Organ-sparing combined-modality treatment for muscle-invasive bladder cancer remains underutilized despite high-quality evidence regarding its efficacy, safety, and preservation of quality of life. It may be offered to patients unwilling to undergo radical cystectomy, as well as those unfit for neoadjuvant chemotherapy and surgery. The treatment plan should be tailored to each patient's characteristics, with more intensive protocols offered to patients who are fit for surgery but opt for organ-sparing. After a thorough, debulking transurethral resection of the tumor and neoadjuvant chemotherapy, the response evaluation should trigger further management with either chemoradiation or early cystectomy in non-responders. A hypofractionated, continuous radiotherapy regimen of 55 Gy in 20 fractions with concurrent radiosensitizing chemotherapy with gemcitabine, cisplatin, or 5-fluorouracil and mitomycin C is currently preferred based on clinical trials. The response should be evaluated with repeated transurethral resections of the tumor bed and abdominopelvic-computed tomography after chemoradiation, with quarterly assessments during the first year. Salvage cystectomy should be offered to patients fit for surgery who failed to respond to treatment or developed a muscle-invasive recurrence. Non-muscle-invasive bladder recurrences and upper tract tumors should be treated in line with guidelines for respective primary tumors. Multiparametric magnetic resonance can be used for tumor staging and response monitoring, as it may distinguish disease recurrence from treatment-induced inflammation and fibrosis.
Journal of clinical medicine. 2023 Feb 16*** epublish ***
Artur Lemiński, Wojciech Michalski, Bartłomiej Masojć, Krystian Kaczmarek, Bartosz Małkiewicz, Jakub Kienitz, Barbara Zawisza-Lemińska, Michał Falco, Marcin Słojewski
Department of Urology and Urological Oncology, Pomeranian Medical University, 70-111 Szczecin, Poland., Department of Urological Cancer, Maria Sklodowska-Curie National Research Institute of Oncology (MSCNRIO), Roentgena 5, 02-781 Warsaw, Poland., Department of Radiotherapy, West-Pomeranian Oncology Center, 71-730 Szczecin, Poland., Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, Borowska 213, 50-556 Wrocław, Poland., Department of Rehabilitation, West-Pomeranian Oncology Center, 71-730 Szczecin, Poland.