Bladder Cancer - Muscle Invasive

Question 1

Initial patient eval and counseling

Answer 1

• Before treatment, do H/P, EUA at TURBT for suspected invasive cancer (Clinical Principle)
• Prior to muscle-invasive bladder cancer management, clinicians should perform a complete staging evaluation, including imaging of the chest and cross sectional imaging of the abdomen and pelvis with intravenous contrast if not contraindicated. Laboratory evaluation should include a comprehensive metabolic panel (complete blood count, liver function tests, alkaline phosphatase, and renal function). (Clinical Principle)
• An experienced genitourinary pathologist should review the pathology of a patient when variant histology is suspected or if muscle invasion is equivocal (e.g., micropapillary, nested, plasmacytoid, neuroendocrine, sarcomatoid, extensive squamous or glandular differentiation). (Clinical Principle)
• For patients with newly diagnosed muscle-invasive bladder cancer, curative treatment options should be discussed before determining a plan of therapy that is based on both patient comorbidity and tumor characteristics. Patient evaluation should be completed using a multidisciplinary approach. (Clinical Principle)
• Prior to treatment, clinicians should counsel patients regarding complications and the implications of treatment on quality of life (e.g., impact on continence, sexual function, fertility, bowel dysfunction, metabolic problems). (Clinical Principle)

Question 2

Treatment - Neoadjuvant/Adjuvant Chemotherapy

Answer 2

Neoadjuvant/Adjuvant Chemotherapy

• Utilizing a multidisciplinary approach, clinicians should offer cisplatin-based neoadjuvant chemotherapy to eligible radical cystectomy patients prior to cystectomy. (Strong Recommendation; Evidence Level: Grade B)
• Clinicians should not prescribe carboplatin-based neoadjuvant chemotherapy for clinically resectable stage cT2-T4aN0 bladder cancer. Patients ineligible for cisplatin-based neoadjuvant chemotherapy should proceed to definitive locoregional therapy. (Expert Opinion)
• Clinicians should perform radical cystectomy as soon as possible following a patient’s completion of and recovery from neoadjuvant chemotherapy. (Expert Opinion)
• Eligible patients who have not received cisplatin-based neoadjuvant chemotherapy and have non-organ confined (pT3/T4and/or N+) disease at cystectomy should be offered adjuvant cisplatin-based chemotherapy. (Moderate Recommendation; Evidence Level: Grade C)

Question 3

Treatment - Radical Cystectomy

Answer 3

Radical Cystectomy

• Clinicians should offer radical cystectomy with bilateral pelvic lymphadenectomy for surgically eligible patients with resectable non-metastatic (M0) muscle-invasive bladder cancer. (Strong Recommendation; Evidence Level: Grade B)
• When performing a standard radical cystectomy, clinicians should remove the bladder, prostate, and seminal vesicles in males and should remove the bladder, uterus, fallopian tubes, ovaries, and anterior vaginal wall in females. (Clinical Principle)
• Clinicians should discuss and consider sexual function preserving procedures for patients with organ-confined disease and absence of bladder neck, urethra, and prostate (male) involvement. (Moderate Recommendation; Evidence Level: Grade C)

Question 4

Treatment - Urinary diversion

Answer 4

Urinary Diversion

• In patients undergoing radical cystectomy, ileal conduit, continent cutaneous, and orthotopic neobladder urinary diversions should all be discussed. (Clinical Principle)
• In patients receiving an orthotopic urinary diversion, clinicians must verify a negative urethral margin. (Clinical Principle)

Question 5

Treatment - Perioperative Surgical Management

Answer 5

Perioperative Surgical Management

• Clinicians should attempt to optimize patient performance status in the perioperative setting. (Expert Opinion)
• Perioperative pharmacologic thromboembolic prophylaxis should be given to patients undergoing radical cystectomy. (Strong Recommendation; Evidence Level: Grade B)
• In patients undergoing radical cystectomy µ -opioid antagonist therapy should be used to accelerate gastrointestinal recovery, unless contraindicated. (Strong Recommendation; Evidence Level: Grade B)
• Patients should receive detailed teaching regarding care of urinary diversion prior to discharge from the hospital. (Clinical Principle)

Question 6

Treatment - Pelvic Lymphadenectomy

Answer 6

Pelvic Lymphadenectomy

• Clinicians must perform a bilateral pelvic lymphadenectomy at the time of any surgery with curative intent. (Strong Recommendation; Evidence Level: Grade B)
• When performing bilateral pelvic lymphadenectomy, clinicians should remove, at a minimum, the external and internal iliac and obturator lymph nodes (standard lymphadenectomy). (Clinical Principle)

Question 7

Bladder preserving approaches - Patient selection

Answer 7

Patient Selection

• For patients with newly diagnosed non-metastatic muscle-invasive bladder cancer who desire to retain their bladder, and for those with significant comorbidities for whom radical cystectomy is not a treatment option, clinicians should offer bladder preserving therapy when clinically appropriate. (Clinical principle)
• In patients under consideration for bladder preserving therapy, maximal debulking transurethral resection of bladder tumor and assessment of multifocal disease/carcinoma in situ should be performed. (Strong Recommendation; Evidence Strength: Grade C)

Question 8

Bladder preserving approaches - Maximal Turbt and Partial Cystectomy

Answer 8

Maximal Turbt and Partial Cystectomy

• Patients with muscle-invasive bladder cancer who are medically fit and consent to radical cystectomy should not undergo partial cystectomy or maximal transurethral resection of bladder tumor as primary curative therapy. (Moderate Recommendation; Evidence Level: Grade C)

Question 9

Bladder preserving approaches - Primary Radiation Therapy

Answer 9

Primary Radiation Therapy

• For patients with muscle-invasive bladder cancer, clinicians should not offer radiation therapy alone as a curative treatment. (Strong Recommendation; Evidence Level: Grade C)

Question 10

Bladder preserving approaches - Multi-Modal Bladder Preserving Therapy

Answer 10

Multi-Modal Bladder Preserving Therapy

• For patients with muscle-invasive bladder cancer who have elected multi-modal bladder preserving therapy, clinicians should offer maximal transurethral resection of bladder tumor, chemotherapy combined with external beam radiation therapy, and planned cystoscopic re-evaluation. (Strong Recommendation; Evidence Level: Grade B)
• Radiation sensitizing chemotherapy regimens should include cisplatin or 5- fluorouracil and mitomycin C. (Strong Recommendation; Evidence Level: Grade B)
• Following completion of bladder preserving therapy, clinicians should perform regular surveillance with CT scans, cystoscopy, and urine cytology. (Strong Recommendation; Evidence Level: Grade C)

Question 11

Bladder preserving approaches - Bladder Preserving Treatment Failure

Answer 11

Bladder Preserving Treatment Failure

• In patients who are medically fit and have residual or recurrent muscle-invasive disease following bladder preserving therapy, clinicians should offer radical cystectomy with bilateral pelvic lymphadenectomy. (Strong Recommendation; Evidence Level: Grade C)
• In patients who have a non-muscle invasive recurrence after bladder preserving therapy, clinicians may offer either local measures, such as transurethral resection of bladder tumor with intravesical therapy, or radical cystectomy with bilateral pelvic lymphadenectomy. (Moderate Recommendation; Evidence Level: Grade C)

Question 12

Patient surveillance and followup - Imaging

Answer 12

Imaging

• Clinicians should obtain chest imaging and cross sectional imaging of the abdomen and pelvis with CT or MRI at 6-12 month intervals for 2-3 years and then may continue annually. (Expert Opinion)

Question 13

Patient surveillance and followup - Laboratory Values and Urine Markers

Answer 13

Laboratory Values and Urine Markers

• Following therapy for muscle-invasive bladder cancer, patients should undergo laboratory assessment at three to six month intervals for two to three years and then annually thereafter. (Expert Opinion)
• Following radical cystectomy in patients with a retained urethra, clinicians should monitor the urethral remnant for recurrence. (Expert Opinion)

Question 14

MIBC treatment algorithm

Answer 14