Chapter 090. Bladder and Renal Cell Carcinomas (Part 3)

Invasive DiseaseThe treatment of a tumor that has invaded muscle can be separated into control of the primary tumor and, depending on the pathologic findings at surgery, systemic chemotherapy. Radical cystectomy is the standard, although in selected cases a bladder-sparing approach is used; this approach includes complete endoscopic resection; partial cystectomy; or a combination of resection, systemic chemotherapy, and external beam radiation therapy. In some countries, external beam radiation therapy is considered standard. In the United States, its role is limited to those patients deemed unfit for cystectomy, those with unresectable local disease, or as part of an experimental...
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Chapter 090. Bladder and Renal Cell Carcinomas (Part 3) Chapter 090. Bladder and Renal Cell Carcinomas (Part 3) Invasive Disease The treatment of a tumor that has invaded muscle can be separated intocontrol of the primary tumor and, depending on the pathologic findings at surgery,systemic chemotherapy. Radical cystectomy is the standard, although in selectedcases a bladder-sparing approach is used; this approach includes completeendoscopic resection; partial cystectomy; or a combination of resection, systemicchemotherapy, and external beam radiation therapy. In some countries, externalbeam radiation therapy is considered standard. In the United States, its role islimited to those patients deemed unfit for cystectomy, those with unresectablelocal disease, or as part of an experimental bladder-sparing approach. Indications for cystectomy include muscle-invading tumors not suitable forsegmental resection; low-stage tumors unsuitable for conservative management(e.g., due to multicentric and frequent recurrences resistant to intravesicalinstillations); high-grade tumors (T1G3) associated with CIS; and bladdersymptoms, such as frequency or hemorrhage, that impair quality of life. Radical cystectomy is major surgery that requires appropriate preoperativeevaluation and management. The procedure involves removal of the bladder andpelvic lymph nodes and creation of a conduit or reservoir for urinary flow. Grosslyabnormal lymph nodes are evaluated by frozen section. If metastases areconfirmed, the procedure is often aborted. In males, radical cystectomy includesthe removal of the prostate, seminal vesicles, and proximal urethra. Impotence isuniversal unless the nerves responsible for erectile function are preserved. Infemales, the procedure includes removal of the bladder, urethra, uterus, fallopiantubes, ovaries, anterior vaginal wall, and surrounding fascia. Previously, urine flow was managed by directing the ureters to theabdominal wall, where it was collected in an external appliance. Currently, mostpatients receive either a continent cutaneous reservoir constructed fromdetubularized bowel or an orthotopic neobladder. Some 70% of men receive aneobladder. With a continent reservoir, 65–85% of men will be continent at nightand 85–90% during the day. Cutaneous reservoirs are drained by intermittentcatheterization; orthotopic neobladders are drained more naturally.Contraindications to a neobladder include renal insufficiency, an inability to self-catheterize, or an exophytic tumor or CIS in the urethra. Diffuse CIS in the bladderis a relative contraindication based on the risk of a urethral recurrence. Concurrentulcerative colitis or Crohns disease may hinder the use of resected bowel. A partial cystectomy may be considered when the disease is limited to thedome of the bladder, a margin of at least 2 cm can be achieved, there is no CIS inother sites, and the bladder capacity is adequate after the tumor has been removed.This occurs in 5–10% of cases. Carcinomas in the ureter or in the renal pelvis aretreated with nephroureterectomy with a bladder cuff to remove the tumor. The probability of recurrence following surgery is predicted on the basis ofpathologic stage, presence or absence of lymphatic or vascular invasion, and nodalspread. Among those whose cancers recur, the recurrence develops in a median of1 year (range 0.04–11.1 years). Long-term outcomes vary by pathologic stage andhistology (Table 90-1). The number of lymph nodes removed is also prognostic,whether or not the nodes contained tumor. Table 90-1 Survival Following Surgery for Bladder Cancer Pathologic Stage 5-Year Survival, % 10-Year Survival, % T2,N0 89 87 T3a,N0 78 76 T3b,N0 62 61 T4,N0 50 45 Any T,N1 35 34 Chemotherapy (described below) has been shown to prolong the survival ofpatients with invasive disease, but only when combined with definitive treatmentof the bladder by radical cystectomy or radiation therapy. Thus, for the majority ofpatients, chemotherapy alone is inadequate to clear the bladder of disease.Experimental studies are evaluating bladder preservation strategies by combiningchemotherapy and radiation therapy in patients whose tumors were endoscopicallyremoved.