Managing locally advanced bladder cancer

Management of muscle-invasive bladder cancer in the elderly

Bladder cancer is rare in patients below the age of 50 years, and most patients are in their 60s and 70s. Radical cystectomy is the preferred approach for patients with localized disease in most European countries and the USA, and evidence is growing in favor of neoadjuvant, platinum-based chemotherapy for patients at high risk of local and systemic relapse. Transurethral resection (TUR) followed by radiotherapy with or without concomitant chemotherapy appears to be a reasonable alternative, particularly in the UK and Canada. However, the elderly pose several treatment dilemmas, including the increased risk of perioperative complications, the management of orthotopic neobladder or different types of urinary diversion, as well as the higher risk of adverse events caused by pelvic radiotherapy and systemic chemotherapy. Multidimensional parameters such as biologic prognostic factors, performance status, functional independence, comorbidities and cognitive function of the patient should be collected in order to tailor treatment to the patient's life expectancy and preferences. Optimized integration of TUR followed by bladder removal (or radiotherapy), with or without adjunctive chemotherapy, can be recommended for otherwise healthy patients. Palliative measures, such as TUR followed by external radiotherapy alone or monochemotherapy, should be reserved for partially impaired patients with moderate comorbidities, in order to maximize the balance of benefits and toxicities. This review summarizes recent data concerning surgery, radiotherapy and systemic chemotherapy for bladder cancer in the elderly, and discusses pros and cons of the currently available therapeutic options.

Molecular detection of noninvasive and invasive bladder tumor tissues and exfoliated cells by aberrant promoter methylation of laminin-5 encoding genes

Laminin-5 (LN5) anchors epithelial cells to the underlying basement membrane, and it is encoded by three distinct genes: LAMA3, LAMB3, and LAMC2. To metastasize and grow, cancer cells must invade and destroy the basement membrane. Our previous work has shown that epigenetic inactivation is a major mechanism of silencing LN5 genes in lung cancers. We extended our methylation studies to resected bladder tumors (n = 128) and exfoliated cell samples (bladder washes and voided urine; n = 71) and correlated the data with clinicopathologic findings. Nonmalignant urothelium had uniform expression of LN5 genes and lacked methylation. The methylation frequencies for LN5 genes in tumors were 21-45%, and there was excellent concordance between methylation in tumors and corresponding exfoliated cells. Methylation of LAMA3 and LAMB3 and the methylation index were correlated significantly with several parameters of poor prognosis (tumor grade, growth pattern, muscle invasion, tumor stage, and ploidy pattern), whereas methylation of LAMC2 and methylation index were associated with shortened patient survival. Of particular interest, methylation frequencies of LAMA3 helped to distinguish invasive (72%) from noninvasive (12%) tumors. These results suggest that methylation of LN5 genes has potential clinical applications in bladder cancers.