Treatment of superficial forms (Tis, Ta, T1) of bladder cancer is to remove the primary tumor and prevent relapse. The main method of surgical treatment of superficial bladder cancer is transurethral resection (TUR). The relapse rate after this intervention is from 40 to 80%. The group with a low risk of relapse includes patients with single Ta tumors, less than 3 cm in size, G1 malignancy – these patients do not need additional treatment. The group at high risk of relapse requiring additional intravesical chemotherapy or immunotherapy includes patients with multiple or frequently recurring TIG3 tumors, cancer in situ. Indication for additional treatment is non-radically performed TUR. In cases of multiple lesions of the bladder with the impossibility of TUR or the presence of contraindications for cystectomy, intravesical administration of drugs can be an independent treatment method.
Intravesical adjuvant chemotherapy reduces the relapse rate compared with TUR by 15-20% and is carried out in the following modes:
adriamycin – 30-50 mg in 50 ml of saline with exposure in the bladder for 1 hour, daily 10 days;
mitomycin C – 40-50 mg in 4 ml of saline with exposure in the bladder for 2 hours, I once a week for 8 weeks.
Recently, gemzar has been used for intravesical administration – 500-2000 mg intravesically with an exposure of 1 hour, 2 times a week for 3 weeks, 2 courses with an interval of 1 week.
Intravesical immunotherapy with BCG vaccine is used in patients with a high risk of developing tumor recurrence (TB, Tis). When using BCG therapy, a decrease in the frequency of tumor progression was noted. Toxic effects are manifested in the form of dysuria, cystitis, hyperthermia, you should remember about the development in rare cases of BCG sepsis. Usually 100-120 mg of the vaccine is injected intraperitoneally in 50 ml of physiological saline, exposure is 2 hours, 6 weeks. In case of recurrent cancer in situ in the absence of a profession, a second course is possible. BCG therapy can be performed with superficial relapses after intravesical chemotherapy.
Intravesical immunotherapy with interferon-a has low toxicity, an increase in the effectiveness of this type of treatment is achieved by increasing the dose of the drug, exposure in the bladder, and a combination with other chemotherapy drugs. It is possible to use interferon-a with the ineffectiveness of BCG therapy.
In addition to TUR, electrovaporization is used as a method of local surgical exposure. The advantages of this method compared with TUR are fewer relapses, effective hemostasis, and prevention of perforation of the bladder wall. The disadvantages include the lack of histological material, which requires a preliminary biopsy, thermal damage to the mouth of the ureters.
The first follow-up examination after TUR with superficial bladder cancer is performed after 3 months. after surgery, in the future, at a low risk of tumor recurrence, the next examination is performed after 6 months, then annually for 5 years. At high risk of relapse, control cystoscopy is performed every 3 months for 2 years, every 4 months for the 3rd year and 1 time every six months at the 4th and 5th years of observation.
Indications for cystectomy in superficial bladder cancer are low-grade tumors (G3) or in situ cancer after ineffective, ineffective (frequent early relapses) intravesical chemotherapy or immunotherapy, subtotal and total bladder damage.
The method of choice for treating invasive bladder cancer is radical cystectomy. The standard scope of the operation is the removal of a bladder with a visceral peritoneum and peri-bubble tissue, prostate gland and seminal vesicles in men or the urethra, anterior wall of the vagina, uterus with appendages in women, with mandatory bilateral pelvic lymphadenectomy. The following options for urine diversion are possible: external (ureterocutaneostomy, intestinal plasty with the formation of “dry” and “wet” growths – Bricker operation), internal urine diversion into the continuous intestine (ureterosigmostomy), creation of an orthotopic bladder with the possibility of controlled urination, for which isolated segments of various parts of the intestine or stomach (operations of Hautmann, Studer, Mainz pouch I, etc.). The most common postoperative complications: intestinal paresis, insufficiency of sutures of various anastomoses, infectious complications. Late complications are observed in 10-25% of patients – scarring of anastomoses, urine reflux, urinary incontinence. Postoperative mortality in leading specialized institutions does not exceed 5%. Relapses after cystectomy are observed in 5-30% of patients, distant metastases in 20-30%; 5-year survival is 50-75%, with metastatic damage to the lymph nodes – 7-15%.
The data on the results of combined treatment using pre- or postoperative radiation therapy are contradictory. Neoadjuvant chemotherapy (CMV, MVAC modes) can be used in patients with a high risk of relapse, adjuvant chemotherapy is used in patients with TK-T4, with metastases to regional lymph nodes, but there is currently no convincing evidence of its effect on survival. However, the effectiveness of neoadjuvant chemotherapy is an important prognostic criterion.
With a single primary tumor up to 5 cm in size, located on the moving walls of the bladder no closer than 3 cm to the neck, in the absence of concomitant carcinoma in situ or severe dysplasia, a bladder resection can be performed. Preoperative radiation or chemotherapy improves treatment outcomes.
Dynamic monitoring of patients after radical cystectomy should be carried out with a frequency of 1 time in 3 months. during the first 6 months, once every six months to 2 years, then annually.
Radiation therapy as an independent method of treatment is used in patients with invasive cancer, mainly in the presence of contraindications for cystectomy or patient refusal from surgical treatment. The best results are achieved in patients with tumors of not more than 7 cm, without concomitant carcinoma in situ. A necessary condition for the possibility of radiation therapy is a sufficient capacity of the bladder, the absence of large diverticula, inflammatory and adhesive processes in the small pelvis, and the absence of severe urinary infection. There is no convincing evidence of the impact of pelvic lymph node irradiation on survival. Remote radiation therapy is carried out in SOD 60-65 Gy, with a SOD of 2 Gy. Complete tumor regression is achieved in 30-50% of patients, 5-year survival is 20-45%. Brachytera is carried out by carefully selected patients with tumors, the sizes of which are up to 5 cm.
Systemic chemotherapy is the main treatment for disseminated bladder cancer, 5-year survival is 15-20%, median life expectancy is 12-14 months.
Until recently, the most effective was the MVAC regimen, the use of which was limited by high toxicity, primarily myelotoxicity. Mortality after applying this regimen is 1.5%. At present, the combination of gemcitabine (gemzar) / cisplatin is widely used, which is not inferior in effectiveness to the MVAC regimen, but has much lower toxicity. Modes with a combination of taxanes and platinum drugs are inferior in effectiveness to the MVAC scheme. Promising are the modes with the inclusion of gemzar, cisplatin, taxanes, including as a second line of therapy or in case of inefficiency of the MVAC regimen.
1. Methotrexate 30 mg / m2 iv in the 1st, 8th day Vinblastine 4 mg / m2 iv in the 1st, 8th day
Cisplatin 100 mg / m2v / in on the 2nd day (every 3 weeks)
2. Methotrexate 30 mg / m2 iv on the 1st, 15th, 22nd days Vinblastine 4 mg / m2 iv on the 1st, 15th days Adriablastin 30 mg / m2 iv on the 2nd day
Cisplatin 100 mg / m2v / v on the 2nd day (every 4 weeks)
3. Gemcitabine 1000 mg / m2 iv on the 1st, 8th, 15th days Cisplatin 70 mg / m2 iv on the 2nd day (every 4 weeks)
4. Gemcitabine 1000 mg / m2 iv on the 8th day Cisplatin 70 mg / m2 iv on the 1st day
Paclitaxel 80 mg / m2 iv on the 1st, 8th day (every 3 weeks)