ESMO Minimum Clinical Recommendations for diagnosis, treatment and follow-up of invasive bladder cancer

L. Sengeløv

Department of Oncology, Herlev University Hospital, Herlev, Denmark


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The crude incidence of bladder cancer in the European Union is 23 cases/100 000 per year, and the mortality is 10 cases/ 100 000 per year. Seventy per cent of patients with bladder cancer are >65 years of age.


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Pathological diagnosis should be made according to the WHO classification from a biopsy obtained by transurethral resection (TUR) of primary tumor; 90% of bladder carcinomas are transitional cell carcinomas.


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Staging and risk assessment should be by complete history and physical examination, blood counts, creatinine, chest X-ray and computed tomography (CT) scan of the abdomen if invasive tumor is diagnosed and cystoscopic examination and TUR with a biopsy and determination of size and the presence of extravesical extension or invasion of adjacent organs.
Patients with bladder cancer should be staged according to the TNM-97 system and be grouped into the following risk categories (Table 1):


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Table 1.
 

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TUR and fulguration are the treatment of choice but careful surveillance is important. Intravesical therapy with BCG or chemotherapy may be used in patients with recurrent superficial tumors [I, A]. Radical cystectomy or curative radiotherapy in patients with high-risk tumors (recurrent, large, multifocal, poorly differentiated or with carcinoma in situ).


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Radical cystectomy with or without pelvic lymph node dissection is considered standard treatment. Patients unfit for surgery should receive full-dose external-beam radiotherapy. TUR with fulguration in selected cases. Neoadjuvant chemotherapy or chemo-radiotheraphy is under investigation to provide organ-sparing treatment.


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Platinum-based combination chemotherapy (methotrexate, vinblastine, doxorubicin, cisplatin or gemcitabine, cisplatin) prolongs survival [I, A]. Patients with T4b and/or N1 may be candidates for cystectomy and lymph node dissection or radiotherapy in selected cases.


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Response evaluation is mandatory after radiotherapy by repetition of cystoscopy after 3 months. Response evaluation during chemotherapy with the initial radiographic tests are recommended.


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For patients treated with full-dose external-beam radiotherapy, cystoscopy and urinary cytology should be performed every 3 months during the first 2 years, and every 6 months thereafter. After cystectomy, clinical control should be performed every 3 months during the first 2 years and subsequently every 6 months for 5 years.


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Levels of Evidence [I–V] and Grades of Recommendation [A–D] as used by the American Society of Clinical Oncology are given in square brackets. Statements without grading were considered justified standard clinical practice by the expert authors and the ESMO faculty.


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Coordinating author for the ESMO Guidelines Task Force: L. Sengeløv, Department of Oncology, Herlev University Hospital, Herlev, Denmark.

Approved by the ESMO Guidelines Task Force: August 2002.

Correspondence to:

ESMO Guidelines Task Force

ESMO Head Office

Via La Santa 7

CH-6962 Viganello-Lugano

Switzerland


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1. Herr HW, Schwalb DM, Zhang ZF et al. Intravesical bacillus Calmette–Guerin therapy prevents tumor progression and death from superficial bladder cancer: ten-year follow-up of a prospective randomized trial. J Clin Oncol 1995; 13: 1404–1408.[Abstract]

2. International Collaboration of Trialists. Neoadjuvant cisplatin, methotrexate, and vinblastine chemotherapy for muscle-invasive bladder cancer: a randomised controlled trial. Lancet 1999; 354: 533–540.[CrossRef][ISI][Medline]

3. Coppin C, Cospodarowicz M. The NCI-Canada trial of concurrent cisplatin and radiotherapy for muscle invasive bladder cancer. Prog Clin Biol Res 1990; 353: 75–83.[Medline]

4. Loehrer PJ, Einhorn LH, Elson PJ et al. A randomized comparison of cisplatin alone or in combination with methotrexate, vinblastine, and doxorubicin in patients with metastatic urothelial carcinoma. J Clin Oncol 1992; 10: 1066–1073.[Abstract]

5. Mead G, Russel M, Clark P et al. A randomized trial comparing methotrexate and vinblastine (MV) with cisplatin, methotrexate and vinblastine (CMV) in advanced transitional cell carcinoma: results and a report on prognostic factors in a Medical Research Council study. Br J Cancer 1998; 78: 1067–1075.[ISI][Medline]

6. von der Maase H, Hansen SW, Roberts JT et al. Gemcitabine and cisplatin versus methotrexate, vinblastine, doxorubicin, and cisplatin in advanced or metastatic bladder cancer: results of a large, randomized, multinational, multicenter, phase III study. J Clin Oncol 2000; 18: 3068–3077.[Abstract/Free Full Text]





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