GASTON LOPEZ FONTANA

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

Comorbilidades de la cirugía

68% re internación

Complicaciones inmediatas

Alteración de QoL.

QUE SE LES PUEDE

OFRECER???

RTU SOLA

RADIOTERAPIA

RESULTADOS

ONCOLOGICOS

CISTECTOMIA PARCIAL < A CISTECTOMIA

QUIMIOTERAPIA

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 forlocalised invasive bladder cancer. Radiother Oncol 2005;75:34–43.

Pollack A, Zagars GK, Swanson DA. Muscle-invasive bladder cancer treated with external beamradiotherapy: prognostic factors. Int J Radiat Oncol Biol Phys 1994;30:267–77.

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.

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.

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

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

4 ESTUDIOS DE FASE 3

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.

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.

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.

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 CISTECTOMIADonat 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.

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 bladdercancer. Urology 2002; 60:62–7.

SOBREVIDA GENERAL

“ A 5 años 50% (36 A 74%)

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.

ALGORITMO

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

RTU VEJIGA

CA UROTELIAL

MUSCULO

INVASIVO

NEADYUVANCIA

RESPTA COMPLETA:

- TAC N

- CITOLOGIA

NEGATIVA

- RTU LECHO NEGATIVA

T2 30 PACIENTES Y SOLO 2 T3

30% ALCANZARON TO O RESPTA COMPLETA

7 PACIENTES CISTECTOMIA RADICAL

25 PAC. RECHAZARON CISTECTOMIA

SEGUIMIENTO 54 MESES

SOBREVIDA CANCER ESPECIFICA A 5 AÑOS 88%