Muscle-Invasive Bladder Cancer: Difference between revisions

Line 363:

* A multi-disciplinary team discussion is preferred for patients considering bladder preservation.

*'''Successful bladder preservation should be viewed as a multimodal therapy involving:'''

*# '''Aggressive TUR'''

*# '''Systemic chemotherapy'''

*# '''Radiation therapy'''

** Historical series have demonstrated inferior results with single modality therapy (radical TUR, chemotherapy alone, or radiation alone) compared to that of radical cystectomy.

====Patient selection====

*'''~~For patients~~ with newly diagnosed non-metastatic MIBC who desire to retain their bladder~~, and for those~~ with significant comorbidities for whom radical cystectomy is not a treatment option, clinicians should offer bladder ~~preserving therapy when clinically appropriate~~'''

*'''Indications[https://pubmed.ncbi.nlm.nih.gov/28456635/ ★]'''

**'''Overall, bladder preserving therapy has been associated with decreased survival compared to RC'''

*#'''Patients with newly diagnosed non-metastatic MIBC who desire to retain their bladder'''

**Studies that support bladder preserving strategies, as a general rule, have highly select patient populations

*#'''Patients with significant comorbidities for whom radical cystectomy is not a treatment option, clinicians should offer bladder'''

*'''Ideal characteristics for bladder preservation (4):'''

*#*'''Overall, bladder preserving therapy has been associated with decreased survival compared to RC'''

*#**'''Patients who are deemed “medically fit” to undergo cystectomy should be offered cystectomy as the standard of care'''

*#*Studies that support bladder preserving strategies, as a general rule, have highly select patient populations

*#*Bladder preservation should be undertaken with the goal of curative therapy and to maintain a functionally intact bladder

*'''Ideal characteristics for bladder preservation (4):[https://pubmed.ncbi.nlm.nih.gov/28456635/ ★]'''

*# '''Unifocal tumor'''

*#'''No CIS'''

*#'''No evidence of hydronephrosis'''

*# '''A tumor that can be completely transurethrally resected'''

*#*'''~~CUA also mentions tumour size <5cm~~, ~~good bladder capacity~~, and ~~motivated patient~~'''

*'''Contraindications'''

**'''Relative'''

**#'''Large tumors unable to be resected by TURBT'''

**#'''Multifocal CIS'''

**#'''T3/T4 tumors,'''

**#'''Presence of hydronephrosis'''

**#Non-urothelial carcinoma

**##Patients with adenocarcinomas, sarcomas, and squamous cell carcinomas have not been included in prospective studies of radiation-based bladder preservation

**'''Unknown how variant histology affects outcomes associated with multi-modal bladder preserving therapy'''

*'''In patients under consideration for bladder preserving therapy, maximal debulking transurethral resection of bladder tumor and assessment of multifocal disease/carcinoma in situ should be performed'''

**In multiple prospective trials, the ability to resect all tumor predicted the best response to bladder preserving therapies.

**'''Random biopsies may help ensure that there is no associated CIS.'''

* '''Patients with large tumors unable to be resected by TURBT, multifocal CIS, T3/T4 tumors, and/or hydronephrosis are not ideal candidates for any type of bladder preserving therapy.'''

*'''Histological considerations'''

**'''Unknown how variant histology affects outcomes associated with multi-modal bladder preserving therapy.'''

** Patients with adenocarcinomas, sarcomas, and squamous cell carcinomas have not been included in prospective studies of radiation-based bladder preservation and thus should not receive this therapy unless medically unfit for cystectomy.

*'''Patients who are deemed “medically fit” to undergo cystectomy should be offered cystectomy as the standard of care; however, bladder preservation is a reasonable option for those who are highly selected and counseled appropriately. Patients who are medically unfit for surgery or who refuse surgery can be considered for bladder preservation.'''

* Bladder preservation should be undertaken with the goal of curative therapy and to maintain a functionally intact bladder

* '''Successful bladder preservation should be viewed as a multimodal therapy involving:'''

*# '''Aggressive TUR'''

*# '''Systemic chemotherapy'''

*# '''Radiation therapy'''

** Historical series have demonstrated inferior results with single modality therapy (radical TUR, chemotherapy alone, or radiation alone) compared to that of radical cystectomy.

==== Multi-modal/Trimodal bladder preserving therapy ====

@@ Line 363: / Line 363: @@
 * A multi-disciplinary team discussion is preferred for patients considering bladder preservation.
+*'''Successful bladder preservation should be viewed as a multimodal therapy involving:'''
+*# '''Aggressive TUR'''
+*# '''Systemic chemotherapy'''
+*# '''Radiation therapy'''
+** Historical series have demonstrated inferior results with single modality therapy (radical TUR, chemotherapy alone, or radiation alone) compared to that of radical cystectomy.
 ====Patient selection====
-*'''<span style="color:#ff0000">For patients with newly diagnosed non-metastatic MIBC who desire to retain their bladder, and for those with significant comorbidities for whom radical cystectomy is not a treatment option, clinicians should offer bladder preserving therapy when clinically appropriate</span>'''
+*'''<span style="color:#ff0000">Indications[https://pubmed.ncbi.nlm.nih.gov/28456635/ ★]</span>'''
-**'''Overall, bladder preserving therapy has been associated with decreased survival compared to RC'''
+*#'''<span style="color:#ff0000">Patients with newly diagnosed non-metastatic MIBC who desire to retain their bladder</span>'''
-**Studies that support bladder preserving strategies, as a general rule, have highly select patient populations
+*#'''<span style="color:#ff0000">Patients with significant comorbidities for whom radical cystectomy is not a treatment option, clinicians should offer bladder</span>'''
-*'''<span style="color:#ff0000">Ideal characteristics for bladder preservation (4):</span>'''
+*#*'''Overall, bladder preserving therapy has been associated with decreased survival compared to RC'''
+*#**'''Patients who are deemed “medically fit” to undergo cystectomy should be offered cystectomy as the standard of care'''
+*#*Studies that support bladder preserving strategies, as a general rule, have highly select patient populations
+*#*Bladder preservation should be undertaken with the goal of curative therapy and to maintain a functionally intact bladder
+*'''<span style="color:#ff0000">Ideal characteristics for bladder preservation (4):[https://pubmed.ncbi.nlm.nih.gov/28456635/ ★]</span>'''
 *# '''<span style="color:#ff0000">Unifocal tumor</span>'''
 *#'''<span style="color:#ff0000">No CIS</span>'''
 *#'''<span style="color:#ff0000">No evidence of hydronephrosis</span>'''
 *# '''<span style="color:#ff0000">A tumor that can be completely transurethrally resected</span>'''
-*#*'''<span style="color:#ff0000">CUA also mentions tumour size <5cm, good bladder capacity, and motivated patient</span>'''
+*'''Contraindications'''
+**'''Relative'''
+**#'''Large tumors unable to be resected by TURBT'''
+**#'''Multifocal CIS'''
+**#'''T3/T4 tumors,'''
+**#'''Presence of hydronephrosis'''
+**#Non-urothelial carcinoma
+**##Patients with adenocarcinomas, sarcomas, and squamous cell carcinomas have not been included in prospective studies of radiation-based bladder preservation
+**'''Unknown how variant histology affects outcomes associated with multi-modal bladder preserving therapy'''
 *'''In patients under consideration for bladder preserving therapy, maximal debulking transurethral resection of bladder tumor and assessment of multifocal disease/carcinoma in situ should be performed'''
 **In multiple prospective trials, the ability to resect all tumor predicted the best response to bladder preserving therapies.
 **'''Random biopsies may help ensure that there is no associated CIS.'''
-* '''Patients with large tumors unable to be resected by TURBT, multifocal CIS, T3/T4 tumors, and/or hydronephrosis are not ideal candidates for any type of bladder preserving therapy.'''
-*'''Histological considerations'''
-**'''Unknown how variant histology affects outcomes associated with multi-modal bladder preserving therapy.'''
-** Patients with adenocarcinomas, sarcomas, and squamous cell carcinomas have not been included in prospective studies of radiation-based bladder preservation and thus should not receive this therapy unless medically unfit for cystectomy.
-*'''Patients who are deemed “medically fit” to undergo cystectomy should be offered cystectomy as the standard of care; however, bladder preservation is a reasonable option for those who are highly selected and counseled appropriately. Patients who are medically unfit for surgery or who refuse surgery can be considered for bladder preservation.'''
-* Bladder preservation should be undertaken with the goal of curative therapy and to maintain a functionally intact bladder
-* '''Successful bladder preservation should be viewed as a multimodal therapy involving:'''
-*# '''Aggressive TUR'''
-*# '''Systemic chemotherapy'''
-*# '''Radiation therapy'''
-** Historical series have demonstrated inferior results with single modality therapy (radical TUR, chemotherapy alone, or radiation alone) compared to that of radical cystectomy.
 ==== Multi-modal/Trimodal bladder preserving therapy ====