SAN FRANCISCO, CA USA (UroToday.com) - Dr. H. Barton Grossman opened his review by acknowledging that considerable progress has been made in understanding, diagnosing, and treating urothelial cancer over the past 10 years.
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Although bacillus Calmette–Guérin (BCG) immunotherapy and the combination chemotherapy regimen of methotrexate, vinblastine, doxorubicin and cisplatin (M-VAC) was introduced in late 70s and 80s, respectively, recent efforts have significantly enhanced the applicability of these important discoveries to the clinic and have resulted in other advances that have improved patient care and provided the groundwork for future progress. He mentioned that over the last decade, we learned that micropapillary and small-cell bladder cancer need aggressive treatment. Kamat and colleagues from MD Anderson Cancer Center showed that bladder-preserving therapy for micropapillary cancer often has a poor outcome, and Siefker-Radtke and colleagues found that neoadjuvant chemotherapy and cystectomy can provide effective treatment for small-cell bladder cancer.
In regards to diagnostic imaging, there has been continuous improvement in endoscopic evaluation of the urothelium with widespread use of cameras and use of high-definition videos. There have also been more improvements in detecting bladder cancer through fluorescence cystoscopy and narrow-band imaging. Although endoscopic evaluation of the upper tract has always been more difficult than the bladder, new approaches such as endoluminal ultrasound are being studied to see if this will provide additional accuracy to supplement endoscopy.
He further went on reviewing the intravesical immunotherapy and chemotherapy for management of bladder cancer. He showed evidence that it is important to know that those patients who experience short-term treatment failure with BCG are at high risk and should promptly receive alternate treatment. Intravesical chemotherapy is often administered on a 6-week schedule, but it is also more effective with maintenance. Single-dose intravesical chemotherapy immediately after resection is recommended for decreasing recurrence in patients who have papillary appearing tumors at the time of cystoscopy and transurethral resection of bladder tumor. Use of MVAC neoadjuvant chemotherapy has been shown by randomized and institutional series that it lowers clinical stage. Because of the toxicity of M-VAC, the combination of gemcitabine and cisplatin (GC) was developed, in 2000, as a less toxic alternative, and more recently, high-dose intensity MVAC or GC regiments have been studied and results are satisfactory.
Regarding changes and advancement in surgery, now we know that extended pelvic lymph node dissection provides benefit, and minimally invasive surgery (e.g., robotic assisted laparoscopy approach) can be performed with similar rate of complication as open approach. He presented the data from the International Robotic Cystectomy Consortium on 939 cystectomies from 16 institutions. Data showed ~9% rate of positive margins and a roughly 20% 90-day readmission rate. At last he talked about advancement in “personalized medicine” in bladder cancer. Coexpression extrapolation (COXEN) analysis is an approach to predict individualized chemotherapeutic outcomes and whole-genome sequencing in predicting outcome in bladder cancer patients after targeted therapy. Dr. Grossman concluded his presentation by saying perhaps in the next decade we will translate these into a layout that allows us to provide heightened care based on the unique characteristics of each individual patient.
Highlights of a presentation by H. Barton Grossman, MD at the 2014 Genitourinary Cancers Symposium - January 30 - February 1, 2014 - San Francisco Marriott Marquis - San Francisco, California USA
The University of Texas MD Anderson Cancer Center, Houston, TX USA