SAN FRANCISCO, CA USA (UroToday.com) - Dr. J. Alfred Witjes presented the 2013 update of the European Organization for Research and Treatment of Cancer guidelines on metastatic and muscle-invasive bladder cancer (MIBC).

A number of important updates to the guidelines were presented encompassing pathogenesis, treatment, and follow-up. Radiation therapy is now identified as a risk factor for bladder cancer, and patients with prior radiation exposure should be approached with an increased index of suspicion.

gucancerssympalt thumbFor patients with MIBC, the role and extent of pelvic lymphadenectomy (LND) has remained a controversial topic. The guidelines recommend pathology reports include the number, size, and tumor involvement of lymph nodes. A total of 9 studies comparing extended to standard LND among patients with cN0M0 disease were reviewed, and 6 studies reported a survival benefit in favor of extended LND. Selection bias and other methodological flaws significantly limit the interpretation of the studies reviewed, however, the guidelines now recommend extended LND be performed in all patients undergoing radical cystectomy (RC). There is no benefit to “super”-extended LND.

Updated results of the largest neoadjuvant chemotherapy trial performed to date (median follow-up 8 years) confirm the efficacy of neoadjuvant chemotherapy (cisplatin, methotrexate, and vinblastine), with improvement in 10-year survival from 30% to 36%. Given our inability to accurately and reliably identify high-risk patients preoperatively, neoadjuvant chemotherapy should be offered to all patients. Patients with pT2 disease should be substratified based on nodal status to identify appropriate candidates for adjuvant chemotherapy. Gemcitabine and cisplatin (GC) is less toxic than MVAC, and addition of paclitaxel to GC improved OS from 12.7 to 15.8 months in a large phase III RCT.

  • Lymphadenectomy is now recommended to be extended
  • On long-term follow-up, the survival advantage of neoadjuvant chemotherapy has again been confırmed
  • Multimodality bladder-sparing treatment is a reasonable option among select patients
  • For patients with metastatic disease unfit for cisplatin, the combination of carboplatin and gemcitabine is an alternative option
  • Oncological follow-up is remains predominantly expert-opinion based

With regards to type of urinary diversion, although historically quality of life is comparable following conduit or neobladder, recent studies favor orthotopic diversion, possibly due to improved surgical techniques. In the right candidates, bladder-sparing therapy with TURBT and chemo-radiation has produced CR rates up to 60-80% at a median follow-up of 42 months. However, bladder-sparing therapy has never been directly compared to radical cystectomy, and patients in multimodality series are highly selected.

Highlights of a presentation by J. Alfred Witjes, MD, PhD at the 2014 Genitourinary Cancers Symposium - January 30 - February 1, 2014 - San Francisco Marriott Marquis - San Francisco, California USA

Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands

Written by Jeffrey J. Tomaszewski, MD, medical writer for UroToday.com

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