Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe)...
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Transcript of Bladder Cancer R. Zenhäusern. Bladder cancer: Epidemiology Incidence:20/100000/year (Europe)...
Bladder Cancer
R. Zenhäusern
Bladder cancer:
Epidemiology• Incidence: 20/100000/year (Europe)• Mortality: 8-9/100000/year
• Fourth most common cancer in men– Incidence: 31.1 mortality: 12.1
• Seventh most common cancer in women– Incidence: 9.5 mortality: 4.5
• At diagnosis >70%: > 65 y of age
Bladder cancer: Histology
• 90-95% transitional-cell carcinoma
• 3% squamos-cell carcinoma
• 2% adenocarcinoma• <1% small-cell carcinoma
Bladder cancer: Entities
• 75-85% superficial bladder cancerpTa, pTis, pT1
• 10-15% muscle-invasive bladder
cancerpT2, pT3, pT4
• 5% metastatic bladder cancerN+, M+
Bladder cancer: Stage and Prognosis
Stage TNM 5-y. Survival
0 Ta/Tis NoMo >85%
I T1 NoMo 65-75%
II T2a-b NoMo 57%
III T3a-4a NoMo 31%
IV T4b NoMo 24%each T N+Mo 14%each T M+ med. 6-9 Mo
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 42% 50% 80%
Progression rate 2% 11% 45%
Superficial Bladder Cancer
Adjuvant Therapy• Reduces relpase rate by 30-80%
– Doxorubicin weekly 6-8 w. / monthly 6-12
– Mitomycin C weekly 6-8 w. / monthly 6-12
– BCG 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 high-grade invasive disease are cured
Results of radical cystectomy
Stage Recurrence-Free Overall Survival5 y. 10y. 5 y. 10y.
T2 N- 89 87 77 57N+ 50 50 52 52
T3a N- 78 76 64 44N+ 41 37 40 26
T3b N- 62 61 49 29N+ 29 29 24 12
T4a N- 50 45 44 23N+ 33 33 26 20
Stein et al JCO 2001;19:666
Results of radical cystectomy
Stage Recurrence-Free /Overall Survival 5 years
Organ-confined (<pT2pNo) 73% 62%
non-organ-confined (>pT2pNo) 56% 49%
Positiv lymph nodes (pT1-4, pN+) 33% 24%
Madersbacher et al JCO 2003;21:690
Chemotherapy for bladder cancer
• Bladder cancer is a chemosensitive disease
• Active single agents.
RR– Cisplatin 30%– Carboplatin 20%– Gemcitabine 20-30%– Ifosfamide 20%
Chemotherapy for bladder cancer
Combination chemotherapy.
RR CR
– MVAC 40-75% <20%– Gemzar / Cisplatin 40-70% 5-15%– Gemzar / Carboplatin 65% 5%– Taxol / Carboplatin 20-40%
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 death5% absolute benefit at 5 yearsOS increased from 45% to 50%
ABC Meta-analysis Collaboration. Lancet 2003;361:1927
Combined Radio- and Chemotherapy
CR 5y.OS
• Radiotherapy 57% 47%
• RT and cisplatin 85% 69%
• RT and carboplatin 70%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
Consolidation: RT + CT cystectomy
Bladder-sparing protocol
Shiply et al. Urology 2002;60:62
T2: 5y / 10y OS: 74% / 66%
T3-T4a: 5y / 10y OS: 53% / 52%
Results of bladder-sparing therapy and cystectomy
Bladder-sparing n Pat. 5y. OS 5y. Survivaltherapy % with Bladder %
Houssett 1997 120 63 NASauer 1998 162 55 44Shipley 1998 123 49 38Shipley 2002 190 54 45Rodel 2002 415 50 42
Cystectomy
Dalbagni 2001 181 36 NAStein 2001 633 48 NA
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 72%• Local control after CR 64% (10 y.)
• distant metastasis 35% (10 y.)
• Disease-specific survival 42% (10 y.)
• Preservation of bladder >80%
Local control Distant metastasis
Rödel et al. JCO 2002;20:3061
Disease-specific survival for patients after salvage cystectomy
50%45%
21% 18%
Rödel et al. JCO 2002;20:3061
TUR and adjuvant Radio-Chemotherapy
• 5 year Survival 50-65%
• Preservation of Bladder38-43%