Seminars in urologic oncology最新文献

Intravesical therapy is a classic approach to the treatment of superficial bladder cancer. Bacillus Calmette-Guerin (BCG) has assumed the role of the most commonly administered agent, and clearly the most effective form of therapy for carcinoma in situ. Recent data quantify the advantage of "booster" treatments over a 3-year interval but suggest that current regimens are not easily tolerated by most patients. Initial studies suggest a role for intravesical interferon in potentiating the effect of BCG. Classic intravesical chemotherapy can decrease tumor recurrence by 14% to 17%, but no data exist to demonstrate any positive effect on decreasing tumor progression. Recent studies suggest a growing rationale for the intravesical administration of a single dose of a chemotherapeutic agent to decrease early tumor recurrence.

In several European cancer centers, the combination of external beam and interstitial radiotherapy with the aim of bladder preservation is standard treatment in a selected group of patients with muscle-infiltrating bladder cancer. Three case reports are presented. The published local control rates at 5 years vary from 64% to 88% and the 5-year overall and disease-free survival range from 47% to 66% and from 62% to 81%, respectively. It is concluded that this approach is successful in preserving the bladder. Conditions for good results are careful selection of patients, excellent cooperation between urologist and radiation oncologist, and modern brachytherapy facilities.

In the United States, local management of muscle-invasive bladder cancer largely remains radical cystectomy with urinary diversion. However, this approach is undergoing transition. Organ-preserving approaches using a combination of multiple modalities have been successfully applied to the management of several types of cancer and clearly play an important role in the management of muscle-invasive bladder cancer as well. Since the 1980s, several single and multi-institutional trials have confirmed that a combined modality organ-preserving approach (chemotherapy administered in conjunction with radiation) consistently confers equivalent overall survival compared with survival following radical cystectomy. These trials are very encouraging and allow organ preservation to be considered an appropriate therapeutic option for patients with muscle-invasive bladder cancer.

Treatment goals for superficial bladder cancer are two-fold: (1) reducing tumor recurrence and the subsequent need for additional therapies (cystoscopy, transurethral resection, intravesical therapy) and the morbidity associated with these treatments; and (2) preventing tumor progression and the subsequent need for more aggressive therapy. The administration of intravesical therapy has become an important component in these treatment goals; however, there remains a group of patients with superficial bladder cancer that are at risk of disease progression, metastases, and death from their disease. The treating urologist must be extremely active and diligent when treating patients with superficial bladder cancer. An understanding of tumor biology and current intravesical therapies is important. Furthermore, and perhaps most important, the timely decision to abandon conservative therapy and proceed with radical cystectomy and urinary diversion should be kept in mind to prevent the potentially lethal sequelae of invasive bladder cancer. In view of the potential for recurrence, stage progression, and significant clinical understaging of patients with superficial bladder cancer, and the fact that radical cystectomy provides excellent results with regard to prevention of local recurrence and overall survival, radical cystectomy should be considered in patients with high-risk factors. Radical cystectomy may also provide important prognostic information and influence the decision for adjuvant therapy based on pathologic criteria. Finally, definite improvements in lower urinary tract reconstruction and nerve-sparing techniques have decreased the social implications of cystectomy for both men and women.