Bladder Cancer
Transitional cell carcinoma may occur at any site within the urinary collecting system from the renal calyx to the ureterovesical junction to the bladder and urethra. The tumors occur most commonly in adults and are rare before 40 years of age. There is a two- to three-fold increase in incidence in men compared with women, which increases further in smokers. The lesions are often multiple and are more common in patients with a prior history of transitional cell carcinoma of the bladder. Local staging depends upon the depth of invasion.
Bladder cancer can present as a low-grade papillary lesion, as an in situ lesion, which can occupy large areas of the mucosal surface, or as an infiltrative cancer that rapidly extends through the bladder wall. The papillary and in situ lesions may be associated with a malignant course, with sudden invasion of the bladder wall. Hematuria (blood in the urine) is the most common presenting sign.
Bladder Cancer Treatment Summaries
Neoadjuvant
Neo-adjuvant approach for locally advanced TCC of the bladder has been studied extensively and has an inherent advantage of the therapy being delivered pre-operatively. Randomized studies now matured to five years and beyond (Intergroup 0080/SWOG8710) continue to show a survival advantage in T2-T4a (muscle invasive tumors). Standard of care should encourage 3 cycles of a platinum based chemotherapy regimen for muscle invasive tumors prior to cystectomy.
References:
- ASCO Educational Book 2005.
- ABC Meta Analysis Collaboration in invasive Bladder Cancer; a systematic review and meta-analysis. The Lancet 2003; 361, 1927-34.
- Doltan, ZA et al. Optimal combined modality treatment improves outcome of locally advanced bladder cancer: Analysis of SWOG 8710, ASCO Abs. # 4531.
- ASCO Educational Book 2006. Perioperative Chemotherapy for Muscle-Invasive Bladder Cancer. By Dean Bajorin, MD, FACP.
Adjuvant
Patients with muscle invasive disease and/or nodal disease, consisting of Transitonal Cell Carcinoma who are post cystectomy are at high risk of recurrence. The recommendation is for 4 cycles of a Cis-Platinum containing regimen, ie MVAC or Cis-Gem. Note: Carboplatin is considered less effective than Cisplatinum.
References:
- NCCN Guidelines – Bladder 2005
- Petrioli, R et al. Comparison between a Cisplatinum containing regimen and a Carboplatin regimen for recurrent or metastatic bladder cancer patients. Cancer 1996; 77: 344-51.
- ASCO Educational Book 2005
Bladder Sparing
Bladder preservation with conservative surgery, XRT/chemotherapy remains controversial as of 2006. Standard treatment for muscle-invasive bladder cancer is still radical cystectomy with pelvic lymph node dissection.
However, for certain select populations (highly motivated) TURBT followed by XRT/chemotherapy can be offered. Please note, even if disease present post-XRT/chemo, surgery still available as salvage.
For these highly select patients, they will need lifelong surveillance secondary to risk of recurrence, either superficial and/or invasive bladder cancer. Salvage cystectomy is recommended for invasive recurrences and conservative approaches can be performed for superficial recurrences.
As of 2006, the optimal chemo/XRT protocol is still not standardized.
References:
- ASCO Educational Book 2006
- Kaufman, et. al. Initial Results in Muscle-Invasive Bladder Cancer of RTOG 95-06: Phase I/II Trial of Transurethral Surgery plus Radiation Therapy with Concurrent Cisplatin and 5-FU followed by Selective Bladder Preservation or Cystectomy Depending on the Initial Response. The Oncologist 2000; 5:471-476.
- Kaufman, et. al. ASCO Abstract 2005. Muscle-invading bladder cancer, RTOG Protocol 99-06: Initial report of a phase I/II trial of selective bladder-conservation employing TURBT, accelerated irradiation sensitized with cisplatin and paclitaxel followed by adjuvant cisplatin and gemcitabine chemotherapy.
Metastatic bladder cancer
Transitional Cell Carcinoma is very sensitive to chemotherapy. Cis-Platinum containing regimens are the standard of care. Carboplatin is sub-optimal compared to Cis-Platinum unless risks of Cis-Platinum outweight benefits. Cis-Gem regimen equals MVAC.
References:
- Von der Maase, H et al. Long term survival results of a randomized trial comparing
- Gemcitabine plus Cis-Platinum with MVAC in patients with bladder cancer. JCO 23: 4602-4608. 2005.
