UROLOGICAL ONCOLOGY

Long-term survival after gemcitabine and cisplatin in patients with locally advanced transitional cell carcinoma of the bladder: focus on supplementary treatment strategies
Als AB, Sengelov L, von der Maase H
Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
Eur Urol. 2007; 52: 478-86

• Objective: The objective was to evaluate response and survival, as well as efficacy of subsequent supplementary treatment and follow-up strategy in patients with locally advanced transitional cell carcinoma of the bladder following combination chemotherapy with gemcitabine and cisplatin (GC).
• Methods: A total of 84 patients with locally advanced (T4b, Nx, M0 or Tx, N2-3, M0) received GC. After chemotherapy, the strategy was close surveillance in patients with complete response, and supplementary radical cystectomy or radiotherapy whenever possible in patients with partial response.
• Results: A total of 25 patients (29.8%) with complete response to chemotherapy were followed by close surveillance. This group achieved a median overall survival of 47.6 mo. Another 25 patients had partial response to chemotherapy. Of these patients, 16 had supplementary treatment, with 10 achieving “no evidence of disease” (NED). Thus, a total of 35 patients achieved NED with a median overall survival of 48.7 mo versus 10.2 mo in patients not achieving NED (hazard ratio=0.10; 95%CI, 0.05-0.20; p<0.0001). The rate of NED was higher in the group of patients who had a cystectomy compared with the group who received radiotherapy as supplementary treatment.
• Conclusions: In patients with locally advanced bladder cancer, NED following chemotherapy alone or chemotherapy plus supplementary cystectomy or radiotherapy is essential to achieve long-term survival. Patients with a partial response should be offered radical cystectomy whenever possible, which seems to be superior to radiotherapy. Close surveillance may be an alternative to immediate cystectomy in patients with complete response following chemotherapy.
  
  
• Editorial Comment
  Patients with locally advanced bladder cancer cannot be cured by surgery or radiotherapy alone. Systemic cytotoxic chemotherapy is the only option here. In contrast to patients with visceral metastases, patients without distant metastases and locoregional disease form a group with rather favorable prognosis. A group of 84 patients with this disease was analyzed for long-term survival after Gemcitabine-Cisplatinum (GC) – based chemotherapy.
  Median overall survival of the group was 16.3 months. There was a significant difference between patients who had no evidence of disease (NED) after GC or after GC and supplementary treatment (e.g. cystectomy) in comparison to those who had a partial response and underwent supplementary treatment. Median survival in the first and second groups was nearly 48 months whereas the third group had less than 12 months median survival. Patients who underwent cystectomy as treatment after GC significantly fared better than patients who received radiotherapy. In conclusion, relative long-term survival is possible in this cohort of patients and multimodal treatment should aim at eradicating all disease possible.

Dr. Andreas Bohle
Professor of Urology
HELIOS Agnes Karll Hospital
Bad Schwartau, Germany
E-mail: boehle@urologie-bad-schwartau.de