingen, Germany.
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