In 2015, the European Association of Urology (EAU) guidelines for the management of muscle-invasive and metastatic bladder cancer have been updated to the 3rd edition, written by Prof. Witjes et al, with a greater emphasis on the important role of multidisciplinary collaboration in muscle-invasive bladder cancer (MIBC).
Tumor staging and grading system
The current staging system uses the 2009 UICC TNM criteria (primary tumor, regional lymph nodes, distant metastases), and for tumor grading, both the WHO 1973 and 2004 grading criteria are used.
Table 1 TNM staging of bladder cancer in the 2009 version of the UICC
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Table 2 WHO 1973 and 2004 grading system for malignancy of uroepithelial carcinoma of the bladder
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Pathological features of MIBC
Identifying which morphologic subtype of bladder cancer belongs to, especially high-grade uroepithelial carcinoma of the bladder, has important clinical significance for the treatment and prognosis of patients. The following types of bladder cancer differentiation are commonly seen today.
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Tumor Assessment Items
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Recommended tests for MIBC
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Recommendations on Tumor Staging
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Treatment strategy
1. Patients with NMIBC who have failed treatment
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2. Neoadjuvant chemotherapy (NAC)
Regardless of the final treatment, patients who have received combination chemotherapy including platinum agents have improved overall survival (OS). However, there is no evidence to suggest which specific group of patients benefits more from neoadjuvant chemotherapy. However, the use of neoadjuvant chemotherapy is somewhat limited considering the general condition of the patient, the development of surgical techniques and the use of conventional chemotherapy in combination.
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3. Radical cystectomy with urinary diversion
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Contraindications to in situ neocystectomy include positive urethral margins, positive margins on any part of the bladder on the specimen (regardless of gender), tumor located in the bladder neck, tumor located in the female urethra, and tumor that has invaded the prostate.
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Figure 1: T2-T4aN0M0 bladder cancer treatment flow
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4. Surgical options for limited tumor with bladder preservation
Transurethral resection of bladder tumor (TURB): single TURB is only suitable for patients with tumor confined to superficial muscle and negative residual lesion re-staging biopsy
5.External irradiation radiotherapy (EBRT)
Single-row EBRT is a treatment option for patients who cannot undergo RC and bladder-preserving surgery. In addition, EBRT can be used for intraoperative hemostasis during transurethral surgery when hemostasis is poor due to extensive growth of the tumor.
6. Chemotherapy and optimal supportive care
For certain patients with limited progressive bladder tumors, first-line chemotherapy regimens including cisplatin have also been reported to allow patients to achieve complete or partial remission.
7. Combination therapy
Combination therapy may also allow some patients to achieve long-term survival rates comparable to early surgery. In addition, delaying surgery decreases patient survival.
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8. Tumors that cannot be surgically removed
Palliative resection is feasible for metastatic bladder cancer
RC is not the treatment of choice for patients with T4 and may be a curative/palliative option for those with symptoms. Urinary diversion is feasible whether or not the patient has undergone palliative resection.
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9. Adjuvant chemotherapy
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Metastatic bladder cancer
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*This level of evidence is weakened by certain statistical issues. gc: gemcitabine + cisplatin; HD-MVAC: high-dose methotrexate + vincristine + adriamycin + cisplatin; G-CSF: granulocyte colony-stimulating factor; MVAC: high-dose methotrexate + vincristine + adriamycin + cisplatin; PCG: paclitaxel + cisplatin + gemcitabine; PS: functional status
Biological markers
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Health-related quality of life (HRQoL)
Factors that determine a person’s subjective quality of life include the patient’s personality traits, the way he or she handles things, and help from society.
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Figure 2: Metastatic bladder cancer treatment process