This document discusses treatment options for muscle-invasive bladder cancer, including radical cystectomy, partial cystectomy, radiotherapy alone, chemotherapy, and trimodal therapy (transurethral resection, chemotherapy, and radiotherapy). It reviews the results of four phase III trials comparing radiotherapy with and without chemotherapy. It also discusses organ preservation rates, oncological outcomes, and quality of life outcomes associated with different treatments. The document concludes that trimodal therapy with transurethral resection followed by chemoradiation based on cisplatin is an option for select patients with T2 bladder cancer without other risk factors, as it can achieve cancer-specific survival rates of 50-82% at 5 years while preserving

1. GASTON LOPEZ FONTANA

2. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA
Cancer J Clin 2012;62:10–29.
Stenzl A, Cowan NC, De Santis M, et al. Treatment of muscle-
invasive and metastatic bladder cancer: update of the EAU
guidelines. Eur Urol 2011;59:1009–18.
Gakis G, Efstathiou J, Lerner SP, et al. ICUD-EAU International
Consultation on Bladder Cancer 2012: radical cystectomy and
bladder preservation for muscle-invasive urothelial carcinoma of
the bladder. Eur Urol 2013;63:45–57.
CISTECTOMIA RADICAL MAS
LINFADENECTOMIA

4.  Comorbilidades de la cirugía
 68% re internación
 Complicaciones inmediatas
 Alteración de QoL.

5. QUE SE LES PUEDE
OFRECER???

6.  RTU SOLA
 RADIOTERAPIA
RESULTADOS
ONCOLOGICOS
 CISTECTOMIA PARCIAL < A CISTECTOMIA
 QUIMIOTERAPIA

7.  RADIOTERAPIA SOLA
 < control local vs TRATAMIENTO TRIMODAL
 Agregar QMT mejora la sobrevida y tasa de preservación (1b)
James ND, Hussain SA, Hall E, et al. Radiotherapy with or without chemotherapy in muscle-
invasive bladder cancer. N Engl J Med 2012;366:1477–88.
Horwich A, Dearnaley D, Huddart R, et al. A randomised trial of accelerated radiotherapy for
localised invasive bladder cancer. Radiother Oncol 2005;75:34–43.
Pollack A, Zagars GK, Swanson DA. Muscle-invasive bladder cancer treated with external beam
radiotherapy: prognostic factors. Int J Radiat Oncol Biol Phys 1994;30:267–77.

8. RTU SOLA
 Tumores pequeños y pacientes seleccionados la tasa de
preservación vesical 60-70%
 Tasa libre de progresión 65%
 Sobrevida Cáncer especifica a 10 años 80%
Leibovici D, Kassouf W, Pisters LL, et al. Organ preservation for muscle-invasive bladder cancer by transurethral
resection. Urol- ogy 2007;70:473–6.
Herr HW. Transurethral resection of muscle-invasive bladder cancer: 10-year outcome. J Clin Oncol 2001;19:89–93.

9. RT + QMT
 Solsona y cols.
 RTU V (enfermedad microscópica) y posterior RT +
QMT vs CISTECTOMIA RADICAL
 Similares resultados oncológicos (todos pT2)
 Prospectivo pero NO randomizado
 Solo 79 casos
Solsona E, Climent MA, Iborra I, et al. Bladder preservation in selected patients with muscle-invasive
bladder cancer by complete transurethral resection of the bladder plus systemic chemotherapy: long-term
follow-up of a phase 2 nonrandomized comparative trial with radical cystectomy. Eur Urol 2009;55:911–
21.

11. Eur Urol. 2014 Jul;66(1):120-37.

12.  Revisión sistemática
 Exclusión: Tratamiento trimodal en Tu No Musculo
Invasivo
 Evaluó
 End Point Primario RESULTADOS
ONCOLOGICOS
- Tasa de respuesta
- Sobrevida cáncer especifica
- Sobrevida general
 End Point secundarios -Tasa de preservación
- Tasa de recurrencia
- QoL

13. 4 ESTUDIOS DE FASE 3

14. James ND, Hussain SA, Hall E, et al. Radiotherapy with or without chemotherapy in muscle-invasive bladder cancer. N Engl
J Med 2012;366:1477–88.
Housset M, Maulard C, Chretien Y, et al. Combined radiation and chemotherapy for invasive transitional-cell carcinoma of
the bladder: a prospective study. J Clin Oncol 1993;11:2150–7.
Tunio MA, Hashmi A, Qayyum A, Mohsin R, Zaeem A. Whole-pelvis or bladder-only chemoradiation for lymph node-
negative invasive bladder cancer: single-institution experience. Int J Radiat Oncol Biol Phys 2012;82:457–62.
Shipley WU, Winter KA, Kaufman DS, et al. Phase III trial of neoadjuvant chemotherapy in patients with invasive bladder
cancer treated with selective bladder preservation by combined radiation therapy and chemotherapy: initial results of
Radiation Therapy Oncology Group 89-03. J Clin Oncol 1998;16:3576–83.

16. RTU P
(MAXIMA Y SEGURA)
- Campo incluye hasta
bifurcación aortica
- 2 regímenes:
- Split
- Continuo
INDUCCION 40 Gy
CONSOLIDACION HASTA 65
Gy
-BASADA EN CISPLATINO
-GRAN CAPACIDAD DE RADIOSENSIBILIZAR
-Diferentes esquemas no han demostrado superioridad
entre ellos
- Mejor control local
Coppin CM, Gospodarowicz MK, James K, et al. Improved local control of invasive
bladder cancer by concurrent cisplatin and preoperative or definitive radiation. The
National Cancer Institute of Canada Clinical Trials Group. J Clin Oncol 1996;14:2901–7.
Danesi DT, Arcangeli G, Cruciani E, et al. Combined treatment of invasive bladder
carcinoma with transurethral resection, induc- tion chemotherapy, and radical
radiotherapy plus concomitant protracted infusion of cisplatin and 5-fluorouracil: a phase I
study. Cancer 1997;80:1464–71.

17.  PACIENTES NO OPERABLES
 Tumor irresecable Sobrevida
general 30-40% a 4 años
Shipley WU, Prout Jr GR, Einstein AB, et al. Treatment of invasive
bladder cancer by cisplatin and radiation in patients unsuited for
surgery. JAMA 1987;258:931–5.

18.  TASA RESPUESTA con TMT 73% ausencia Tu
visible
(-) en biopsia lecho
(-) citología
MEJOR SOBREVIDA VS LOS QUE NO RESPONDIERON
30% TIENEN TUMOR EN LA PIEZA DE CISTECTOMIA
Donat SM, Herr HW, Bajorin DF, et al. Methotrexate, vinblastine, doxorubicin and cisplatin chemotherapy
and cystectomy for unre- sectable bladder cancer. J Urol 1996;156:368–71.

19. SOBREVIDA CA ESPECIFICA
 A 5 años 50 a 82%
Shipley WU, Kaufman DS, Zehr E, et al. Selective bladder preser- vation by combined
modality protocol treatment: long-term out- comes of 190 patients with invasive bladder
cancer. Urology 2002; 60:62–7.
SOBREVIDA GENERAL
“ A 5 años 50% (36 A 74%)

21.  CANDIDATO IDEAL PARA TMT…
 T2
 Ausencia de uronefrosis
 Ausencia de CIS extenso
 Ausencia de afectacion del estroma prostatico
Gakis G, Efstathiou J, Lerner SP, et al. ICUD-EAU International Consultation on Bladder
Cancer 2012: radical cystectomy and bladder preservation for muscle-invasive urothelial
carcinoma of the bladder. Eur Urol 2013;63:45–57.

23. ALGORITMO

25. NEOADYUVANCIA BASADA EN CISPLATINO (NE 1A)
Grossman HB, Natale RB, Tangen CM et al: Neoadjuvant chemotherapy
plus cystectomy compared with cystectomy alone for locally advanced
bladder cancer. N Engl J Med 2003; 349: 859.
RETROSPECTIVO

26. RTU VEJIGA
CA UROTELIAL
MUSCULO
INVASIVO
NEADYUVANCIA
RESPTA COMPLETA:
- TAC N
- CITOLOGIA
NEGATIVA
- RTU LECHO NEGATIVA

27. T2 30 PACIENTES Y SOLO 2 T3
30% ALCANZARON TO O RESPTA COMPLETA
7 PACIENTES CISTECTOMIA RADICAL
25 PAC. RECHAZARON CISTECTOMIA
SEGUIMIENTO 54 MESES

28. SOBREVIDA CANCER ESPECIFICA A 5 AÑOS 88%