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Bladder Cancer

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									Bladder Cancer
R. Zenhäusern

Bladder cancer:
• Incidence: • Mortality:

Epidemiology

20/100000/year (Europe) 8-9/100000/year

• Fourth most common cancer in men
– Incidence: 31.1
– Incidence: 9.5

mortality: 12.1
mortality: 4.5

• Seventh most common cancer in women

• At diagnosis >70%: > 65 y of age

Bladder cancer:
• 90-95% • 3% • 2% • <1%

Histology

transitional-cell carcinoma squamos-cell carcinoma adenocarcinoma small-cell carcinoma

Bladder cancer:

Entities

• 75-85% superficial bladder cancer pTa, pTis, pT1
• 10-15% muscle-invasive bladder cancer

pT2, pT3, pT4
• 5% metastatic bladder cancer N+, M+

Bladder cancer:
Stage
0 I II III IV

Stage and Prognosis
5-y. Survival
NoMo NoMo NoMo NoMo NoMo N+Mo M+ >85% 65-75% 57% 31% 24% 14% med. 6-9 Mo

TNM
Ta/Tis T1 T2a-b T3a-4a T4b each T each T

Superficial Bladder Cancer
pTa, pT1, Tis
• Standard of care=intravesical Therapy  transurethral resection
• Relapse rate: 70%  adjuvant therapy

Superficial Bladder Cancer
• Histological grading is important
G1 G2 G3

Relapse rate
Progression rate

42% 50% 80%
2% 11% 45%

Superficial Bladder Cancer
Adjuvant Therapy
• Reduces relpase rate by 30-80%
– Doxorubicin – Mitomycin C – BCG weekly 6-8 w. / monthly 6-12 weekly 6-8 w. / monthly 6-12 weekly 6-8 w. /Mo 3 and 6

Invasive bladder cancer
• Standard of care = Radical cystectomy with pelvic lymphadenectomy
Only about 50% of patients with highgrade invasive disease are cured

Results of radical cystectomy
Stage Recurrence-Free 5 y. 10y. NN+ NN+ NN+ NN+ 89 50 78 41 62 29 50 33 87 50 76 37 61 29 45 33 Overall Survival 5 y. 10y. 77 52 64 40 49 24 44 26 57 52 44 26 29 12 23 20

T2 T3a T3b T4a

Stein et al JCO 2001;19:666

Results of radical cystectomy
Stage Organ-confined (<pT2pNo) Recurrence-Free /Overall Survival 5 years 73% 62%

non-organ-confined (>pT2pNo)
Positiv lymph nodes (pT1-4, pN+)

56%
33%

49%
24%

Madersbacher et al JCO 2003;21:690

Chemotherapy for bladder cancer
• Bladder cancer is a chemosensitive disease • Active single agents.

– – – –

Cisplatin Carboplatin Gemcitabine Ifosfamide

RR 30% 20% 20-30% 20%

Chemotherapy for bladder cancer
Combination chemotherapy.

RR – – – – MVAC Gemzar / Cisplatin Gemzar / Carboplatin Taxol / Carboplatin 40-75% 40-70% 65% 20-40%

CR <20% 5-15% 5%

Adjuvant chemotherapy
• Six randomised trials have compared CT

with observation after cystectomy or RT • 4x no survival benefit • 2x benefit from adjuvant CT  no standard of care
– node positive disease, lymphovascular invasion, positive margins

Neoadjuvant chemotherapy
• Meta-analysis of ten randomised trials (2688 patients)
13% reduction in risk of death 5% absolute benefit at 5 years OS increased from 45% to 50%
ABC Meta-analysis Collaboration. Lancet 2003;361:1927

Combined Radio- and Chemotherapy
CR • Radiotherapy 57% 5y.OS 47%

• RT and cisplatin
• RT and carboplatin

85%
70%

69%
57%

Birkenhake et al. Strahlenther Onkol 1998;174:121

Bladder-sparing therapy for invasive bladder cancer
• High probability of subsequent distant metastasis after cystectomy or radiotherapy alone (50% within 2 years) • Radiotherapy im comparison with cystectomy has inferior results (local control 40%)
• muscle-invasive bladder cancer is often a systemic disease

 combined modality therapy

Bladder-sparing protocol
Transurthral resection
Induction Therapy: Radiation + chemotherapy
(cisplatin, paclitacel)

Cystoscopy after 1 month
no tumor tumor cystectomy

Consolidation: RT + CT

Bladder-sparing protocol
T2: 5y / 10y OS: 74% / 66%

T3-T4a: 5y / 10y OS: 53% / 52%

Shiply et al. Urology 2002;60:62

Results of bladder-sparing therapy and cystectomy
Bladder-sparing
therapy
Houssett 1997 Sauer 1998 Shipley 1998 Shipley 2002 Rodel 2002 120 162 123 190 415 181 633 n Pat. 5y. OS % 63 55 49 54 50 36 48 5y. Survival
with Bladder %

NA 44 38 45 42 NA NA

Cystectomy
Dalbagni 2001 Stein 2001

Combined-modality treatment and organ preservation in invasive bladder cancer
Rödel et al. JCO 2002;20:3061
415 patients with T1 high-risk, T1-4, No-1 Treatment: 1. Transurethral resection 2. RT (n=126), RCT (n=289) RT median 54 Gy, CT cisplatin week 1, 5 3. Restaging-TUR

Combined-modality treatment and organ preservation in invasive bladder cancer
• Rödel et al. JCO 2002;20:3061

• • • • •

Complete remission Local control after CR distant metastasis Disease-specific survival Preservation of bladder

72% 64% (10 y.) 35% (10 y.) 42% (10 y.) >80%

Local control

Distant metastasis

Rödel et al. JCO 2002;20:3061

Disease-specific survival for patients after salvage cystectomy

50% 21%

45% 18%

Rödel et al. JCO 2002;20:3061

TUR and adjuvant Radio-Chemotherapy
• 5 year Survival 50-65%

• Preservation of Bladder

38-43%


								
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