AUA 2017: Muscle-Invasive Bladder Cancer Guidelines
The guideline offers recommendations on the diagnosis, management, and surveillance for patients with MIBC. Those with variant histology present an ominous diagnosis and may require a divergence from the standards below. Aside from obtaining a full history and performing a physical examination as well as transurethral resection of bladder tumor (TURBT), the panel strongly recommended an examination under anesthesia at the time of TURBT. They also suggested cross-sectional imaging without specific recommendations. However, the panel did not recommend positron emission tomography-computed tomography (CT) over conventional CT or magnetic resonance imaging. Chest imaging is recommended for all patients, but a CT thorax scan is also suggested for individuals with a smoking history. Curative treatment options should be discussed before determining a plan of therapy that is based on both patient comorbidity and tumor characteristics, including surgery, chemotherapy, and radiotherapy. Multidisciplinary consultation and discussion are strongly encouraged.
The panel strongly recommends use of neoadjuvant chemotherapy with the focus on use of cisplatin-based chemotherapy. Radical cystectomy (RC) with bilateral pelvic lymph node dissection (internal iliac, external iliac, and obturator lymph nodes resected at minimum) should be performed as soon as possible within a recommend 12 weeks of diagnosis. In patients undergoing RC, all diversions, including ileal conduit, continent cutaneous, and orthotopic neobladder, should be discussed. Those who did not receive neoadjuvant chemotherapy should be offered adjuvant cisplatin-based chemotherapy when advanced disease present on pathology. Perioperative thromboembolic prophylaxis is recommended as well as clinical care pathways that may lessen ileus, including the use of mu-opioid-antagonist therapy.
For patients who desire to retain their bladder, and for those with significant comorbidities for whom RC is not a treatment option, bladder preservation options may be considered. Maximal debulking TURBT and assessment of multifocal disease/carcinoma in situ should be performed. Patients with MIBC who are medically fit and consent to RC should not undergo partial cystectomy or maximal TURBT as primary treatment. Radiotherapy should be administered with chemotherapy and subsequent surveillance, including cystoscopy and imaging (see below).
Surveillance for all patients should include imaging for 6 to 12 months for 2 to 3 years, repeated annually along with laboratory work at 3 to 6 month intervals for 2 to 3 years, then annually thereafter. Those with retained urethras should be monitored for urethral recurrence. Patient survivorship is strongly encouraged. In summary, the MIBC guidelines are comprehensive and mirror the European Association of Urology guidelines. However, the support from numerous organizations demonstrates the multidisciplinary approach needed to manage this lethal disease.
Presented By: Jeffrey Holzbeierlein, MD, University of Kansas, Kansas City, KS
Written By: Stephen B. Williams, MD, Assistant Professor in Urology, The University of Texas Medical Branch, Galveston, TX, and Ashish M. Kamat, MD Professor, Department of Urology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX.
at the 2017 AUA Annual Meeting - May 12 - 16, 2017 – Boston, Massachusetts, USA