MIBC and Radical Cystectomy in the Elderly: A Systematic Review
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Lymphadenectomy
Bladder cancer is one of the most common cancers worldwide causing a significant burden on healthcare system and society. Muscle-invasive bladder cancer (MIBC) is highly fatal, and if untreated, >85% of patients die within 2 years of diagnosis. Although radical cystectomy (RC) is the preferred treatment of choice in patients with MIBC, bladder preservation can be considered in patients who are either not eligible for cystectomy or are not willing to undergo cystectomy. The goal of bladder preservation is to achieve cancer survival at least equivalent to RC and to maintain better quality of life including sexual function. Strategies for bladder preservation include partial cystectomy, radical transurethral resection, radiation therapy, and chemotherapy. It is widely accepted that combination of these approaches could result in better outcomes in patients with MIBC. In this review, we describe different approaches for bladder preservation and their outcomes.
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Background and purpose:For muscle-invasive bladder caner patients,the recommended treatment is radical cystectomy.While some patients are not suitable or unwilling to this treatment,bladder preserving treatment provides another choice.This research aimed to assess the curative effect,influencing factors of partial cystectomy plus chemotherapy for muscle-invasive bladder cancer.Methods:From Jan.2002 to Apr.2005,52 patients with muscle-invasive bladder cancer underwent partial cystectomy plus chemotherapy(PC group),contrast to 47 patients which underwent radical cystectomy(RC group).The overall survival rates(OS) of the two groups were analyzed.Results:There is no significant difference of overall survival between the two groups(P=0.279).For stage T3 and recurrent patients the PC group had significantly lower survival rates than RC group(P=0.048).Conclusion:Partial cystectomy plus chemotherapy provides a choice for the treatment of muscle-invasive bladder cancer.
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Bladder cancer is a common malignancy seen in older adults with coexisting medical illnesses. The management of patients with muscle invasive disease includes perioperative chemotherapy and radical cystectomy; however, patients may decline surgery and older patients with comorbid conditions may not be candidates for surgery and thus alternative treatment strategies are needed. Trimodality bladder preservation protocols for muscle invasive bladder cancer have generally included only those patients who are candidates for a salvage cystectomy. In this review, we discuss the current status of bladder preservation treatment options for patients with muscle-invasive disease who are not candidates for cystectomy or who decline surgery and highlight the need for clinical trials investigating novel treatment approaches in this older patient population.
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Radical cystectomy with pelvic lymphadenectomy represents the gold standard for treatment of muscle-invasive bladder cancer. Extent of the lymph node dissection and lymph node involvement during radical cystectomy are the most powerful prognostic factors associated with poor oncological outcome. However, the optimal boundaries of the lymph node dissection during a radical cystectomy are controversial. The published literature based mostly on retrospective studies suggests that increasing the number of nodes excised may have therapeutic and diagnostic benefits without significantly increasing the surgical morbidity. These conclusions are, however, influenced by selection and surgeon biases, inconsistencies in the quality of the surgery, and node count variability. In this paper, we establish the current understanding about the utility of lymphadenectomy during a radical cystectomy for muscle-invasive bladder cancer.
Lymphadenectomy
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Urothelial cancer
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In the U.S., radical cystectomy has long been considered the standard of care for patients with muscle-invasive bladder cancer. However, radical cystectomy (with or without the creation of an orthotopic diversion) is a complex surgical procedure requiring intensive perioperative support services, and most patients with muscle-invasive disease are older than 70. During the past 2 decades, patients treated at academic centers have …
Urinary diversion
Radical surgery
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Bladder cancer is the 4th commonest malignancy in the United Kingdom and worldwide there are nearly 400,000 new cases every year with over 150,000 deaths. The gold standard treatment for muscle invasive bladder cancer is radical cystectomy with neoadjuvant chemotherapy. Despite this the overall survival at 5 years is only around 50%. To improve outcomes new pre-clinical models of greater physiological relevance are needed and the ability to translate research from the laboratory to clinical practice needs to be improved. The tyrosine kinase HER2 is an attractive therapeutic target in bladder cancer and has the potential to be used in clinical practice. The hypothesis of this thesis was that HER2 would be a prognostic biomarker in patients with bladder cancer requiring radical cystectomy and that it has a critical role in bladder cancer cell invasiveness. To test this the aims were firstly to create a novel three dimensional cell culture to be used as a more physiological method of studying the invasiveness of bladder cancer. Secondly a tissue micro-array and associated database of cystectomy patients was created for biomarker discovery and to investigate the role of HER2 and its family members as biomarkers in patients with bladder cancer treated with cystectomy. The novel three dimensional organotypic model was successfully optimized and its ability to reproduce invasive characteristics confirmed with primary invasive cancer cells harvested from a cystectomy patient. Lenti-viral knockdown of HER2 failed to affect the invasive nature of the T24 cell line. The TMA consisted of 226 cystectomy patients treated over a 10-year period with a median follow up of 49 months. The 5-year overall survival was 48.8% with a cancer specific survival of 62.1% and 27.4% of patients received neo-adjuvant chemotherapy. 17% of patients overexpressed HER2 and HER2 was an independent risk factor for worse overall survival with a hazard ratio of 1.66. Other biomarkers screened for included Nrf-2, which this TMA suggests predicts response to cisplatin based chemotherapy, AIMP3 which may predict resistance to radiation when down regulated and b-HCG, which demonstrated a potential role as a marker of recurrence when measured in blood serum. In conclusion, HER2 appears to be prognostic of poor outcome in this cohort but is not critical for bladder cancer invasion in the organotypic model. The process of testing this has created two valuable models for biomarker discovery that will be used in future research.
Clinical Significance
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