The role of neoadjuvant and adjuvant chemotherapy in urothelial cancer pati-ents suitable for cystectomy
DOI: 10.22591/magyurol.2018.1.maraza.2
Authors:
Maráz Anikó dr., Varga Linda dr.
Szegedi Tudományegyetem, Onkoterápiás Klinika, Szeged (igazgató: Kahán Zsuzsanna dr.)
Summary
Introduction: Based on randomized studies and meta-analyses, survival data of metastatic bladder cancer patients are more favorable if they receive neoadjuvant or adjuvant cisplatin-based chemotherapy before or after cystectomy. Data of neoadjuvant therapy are more favorable, although in Hungary, it has only been administered in the recent years. In comparison with the Western European countries, in Hungary, cystectomy requires significant experience and caution of the surgeon due to the advanced stages and the co-morbidities of the patients. In case of these patients, neoadjuvant therapies could only be performed if multidisciplinary tumor boards would make the decision before cystectomy, and if the procedures for the patients would be adequately defined. Our article summarizes the evidence of different studies, international guidelines, and the results of pre- and postoperative chemotherapy in case of muscle-invasive urothelial cancer patients who underwent radical cystectomy.
Patients, methods: Based on the ESMO and EAU guidelines, we interpret the different advantages of neoadjuvant chemotherapy, such as early decrease of tumor spreading, opportu-nity of tumor down-staging, improving the ratio of R0 resection, knowledge of chemosensitivity, and the well-known benefits of the adjuvant chemotherapy, such as appropriate pathological staging and earlier definitive operation. We analyzed the result of the most important phase III studies and meta-analyses of neo-adjuvant and adjuvant chemotherapy regarding the type of chemotherapy protocols, stage of the participants, and the effectivity.
Results: Based on the meta-analyses, in case of neoadjuvant cisplatin-based chemotherapy, the 5-year survival benefit is 5%. In a Norwegian phase III study, the benefit was 8%, in case of T3 patients, it was 11%, and according to the 8-year follow-up data, it was 16%. The outcome is even more favorable in case of patients who respond well to neoadjuvant chemotherapy (pCR 12–50% MVAC, 12–22% in case of GC protocol). More than 3 months delay of cystectomy does not significantly reduce the survival if chemotherapy is performed before the operation. Results of adjuvant phase III studies and meta-analyses are not so unambiguous as neoadjuvant data, but chemotherapy seems to influence favorably the survival, especially in case of pT3/4 and/or N+ (and high grade or margin positivity) cases. The outcome of adjuvant chemotherapy is more favorable than in case of deferred chemotherapy started after progression.
Conclusions: Based on the current knowledge, neoadjuvant cisplatin-based chemotherapy is recommended for patients with T2b-T4a tumors before radical cystectomy. If the patients cannot receive cisplatin, neoadjuvant chemotherapy does not have any advantage. In case of T2aN0 stage, the potential presence of micrometastases is lower due to the smaller tumor mass; thus, neoadjuvant chemotherapy can be administered individually in this stage. Adjuvant chemotherapy is recommended in case of all patients with pT3/4 and/or N+ tumor or positive resection margin who did not receive neoadjuvant chemotherapy.
Leave a Reply
You must be logged in to post a comment.