| SYSTEMIC
TREATMENT FOR INVASIVE BLADDER CANCER: NEOADJUVANT CHEMOTHERAPY AND LAPAROSCOPIC
RADICAL CYSTECTOMY
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To the Editor:
The
standard treatment for invasive transitional cell carcinoma (TCC) is radical
cystectomy (RC) with lymphadenectomy; however, defining adequate therapy
in every patient with invasive TCC remains difficult, because multiple
biologic behavior patterns can be found in this disease (1).
Laparoscopy has come forward in oncologic
urologic surgery to reproduce traditional operations in the endoscopic
environment in order to minimize morbidity without compromising cancer
outcomes. Laparoscopic radical cystectomy (LRC) was conceived as a procedure
that could actually diminishes the associated morbidity of RC, while maintaining
the oncological objectives.
Quality indicators in RC are well established
nowadays: Mortality should not be higher than 2% to 4%. Positive surgical
margin rates should be lower than 10% overall and 15% in pT3 or pT4 and
the median number of pelvic nodes retrieved in the lymphadenectomy should
be 10-14 (2). Simultaneously, orthotopic neobladder has become a surgical
standard that improved the quality of life of these patients (3).
The surgical technique for radical cystectomy
has specific technical objectives that should be met in every case (2):
1. Complete bladder cancer resection even in locally advanced tumors.
2. Minimal blood loss with early vascular control of superior and inferior
vesical arteries.
3. Complete pelvic lymph node dissection.
4. Avoidance of tumor cell spillage.
Nowadays, the best outcomes in bladder cancer
therapeutics are probably obtained when there is radical cystectomy in
a systemic treatment setting. Neoadjuvant treatment has shown interesting
advantages in patients with bladder cancer because it offers 5% of survival
and 14% decreased risk of associated disease mortality (1). One might
argue that two third of the patients would be treated without any response
and survival advantage may be outweighed by potential treatment morbidity,
with an important number of patients receiving chemotherapy to reach the
5% benefit, however, selection of the population incorporated in the protocols
should address this issue.
Adequate surgical endoscopic skill developed
in the last two decades and advances accomplished in the management of
pulmonary, cardiovascular and hemodynamic effects of pneumoperitoneum
allows offering laparoscopy as a safe alternative for these patients and
recent data (4). Furthermore, as LRC has been reported with perioperative
and functional outcomes comparable with open surgery and adequate mid-term
cancer control (5), combining neoadjuvant therapy and LRC, would add the
benefits of each one, and perhaps offer a more effective treatment for
patients with invasive bladder cancer: The objective would be oncological
efficacy with less morbidity. Clinical protocols addressing results of
this mentioned way of treatment would be responsible for final answers
in this matter and this constitutes our proposal for laparoscopy teams
and medical oncologist, to unite for a common objective.
At the beginning of our experience with
LRC the main consideration for surgery in bladder carcinoma was the precarious
health of this patient’s population. Things have not changed much;
Haber and Gill (6) have reported important percentages of smokers (65%),
hypertension (59%) and cardiac disease (17%) in there series of long term
follow-up for LRC. Today, we know that physiological changes incurred
as a result of pneumoperitoneum have minimal adverse effects in the majority
of patients undergoing laparoscopic surgery; therefore, in the setting
of systemic treatment, LRC might represents the low morbidity surgical
option for the patient who had neoadjuvant therapy. Minimizing operative
trauma becomes even more important for these patients. To open the path,
there is need for clinical protocols incorporating these therapeutical
options in order to address initially the morbidity and mortality while
keeping in mind the oncological safety.
Take
Home Message
The
combination of two effective treatments -medical and surgical- would probably
offer a great advantage to patients with invasive bladder cancer. Laparoscopic
cystectomy might represent a low morbidity surgical option to patients
who have previously received chemotherapy for invasive bladder carcinoma.
Acknowledgement
The
Institut Mutualiste Montsouris has started a protocol on neoadjuvant chemotherapy
and laparoscopic cystectomy, funded in part by a Clinical Research Grant
from Oficina de Investigacion, Confederacion Americana de Urologia, CAU.
REFERENCES
1. Herr HW, Dotan Z, Donat SM, Bajorin DF: Defining optimal
therapy for muscle invasive bladder cancer. J Urol. 2007; 177: 437-43.
2. Herr HW, Smith JA, Montie JE: Standardization of radical cystectomy:
time to count and be counted. BJU Int. 2004; 94: 481-2.
3. Hautmann RE, Volkmer BG, Schumacher MC, Gschwend JE, Studer UE: Long-term
results of standard procedures in urology: the ileal neobladder. World
J Urol. 2006; 24: 305-14.
4. O’Malley C, Cunningham AJ: Physiologic changes during laparoscopy.
Anesthesiol Clin North America. 2001; 19: 1-19.
5. Haber GP, Crouzet S, Gill IS: Laparoscopic and robotic assisted radical
cystectomy for bladder cancer: a critical analysis. Eur Urol. 2008; 54:
54-64.
6. Haber GP, Gill IS: Laparoscopic radical cystectomy for cancer: oncological
outcomes at up to 5 years. BJU Int. 2007; 100: 137-42.
Dr.
Eric Barret, Dr. Rafael Sanchez-Salas
& Dr. Guy Vallancien
Department of Urology, Institut Montsouris
Université Paris Descartes
42, Bd Jourdan, 75014
Paris, France
E-mail: eric.barret@imm.fr
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