Case study 114.1

A 65-year-old male presents with gross painless hematuria. Diagnostic bladder tumor resection demonstrates muscle invasion, exam under anesthesia suggests a three-dimensional (3D) mass, and imaging demonstrates unilateral hydronephrosis with an epidermal growth factor receptor (EGFR) of >50.

1. What is the best treatment option in this otherwise healthy patient?

Radical cystectomy with urinary diversion
Neoadjuvant methotrexate, vinblastine, adriamycin, and cisplatin (M-VAC) followed by radical cystectomy and urinary diversion
Definitive radiation
Radiation + gemcitabine
Palliative chemotherapy

In 2003, Grossman et al. published the Southwest Oncology Group (SWOG) randomized trial that was initiated in 1987. This paper demonstrated a dramatically increased survival in patients with locally advanced disease. As compared to cystectomy alone, patients who had neoadjuvant chemotherapy with methotrexate, vinblastine, doxorubicin, and cisplatin had a 31-month improved survival. Further, patients who had a complete response to neoadjuvant chemotherapy (i.e., pT0) had the longest survival, with the median not being reached for the study. Since this publication, a non-inferiority trial was published with regard to a gemcitabine and cisplatin combination as an alternative therapy with fewer reported adverse side effects. Further, a dose-dense regimen of M-VAC has also been found to have similar outcomes with less adverse events and imaging demonstrates unilateral hydronephrosis with an estimated glomerular filtration rate (eGFR) >50 ml/min.

Case study 114.2

A 54-year-old male presents with gross painless hematuria. Diagnostic bladder tumor excision demonstrates a superficial non-invasive (i.e., cTa) bladder cancer. Imaging demonstrates no evidence for disease.

1. What is the best treatment option for this patient?

Radical cystectomy with urinary diversion
Intravesical mitomycin C
Intravesical bacillus Calmette–Guerin (BCG) induction only
Observation with cystoscopy and repeat resection as warranted
Intravesical BCG induction + maintenance

Since the discovery of the decreased incidence of bladder cancer recurrence by Morales et al. in 1976, BCG has been the preferred regimen for the management of superficial bladder cancers. This immunotherapy is administered intravesically, is held within the bladder for 1–2 hours, and is given once a week for 6 weeks ∼4 weeks after transurethral resection of bladder tumor (TURBT). In 2000, SWOG published the results of a maintenance regimen trial, which demonstrated a dramatic increase in recurrence-free survival in the maintenance arm (36 vs. 77 months). Maintenance is described as a 3-week course of BCG given at 3, 6, 12, 18, 24, 30, and 36 months. Routine cystoscopy is performed prior to each of the administrative doses to ensure no development of tumor recurrence.

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114: Surgical Aspects of Bladder Cancer

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