This document discusses treatment options for urinary bladder carcinoma. It covers non-muscle invasive bladder cancer (NMIBC), muscle invasive bladder cancer (MIBC), and metastatic disease. For NMIBC, transurethral resection of bladder tumor (TURBT) followed by intravesical immunotherapy like BCG is recommended. For MIBC, radical cystectomy with pelvic lymphadenectomy and urinary diversion is the standard treatment. Neoadjuvant chemotherapy may improve survival for MIBC. Adjuvant chemotherapy is recommended for high-risk MIBC following cystectomy.

1. TREATMENT OF
CARCINOMA
URINARY BLADDER
G. Lakshmi Deepthi

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. Staging : AJCC 2010—TNM-UICC

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. TREATMENT GROUPS:
 NON MUSCLE INVASIVE (NMIBC)
Tis , Ta , T1
 MUSCLE INVASIVE (MIBC)
T2 onwards , N1
 METASTATIC CASES
M1

6. NMIBC :
Aim : prevent recurrence
disease progression to a life threatening stage
Modality :
 TURBT – standard of care
 Adjuvant intra-vesical therapy – immunotherapy /
chemotherapy

7. TURBT - PROCEDURE

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. • 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. 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. PRECAUTIONS :

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.  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. 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. 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. OTHER INTRAVESICAL AGENTS :

27. Device Assisted Therapies:
THERMOCHEMOTHERAPY

28. EMDA PDT

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. EUA –SURVEILLANCE :

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. MUSCLE INVASIVE
BLADDER CANCER
(MIBC) – 20% of cases

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. SURGERY :
 RADICAL CYSTECTOMY
 BLADDER PRESERVATION SURGERY

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. • 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. 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. Procedure :
Enbloc removal of pelvic lymph nodes along with pelvic
organs anterior to rectum

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. 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. Standard LND Extended LND
Pelvic Lymphadenectomy

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. URINARY DIVERSIONS
CONTINENT ILEOSTOMY
CUTANEOUS URETEROSTOMY
ORTHOTOPIC NEOBLADDER
ILEAL CONDUIT

44. ORTHOTOPIC NEOBLADDER
15-20 cm
44 cm
Ureters
attached
Connect to urethra
Ileum
detubularized
Reservoir
STUDER ILEAL NEOBLADDER

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. 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. SURVIVAL AFTER RADICAL
CYSTECTOMY :

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. 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. With platinum
based NACT,
absolute benefit in
survival of 5% at
5 years

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. 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. • 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. 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.  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. 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. 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. 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. 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

61. 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

62. 5) Trimodality Therapy
TURBT + CHEMO + RT

63. 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

64. MGH ERLANGEN

65. RTOG Protocols and Results of
Multimodality Treatment for Muscle-
Invading Bladder Cancer

66. 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

67. 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.

68. 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

69. CYSTECTOMY vs
TRIMODALITY THERAPY :

70. 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

71.  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

72. 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

73.  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:

74. Lateral fields
• Anterior : anterior to bladder with a margin with 1.5 – 2cm
• Posterior : 2-3 cm posterior to bladder

75. BOOST
 Prone position

76. 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

77. 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

78. 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

79. NODAL CONTOURING :

80. CONTOURING IN POST OP
CASES: (RTOG)

81. BEAM ARRANGEMENT

82. BOOST PHASE :

83. 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.

84.  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.

85. PROBLEMS IN BLADDER
RADIOTHERAPY :
 Organ motion
 Delineation errors
 Set up errors
 Treatment verification
 Reproducibility of bladder volume

86.  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

87. 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

88. Composite Volume :

89. 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

90. 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.

91. 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

92. METASTATIC DISEASE :
Chemotherapy plays the main role in management
 Chemosensitive
 Objective response rates : 12-73%
 Complete response rates :0-35%

93. 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.

94. 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

95. OTHER REGIMENS

96. 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

97. 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

99. TREATMENT SUMMARY

100. 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.

101. Thank You …