Surgical Management of Bladder Carcinoma

Rafael Carrion, MD, John Seigne, MB

Disclosures

Cancer Control. 2002;9(4) 

In This Article

The Role of Cystectomy in Locally Advanced Bladder Cancer

Less than 50% of patients with locally advanced or node-positive bladder cancer will survive if treated by surgery (cystectomy) alone. Several large trials of combination chemotherapy administered prior to surgery have suggested a survival benefit with the neoadjuvant approach.[10,11] The patient group demonstrating the most benefit in terms of long-term survival are those who have an excellent response to the chemotherapy. In the M.D. Anderson trial,[10] 40% of the patients had no evidence of tumor in the specimen at the time of cystectomy (good responders) after 2 cycles of MVAC (methotrexate, vinblastine, doxorubicin, and cisplatin) chemotherapy. Only 12% of these "good responders" had a subsequent relapse. Of the patients with persistent viable pelvic nodal disease after 2 cycles of chemotherapy (poor responders), 86% subsequently died of progressive bladder cancer.

Surgery appears to be provide important consolidation after chemotherapy even in patients who have a clinical complete response. In a study from the Memorial Sloan-Kettering Cancer Center,[44] 30% of patients with a clinical complete response to chemotherapy were found at surgery to have unsuspecting residual disease, and only 1 of 12 patients with major responses to chemotherapy but who refused surgery were alive at 3 years. Based on these data, we recommend 2 to 3 cycles of preoperative MVAC chemotherapy to patients with locally advanced bladder cancer whom we believe to be unresectable at the time of examination under anesthesia. Additionally, we recommend radical cystectomy to the group achieving a complete or substantial partial response. Patients who do not achieve a good clinical response are likely to be unresectable or progress rapidly despite surgery. We recommend second-line chemotherapy to this poor-prognosis patient group.

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