New Clinical Practice Guidelines, November 2017

John Anello; Brian Feinberg; Richard Lindsey; Cristina Wojdylo; Olivia Wong, DO; Yonah Korngold; John Heinegg; Sam Shlomo Spaeth

Disclosures

November 08, 2017

In This Article

Bladder Cancer

National Comprehensive Cancer Network

Laboratory studies, such as a complete blood cell count and chemistry profile, including alkaline phosphatase, must be performed, and the patient should be assessed for the presence of regional or distant metastases. This evaluation should include chest imaging and a bone scan in patients with symptoms or a clinical suspicion of bone metastasis (eg, elevated alkaline phosphatase, focal bone pain). An abdominal/pelvic CT or MRI is used to assess the local and regional extent of disease.

A pelvic lymph node dissection (PLND) is considered an integral part of the surgical management of bladder cancer. Patient factors that may preclude a PLND include severe scarring secondary to previous treatments or surgery, advanced age, or severe comorbidities.

Partial cystectomy is most frequently recommended for lesions that develop on the dome of the bladder and have no associated Tis (carcinoma in situ) in other areas of the urothelium. Relative contraindications to this procedure are lesions that occur in the trigone or bladder neck.

The decision to recommend adjuvant radiation or chemotherapy is based on the pathologic stage (ie, positive nodes or perivesical tissue involvement) or presence of a positive margin, similar to that for patients who undergo a radical cystectomy.

Neoadjuvant chemotherapy followed by radical cystectomy is a category 1 recommendation. Patients with hearing loss or neuropathy, poor performance status, or renal insufficiency may not be eligible for cisplatin-based chemotherapy. If neoadjuvant cisplatin-based chemotherapy cannot be given, neoadjuvant chemotherapy is not recommended. For patients with borderline renal function or minimal dysfunction, a split-dose administration of cisplatin may be considered.

Adjuvant chemotherapy may be given to patients with high-risk pathology who did not receive neoadjuvant chemotherapy.

A minimum of 3 cycles of a cisplatin-based combination, such as dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin (ddMVAC), gemcitabine plus cisplatin (GC), or CMV, may be used in patients undergoing perioperative chemotherapy.

Patients with tumors that are ≤pT2 and have no nodal involvement or lymphovascular invasion after cystectomy are considered to have lower risk and are not recommended to receive adjuvant chemotherapy.

It is reasonable to consider adjuvant radiation in patients with pT3/pT4 pN0–2 urothelial bladder cancer after radical cystectomy.

The decision to use a bladder-preserving approach is partially based on the location of the lesion, depth of invasion, size of the tumor, status of the “uninvolved” urothelium, and status of the patient (eg, bladder capacity, bladder function, comorbidities). Bladder preservation as an alternative to cystectomy is generally reserved for patients with smaller solitary tumors, negative nodes, no carcinoma in situ, no tumor-related hydronephrosis, and good pretreatment bladder function. Patients who are medically fit for radical cystectomy but who have hydronephrosis are poor candidates for bladder-sparing procedures.

RT alone is inferior to RT combined with chemotherapy for patients with an invasive bladder tumor, and it is not considered standard for patients who can tolerate combined therapy.

Transurethral resection of bladder tumor (TURBT) alone may be an option for patients with cT2, cT3, or cT4a disease who are not candidates for cystectomy.

Follow-up after cystectomy should include urine cytology, liver function tests, creatinine, and electrolytes. Imaging of the chest, upper tracts, abdomen, and pelvis should be conducted at intervals based on the recurrence risk. Patients should be monitored annually for vitamin B12 deficiency if a continent urinary diversion was created.

Reference

  • Spiess PE, Agarwal N, Bangs R, et al. Bladder cancer, version 5.2017, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2017 Oct;15(10):1240-67.

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