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Bladder cancer

management of bladder cancer

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Bladder cancer

  1. 1. TREATMENT OF CARCINOMA URINARY BLADDER G. Lakshmi Deepthi
  2. 2. Epidemiology : Most common tumor of the urinary tract & second most common cause of death. • Worldwide -Bladder cancer is the 7th most common cancer Incidence -330380cases /yr – 4.5% Mortality – 123051/yr -- 2.6% Europe > rest of the world • INDIA : 12th most common cancer Incidence -13151 cases/yr -- 2.8% Mortality –7664/yr -- 2.1% • Males : Females = 3:1 • Whites > Blacks.
  3. 3. Staging : AJCC 2010—TNM-UICC
  4. 4. STAGE TNM 5-Y. SURVIVAL 0 Ta/TisNoMo >85% I T1NoMo 65-75% II T2a-b NoMo 57% III T3a-4aNoMo 31% IV T4bNoMo 24% Any TN+Mo 14% Any TM+ med. 6-9 Mo SEER
  5. 5. TREATMENT GROUPS:  NON MUSCLE INVASIVE (NMIBC) Tis , Ta , T1  MUSCLE INVASIVE (MIBC) T2 onwards , N1  METASTATIC CASES M1
  6. 6. NMIBC : Aim : prevent recurrence disease progression to a life threatening stage Modality :  TURBT – standard of care  Adjuvant intra-vesical therapy – immunotherapy / chemotherapy
  7. 7. TURBT - PROCEDURE
  8. 8. EUA-- RESECTION TECHNIQUES Small tumors (<1 cm) can be resected en bloc. • Specimen should contain complete tumor plus part of underlying bladder wall Larger tumors should be resected separately in fractions and include: • Exophytic part of the tumor • Underlying bladder wall with the detrusor muscle • Edges of the resection area
  9. 9. TURBT Report : Pathologist should comment on: • Size • tumour grade • depth of tumour invasion, • presence of CIS • whether the detrusor muscle is present in the specimen. • specify the presence of LVI or unusual (variant) histology If there is uncertainty over the pathology, a further early re- resection (2-6 wk.) is indicated.
  10. 10. COMPLICATIONS : Early :  Infection  Bleeding  Bladder perforation Late Complications :  Urethral manipulation and/or dilation -- meatal stenosis, urethral stenosis, or urethral stricture.  Related to resection or fulguration of the ureteral orifice -- ureteral stenosis.
  11. 11. Immediate, single, postoperative instillation of intravesical chemotherapy  70 % chance of recurrence  15% progress to muscle invasive disease  <5% will present with metastatic disease Meta analysis by EORTC : • 12% absolute reduction in tumour recurrence • no significant differences in efficacy among the chemotherapeutic agents studied. • Therefore, choice of agent is optional.
  12. 12. Other Agents : Similar In Efficacy  Thiotepa – high risk of myelosuppression  Doxorubicin -- cystitis, decreased bladder capacity, and hematuria  Epirubicin– same as doxorubicin but milder not approved for intravesical use in US  Mitomycin C --dysuria and urinary frequency, dystrophic calcification MOST COMMONLY USED … Dose – 40mg in 20cc sterile water.
  13. 13. REPEAT TURBT :When ? Why ? Whom? INDICATIONS :  Incomplete resection of the primary tumor  Absence of muscle in the initial pathologic specimen,  High-grade tumors,  Pathologic stage T1 tumors RATIONALE : • the risk of upstaging on second TURBT is 25%. (Schwaibold et al, 2000). • the risk of residual tumor on second TURBT is 60% (Klan et al, 1991; Mersdorf et al, 1998; Ghoneim et al.1997) High-grade Ta Or Any T1 Urothelial Ca.
  14. 14. RANDOM BIOPSIES??  Low-risk–appearing tumors and negative cytology -- should not undergo random biopsy  Always indicated in high-risk tumors (high-grade T1, multiple tumors, recurrent multiple tumors, or CIS)  The locations are usually lateral to each ureteral orifice (N 2), lateral walls (N 2), posterior wall (N 1), superior wall (N 1), and prostate (N 1).
  15. 15. TURBT – NMIBC SCORING : LOW RISK :  Tumor <3cm  Grade 1 disease  T1a with no e/o CIS 15% chance of recurrence 0.2% risk of progression INTERMEDIATE RISK :  Multiple grade I tumors  Multiple Grade II, stage Ta  Single grade II, stage T1 38% chance of recurrence 5% risk of progression HIGH RISK : • stage Ta or T1 • Grade III, • CIS 61% -recurrence risk 17%-risk of progression
  16. 16. ADJUVANT INTRAVESICAL THERAPY – IN WHOM ???  CIS associated with ta or T1 tumors  Any G3 tumor  Multifocal tumors  Those whose tumors rapidly recur following TURBT of the initial bladder tumor.  Urothelial carcinoma involving the prostatic mucosa or ducts
  17. 17. For intermediate and high -risk disease: Intravesical chemotherapy or BCG induction plus maintenance should be initiated following complete TURBT and single, immediate instillation of chemotherapy.
  18. 18. CHEMOTHERAPY  Directly kills tumor cells  Increasing dose increases cell killing  Penetrates bladder by diffusion  Given within 6hrs,prevents tumor seeding  E.g. : mitomycin C, thiotepa ,doxorubicin, gemcitabine  Stimulates patient immune system to kill tumor cells  Increasing dose will suppress patient’s immune system  Attaches to receptors  Immediate immunotherapy is very toxic .  BCG , interferon alpha and BCG. IMMUNOTHERAPY The NCCN– BCG is the preferred intravesical option.
  19. 19. • Reducing disease recurrence in high-risk patients. • No difference in disease progression or survival . • irrespective of the actual tumor risk status intermediate- or high-risk
  20. 20. BCG  BCG is a live, attenuated strain of Mycobacterium bovis  MOA : triggers an inflammatory cascade, inducing neutrophil and Th1 chemotaxis.  The vaccine is reconstituted with 50 mL of saline and should be administered through a urethral catheter under gravity drainage  Treatments should generally begun 2 to 4 weeks after tumor resection  After instillation, the patient should retain the solution for 2 hours
  21. 21. PRECAUTIONS :
  22. 22. SCHEDULE: Induction :  Weekly for 6 weeks intravesically --- 2 weeks from TURBT.  Cystoscopy with urinary cytology and possible biopsy should be done at 3 months to confirm the absence of recurrence or progression Maintenance : SWOG regimen of 3 weekly instillations at 3, 6, and every 6 months for 3 years.
  23. 23.  All guidelines and meta-analyses recommend at least 1 year of BCG maintenance therapy .  Full-dose BCG is the standard  Complete remission is obtained in up to 70% of cases  If cytology and biopsies remain positive, another cycle may produce an additional 15% complete remission.
  24. 24. COMPLICATIONS :  Irritative lower urinary tract symptoms (LUTS) (27%-95%),  Fever greater than 39.5°c (2.9%),  Hematuria (1.0%),  Granulomatous prostatitis (0.9%),  Granulomatous pneumonitis or hepatitis (0.7%)  Arthralgia (0.5%),  Epididymitis (0.4%),  Severe disseminated BCG sepsis (0.4%)  Very rare rashes, ureteral obstruction, bladder contraction, and renal abscesses (all <0.3%)
  25. 25. CONTRAINDICATIONS : Absolute : • Immunosuppressed and immuno-compromised • Immediately after TURBT/TURP, gross hematuria or traumatic foley (disrupted urothelium) • History of BCG Sepsis Relative : • Active UTI • Total incontinence • Liver disease • History of TB • Poor performance status or advanced age
  26. 26. OTHER INTRAVESICAL AGENTS :
  27. 27. Device Assisted Therapies: THERMOCHEMOTHERAPY
  28. 28. EMDA PDT
  29. 29. Cystectomy in NMIBC :  Ta low- or intermediate-risk disease--if bladder-sparing modalities have failed.  In a high-risk patient with multiple recurrent tumors, or T1 tumors with associated CIS, LVI, or variant histologies.  In a high-risk patient with persistent or recurrent disease within one year following treatment with two induction cycles of BCG or BCG maintenance NO ROLE OF RADIOTHERAPY IN NMIBC
  30. 30. EUA –SURVEILLANCE :
  31. 31. TREATMENT OF RECURRENCES :  Low-risk Patients -- treat as intermediate risk  Intermediate-risk patients, consider risk category: Intermediate-risk:  TURBT plus single, immediate chemotherapeutic instillation f/b Repeat chemotherapy or BCG induction plus maintenance High Risk :  TURBT plus single, immediate chemotherapeutic instillation f/b BCG induction plus maintenance or Radical cystectomy  For High-grade Recurrences In High-risk Patients ◦ Radical cystectomy (preferred) ◦ TURBT plus additional intravesical instillations if patient is not suitable for cystectomy
  32. 32. MUSCLE INVASIVE BLADDER CANCER (MIBC) – 20% of cases
  33. 33. TREATMENT OPTIONS No diff in OS , cause specific survival, and distant recurrence free survival BLADDER PRESERVATION PROTOCOLS RADICAL CYSTECTOMY WITH URINARY RECONSTRUCTION RELAPSE OR PROGRESSION If left untreated 85% of patients will die by 2yrs
  34. 34. SURGERY :  RADICAL CYSTECTOMY  BLADDER PRESERVATION SURGERY
  35. 35. Indications For Radical Cystectomy  MIBC (cT2-T4a N0M0)  NMIBC --- G3 disease is multifocal or associated with CIS when bladder tumors rapidly recur, in multifocal areas following intravesical drug therapy  Histological variants : squamous cell carcinoma, adenocarcinoma, and sarcomatoid or spindle cell carcinoma  Palliation for pain, bleeding, or urinary frequency
  36. 36. • lymph node metastases are un-resectable because of bulk or proximal extent above the common iliac vessels; • there is evidence of extensive peri-ureteral disease; • the bladder is fixed to the pelvic sidewall; or • tumor is invading the recto-sigmoid colon. Cystectomy not to be performed if:
  37. 37. SURGERY :  Radical Cystectomy Cystoprostatectomy Cystoprostatourethrectomy  Lymph node dissection  Urinary diversion – Conduit urinary diversion Continent cutaneous reservoir Orthotopic neo-bladder Standard of care – high grade invasive bladder cancer
  38. 38. Procedure : Enbloc removal of pelvic lymph nodes along with pelvic organs anterior to rectum
  39. 39. PELVIC LYMPHADENECTOMY  ~25% have LN involvement at cystectomy  Accurate staging Assessment of prognosis Adjuvant therapies (chemotherapy, clinical trials)  Therapeutic benefit ◦ Removal of micro-metastatic disease
  40. 40. Lymphadenectomy Boundaries :  Superior – level of inferior mesenteric artery  Lateral – over IVC or aorta to genito femoral nerve  Distal – medial- lymph node of Cloquet lateral – circumflex iliac vein Includes : obturator,hypogastric,presciatic, Presacral lymph nodes Minimum 15 Lymph nodes
  41. 41. Standard LND Extended LND Pelvic Lymphadenectomy
  42. 42. Urinary Diversion  Use of intestinal segment to bypass/ reconstruct/ replace the normal urinary tract  Goals: ◦ Storage of urine without absorption ◦ Maintain low pressure even at high volumes to allow unobstructed flow of urine from kidneys ◦ Prevent reflux of urine back to the kidneys ◦ Socially-acceptable continence  “Ideal” diversion has yet to be discovered
  43. 43. URINARY DIVERSIONS CONTINENT ILEOSTOMY CUTANEOUS URETEROSTOMY ORTHOTOPIC NEOBLADDER ILEAL CONDUIT
  44. 44. ORTHOTOPIC NEOBLADDER 15-20 cm 44 cm Ureters attached Connect to urethra Ileum detubularized Reservoir STUDER ILEAL NEOBLADDER
  45. 45. Complications :  Metabolic— Electrolyte abnormalities Renal calculi Decreased renal function Infection Vit B12 malabsorption  Neuro-mechanical Atonic Hyperperistaltic contractions  Surgical : SHORT TERM LONG TERM Acute acidosis(16%) Urine leak(3-16%) Bowel obstruction(10%) Pyelonephritis(5-15%) Ureteral/intestinal obstruction(15%) Renal deterioration(15%) Renal failure(5%) Stoma problems(15%) Intestinal stricture(10-15%)
  46. 46. Prostate sparing cystectomy :  For preserving continence and potency  Not preferred – as co-existent prostate cancer and prostate urothelial cancer seen in 23-54% of cases. 29% significant leading to local recurrence and distant metastasis.
  47. 47. SURVIVAL AFTER RADICAL CYSTECTOMY :
  48. 48. NEOADJUVANT THERAPY: CHEMOTHERAPY : (ASCO)  Neoadjuvant chemotherapy is recommended for T2-T4a, cN0M0 bladder cancer  recommend use of three cycles of cisplatin-based combination chemotherapy; specifically M-VAC or CMV RADIOTHERAPY:  Preoperative radiotherapy has not shown to improve survival  Preoperative radiotherapy for operable MIBC can result in tumor down-staging after 4-6 weeks .
  49. 49. TRIALS ON NACT:  SWOG – 2 arms Surgery (median survival) - 3.8yrs NACT f/b surgery – 6.2yrs  UK/EORTC trial CMV surgery CMV RT  16% reduction in risk of distant metastasis  10yr survival increased from 30—>36%  3yr survival increased from 50-56%
  50. 50. With platinum based NACT, absolute benefit in survival of 5% at 5 years
  51. 51. Recurrence Following Surgery :  Local recurrence – 6-9% within soft tissue field of exenteration  Distant recurrence – 20-35% outside pelvis  Urethral –6-10% new tumor in retained urethra
  52. 52. Adjuvant Chemotherapy NCCN,EAU recommendations for adjuvant chemotherapy are if neoadjuvant chemotherapy was not given 1. T3 or more 2. Node positive 3. Positive margins ADJUVANT TREATMENT
  53. 53. • Benefit for OS and DFS in MIBC patients who underwent adjuvant chemotherapy after radical cystectomy compared with those who underwent surgery alone • Lymph node–positive patients benefit more than lymph node–negative patients in terms of DFS • Beneficial role of cisplatin-based adjuvant chemotherapy in MIBC EAU
  54. 54. Adjuvant Radiotherapy :  No strong evidence supporting RT in the adjuvant setting  Maybe given in cases of high risk for loco-regional relapse : 1. Positive surgical margins 2. Tumor spillage  Postoperative radiation is indicated in the setting of a positive surgical margin after partial cystectomy  If the pelvic lymph nodes are known to be negative, the whole bladder and abdominal wall incision --dose of 40 Gy (45 Gy without con- current chemotherapy),  with a cone-down boost for a total of 56 Gy high risk area
  55. 55.  A final postoperative pathologic study demonstrating positive pelvic lymph nodes is not an indication for pelvic irradiation as a single adjuvant therapy.  Primary need is for the systemic treatment.  High likelihood of occult micrometastatic disease (>80%) and, if positive margins exist in addition to positive lymph nodes  Radiation therapy can be given to the bladder bed in addition to chemotherapy in a younger patient when the pathologic indications are strong,.
  56. 56. BLADDER PRESERVATION STRATEGIES :  Conservative Surgery Partial Cystectomy TURBT  Radical External Beam Radiation Therapy ±Brachytherapy boost  Combined modality treatment Chemotherapy + TURBT/Partial cystectomy Trimodality : maximal TURBT, chemotherapy & radiotherapy
  57. 57. 1) TURBT INDICATIONS :  initial occurrence of bladder cancer;  no CIS;  size less than or equal to 3 cm;  stage T2 (no palpable mass); and  not in the dome or high posterior wall because of the risk of bowel injury TURBT is usually not sufficient as monotherapy in muscle- invading bladder cancer.
  58. 58. 2) Partial Cystectomy INDICATIONS :  the lesion is solitary  located in a region of the bladder that allows for complete excision with a 2-cm tumor-free margin, such as the bladder dome)  Bilateral pelvic lymphadenectomy is performed at the time of surgery for pathologic staging of the nodes  local recurrence rates range from 38% to 78%  Rarely performed
  59. 59. 3)Radical External Beam Radiation Therapy  Historically, EBRT was used as monotherapy  Factors having significant favourable effect on local control with Radiotherapy: ◦ Early clinical stage (T2 and T3a) ◦ Absence of ureteral obstruction ◦ Visibly complete TURBT ◦ Small tumor size (<5 cm) solitary , Papillary / Sessile absence of coexisting carcinoma in situ
  60. 60. 4) Interstitial Brachytherapy  combined with EBRT to provide a radiation boost to the primary tumor  Indication: Solitary TCC with a diameter of less than 5 cm • Five-year local control rates for selected patients 70% -90% • High rates of bladder preservation • Acute toxicity :Fistula formation with wound leakage
  61. 61. 5) Trimodality Therapy TURBT + CHEMO + RT
  62. 62. Ideal Candidate :  Primary T2 to T3a tumors that are unifocal  Tumor size less than 5 cm in maximum diameter  Tumor not associated with extensive CIS  No presence of ureteral obstruction or tumor-associated hydronephrosis  Good capacity of the bladder  Visibly complete TURBT  Adequate renal function to allow cisplatin to be given concurrently with irradiation
  63. 63. MGH ERLANGEN
  64. 64. RTOG Protocols and Results of Multimodality Treatment for Muscle- Invading Bladder Cancer
  65. 65. RTOG Conclusions :  Combined modality provided better bladder preservation.  Cisplatin was the best sensitizer  Safe and easily administered  Neoadjuvant CT did not added any survival advantage and the trial was closed early.  Altered fractionation especially accelerated fractionation has given better control rates in Phase 2 trial
  66. 66. NACT before CRT???  16% reduction in the risk of death  increase in 3-year survival 50% -> 56%  10-year survival from 30% -> 36%,  median survival time of 7 months  CMV chemotherapy improves outcome as first- line adjunctive treatment for invasive bladder cancer compared to cystectomy or radiotherapy alone.
  67. 67. IMPACT OF NEOADJUVANT CHEMOTHERAPY ON ORGAN PRESERVATION IN MUSCLE INVASIVE URINARY BLADDER CARCINOMA Dr. Chinna Babu Dracham* , Dr. Narendra Kumar* , Dr. Santosh Kumar** Dr. Budhi Singh Yadav * , Dr. Anupam Lal# , Dr. Ravi Mohan** • Conservative treatment in patients with muscle-invasive bladder cancer provides a high probability of local response with acceptable toxicity in properly selected patients. • Our trial shows that organ preservation with neo adjuvant chemotherapy is a valid option in early MIBC
  68. 68. CYSTECTOMY vs TRIMODALITY THERAPY :
  69. 69. RADIOTHERAPY IN BLADDER CANCER  Concurrent chemo-radiation as a part of multi-modality bladder sparing protocol in T2-T4 N0 M0  Neo adjuvant radiotherapy  Adjuvant radiotherapy  Pelvic recurrence after radical cystectomy  Palliative radiotherapy for metastatic cases
  70. 70.  Phase 1- ◦ The whole pelvis, encompassing the pelvic lymph nodes, bladder, and proximal urethra ◦ Elective irradiation of the pelvic lymph nodes  Phase 2- then cone-down to boost the bladder alone
  71. 71. CONVENTIONAL PLANNING TRIPLE CONTRAST –BLADDER LOCALISATION  Foley catheter inserted shortly after the patient has voided.  Post-voiding urine residual is measured,  This volume is replaced by an equal volume of bladder contrast plus an additional 25 mL of contrast and 15 mL of air.  The patient is immobilized in a supine position
  72. 72.  Superior :at the L5-S1 disc space  Inferior : below obturator foramen.  Laterally:1.5-2 cm to the bony pelvis at its widest section  Dose:40-45 GY @ 1.8-2Gy/# Phase I:
  73. 73. Lateral fields • Anterior : anterior to bladder with a margin with 1.5 – 2cm • Posterior : 2-3 cm posterior to bladder
  74. 74. BOOST  Prone position
  75. 75. PORTALS :  anterior – bladder with a margin of 1-5-2cm  lateral – bladder with a margin of 1.5-2cm  oblique – are selected at an angle which spares the rectum completely and encompasses the bladder with 1.5 cm margin FIELDS :  3 field – 2 laterals and one anterior (or) 2 obliques and one anterior  DOSE :60-66 Gy to bladder tumor
  76. 76. CONFORMAL RADIOTHERAPY : PLANNING CT :  Supine, arms on chest  Knee and ankle immobilization  Empty rectum  Empty bladder 15 minutes before  The scan is performed with 3–5 mm slices from the lower border of L5 to the inferior border of the ischial tuberosities.  All planning and treatment should be carried out with the bladder empty
  77. 77. Contouring Guidelines :  GTV –primary bladder tumor  CTV –whole bladder and any extra-vesical extension Men : entire prostate women : the proximal 2 cm of urethra is also considered as part of the target field  PTV –1.5-2cm around CTV
  78. 78. NODAL CONTOURING :
  79. 79. CONTOURING IN POST OP CASES: (RTOG)
  80. 80. BEAM ARRANGEMENT
  81. 81. BOOST PHASE :
  82. 82. DOSE :  A total dose of 45 to 50 Gy is delivered to the pelvis and 55 to 70 Gy to the bladder tumor bed, achieving favorable rates of local control  Total RT dose is important for loco-regional control.  Hyper-fractioned RT schemes, provide a higher local control in relation to conventional RT. (Naslund et al., Martin et al.)  Accelerated and hypo-fractionated RT schemes are not recommended, and may present higher toxicity.
  83. 83.  Conformal planning is the standard of care and usually ensures satisfactory PTV coverage.  IMRT offers increased conformity and potential dosimetric improvements to organs at risk . (Van Rooijen et al. Turgeon et al. )  IMRT can be used in selected cases to boost defined gross disease.  Hsieh et al ---Helical tomotherapy had statistically significantly better organ sparing results.  Disadvantages include prolonged treatment delivery time, increased MU, the close delineation of the radiation field to the tumor might lead to higher risk of geographic miss.
  84. 84. PROBLEMS IN BLADDER RADIOTHERAPY :  Organ motion  Delineation errors  Set up errors  Treatment verification  Reproducibility of bladder volume
  85. 85.  Organ motion is the dominant source of error in the planning and delivery of radiotherapy to the bladder  Anisotropic margins –2cm superior and anterior 1.5cm all other sides  Empty bladder treatments  OAR’S motion – PRV margin of 0.8-1.6 cm to rectum
  86. 86. Advances in radiotherapy …  Elekta Synergy System comprises a kilovoltage radiograph source and detection panel mounted on the gantry of a treatment linear accelerator  IGRT with implanted fiducials  Adaptive planning – Composite volume Adaptive organ localisation In conclusion, without IGRT, generous margins in the range of 2–3 cm have to be applied in order to account for organ motion, implying large treatment volumes and dose-limiting toxicity
  87. 87. Composite Volume :
  88. 88. PELVIC RECURRENCE AFTER CYSTECTOMY  Proximal urethral recurrences with CRT  65–70 Gy.  For pelvic sidewall recurrences, the doses are limited by the presence of small bowel in the field.  Still, radiation with concurrent cisplatin can be given to doses tolerated by the intestine, ileal loop, and stoma, usually 50 –56 Gy
  89. 89. PALLIATIVE RADIOTHERAPY  For rapid relief of pain  Hematuria  Painful bony metastasis  Dose : 30Gy/10#/2wks or 8Gy single # or 20Gy/5#/1wk  For Bony Metastasis :Meta-analysis that revealed no difference in complete or overall pain relief between single and multifraction.  Palliation to inoperable patients, when not suitable for chemotherapy.
  90. 90. Radiation Toxicity Acute effects:  Dysuria  Urgency  Frequency  Diarrhoea Late effects:  Chronic irritative cystitis  Hemorrhagic cystitis  Bladder contracture  Rectal stricture  Small bowel obstruction 79% of patients had normal bladder function at 10 yrs
  91. 91. METASTATIC DISEASE : Chemotherapy plays the main role in management  Chemosensitive  Objective response rates : 12-73%  Complete response rates :0-35%
  92. 92. Regimens : 1st line : MVAC  Methotrexate 30mg/m2 --days 1, 15 and 22;  Vinblastine 3 mg/m2 -- days 2, 15 and 22  Doxorubicin 30 mg/m2 - day 2  Cisplatin 70 mg/m2 -- day 2  Cycles were repeated every 28 days, until tumour progression or for a maximum of six cycles  Side effects : high-grade granulo- cytopenia, neutropenic fever, sepsis, mucositis, nausea and vomiting  median survival of 18.2 months -- 4.4 months.
  93. 93. Gemcitabine and Cisplatin Regimen  Gemcitabine 1000mg/m2 –day 1,8,15  Cisplatin 70mg/m2 –day 1,2  GC provided a similar survival advantage to M-VAC, with a better safety profile and tolerability.  GC as a first-line chemotherapy in patients with locally advanced or metastatic urothelial carcinoma
  94. 94. OTHER REGIMENS
  95. 95. Patients Unfit For Cisplatin-based Therapy :  gemcitabine plus carboplatin  gemcitabine and paclitaxel appears to have good activity, with phase II studies suggesting that this regimen has response rates and survival comparable to GC, with minimal toxicity.  Gemcitabine and docetaxel demonstrated a response rate of 33% and median survival of 12 months in a trial of 27 patients with advanced TCC
  96. 96. 2nd LINE :  Several agents have been tried  Epothilones, vinflunine and pemetrexed are among the newer agents that have been shown to have modest activity in clinical trials  Vinflunine --an improvement in progression-free survival, from 1.5 to 3 months.  clinical trial participation
  97. 97. TREATMENT SUMMARY
  98. 98. CONCLUSION :  Complete TURBT followed by appropriate staging is the first step in the treatment of any bladder cancer patient.  Radical cystectomy has been considered the gold standard treatment  However has poor quality of life.  In all organ-sparing management, RT remains the principal part of the local treatment .  Proper patient selection is very essential for organ preservation with trimodality treatment.  Improve QoL with organ preservation is a significant consideration for patients with bladder cancer.
  99. 99. Thank You …
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management of bladder cancer

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