New data regarding diagnosis and treatment of muscle-invasive and metastatic bladder cancer (MiM-BC) has emerged and led to an update of the European Association of Urology (EAU) guidelines for MiM-BC.
Objective
To review the new EAU guidelines for MiM-BC.
Evidence acquisition
A comprehensive workup of the literature obtained from Medline, the Cochrane central register of systematic reviews, and reference lists in publications and review articles was developed and screened by a group of urologists, oncologists, and radiologist appointed by the EAU Guideline Committee. Previous recommendations based on the older literature on this subject were taken into account. Levels of evidence and grade of guideline recommendations were added, modified from the Oxford Centre for Evidence-based Medicine Levels of Evidence.
Evidence synthesis
The diagnosis of muscle-invasive bladder cancer (BCa) is made by transurethral resection (TUR) and following histopathologic evaluation. Patients with confirmed muscle-invasive BCa should be staged by computed tomography (CT) scans of the chest, abdomen, and pelvis, if available. Adjuvant chemotherapy is currently only advised within clinical trials. Radical cystectomy (RC) is the treatment of choice for both sexes, and lymph node dissection should be an integral part of cystectomy. An orthotopic bladder substitute should be offered to both male and female patients lacking any contraindications, such as no tumour at the level of urethral dissection. Multimodality bladder-preserving treatment in localised disease is currently regarded only as an alternative in selected, well-informed, and compliant patients for whom cystectomy is not considered for clinical or personal reasons. An appropriate schedule for disease monitoring should be based on (1) natural timing of recurrence, (2) probability of disease recurrence, (3) functional deterioration at particular sites, and (4) consideration of treatment of a recurrence. In metastatic disease, the first-line treatment for patients fit enough to sustain cisplatin is cisplatin-containing combination chemotherapy. Presently, there is no standard second-line chemotherapy.
Conclusions
These EAU guidelines are a short, comprehensive overview of the updated guidelines of (MiM-BC) as recently published in the EAU guidelines and also available in the National Guideline Clearinghouse.
Introduction
Publications concerning muscle-invasive and metastatic bladder cancer (MiM-BC) are mostly based on retrospective analyses, including some larger multicentre studies and well-designed controlled studies. Few randomised studies are available on the diagnosis and surgical treatment of MiM-BC, and qualified, evidence-based data for many important clinical aspects do not reach levels usually obtained in some of the medical areas.
Section snippets
Methods
The recommendations provided in the current guidelines are based on a systemic literature search using Medline, the Cochrane Central Register of Systematic Reviews, and reference lists in publications and review articles. Previous recommendations on MiM-BC have been taken into account [1].
A thorough workup of the literature referenced in Medline and other public databases since the last update of MiM-BC was performed. Based on this workup, all members composed the conclusions and
Local staging of invasive bladder cancer
Both computed tomography (CT) and MRI scans can be used for assessment of local invasion [23], but they are unable to detect microscopic invasion of perivesical fat (T3a). The aim of CT and MRI scanning is therefore to detect T3b disease or higher. For the bladder, MRI scanning has superior soft tissue contrast resolution compared with CT scanning but poorer spatial resolution. In studies prior to the availability of MDCT, MRI scanning was reported to be more accurate for local assessment. The
Neoadjuvant chemotherapy
The advantages of neoadjuvant chemotherapy—that is, administering chemotherapy to patients with clinically operable transitional cell carcinoma (TCC) of the urinary bladder before the planned definitive surgery (or radiation)—are manifold: Chemotherapy is delivered at the earliest time point, when the burden of micrometastatic disease is expected to be low; in vivo chemo-sensitivity is tested; and tolerability of chemotherapy is expected to be better before than after cystectomy. However, there
Radical surgery and urinary diversion
Radical cystectomy (RC) is currently the standard treatment for localised, muscle-invasive BCa in most countries of the Western hemisphere [42], [43]. New interest in quality-of-life (QoL) issues has increased the trend towards preservation of the urethra to make an orthotopic neobladder possible as well as preservation of intrapelvic autonomic nerves to improve potency and continence as well as towards bladder-preservation treatment modalities like radiotherapy (RT) and/ or chemotherapy. PS
Adjuvant chemotherapy
To date, there have been only five published randomised trials of adjuvant chemotherapy and one meta-analysis, with updated individual patient data from six trials and a total of only 491 patients for survival analysis [37], [71], [72], [73], [74], [75].
Furthermore, all these trials are suboptimal with serious deficiencies, such as low sample size (underpowered), use of substandard chemotherapy, early stopping of patient entry, and flaws in design and statistical analysis, including irrelevant
Follow-up of patients with muscle-invasive bladder cancer
The authors would like to stress that any advice related to follow-up is entirely based on expert consensus and level-4 evidence data. An appropriate schedule for disease monitoring should be based on the natural timing of recurrence, the probability of disease recurrence, functional deterioration at particular sites, and consideration of treatment of a recurrence [84]. In general, follow-up oncologic surveillance can be stopped after 5 yr, but continuation with functional surveillance
