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Case History

Image not available. An otherwise healthy 65-year-old female smoker is admitted as an emergency with acute bilateral loin pain and anuria. There is history of recurrent haematuria and dysuria over the last few months. An ultrasound reveals that she has bilateral hydronephrosis secondary to a lesion in the trigone of the bladder. Her renal function is partly restored with bilateral ureteric stents.

What are the next steps in the diagnostic work-up of this patient?

Biopsies confirm the presence of a transitional cell carcinoma (TCC) of the bladder that is invading the muscle but not beyond.

What treatment options are available?

Is there any evidence for the use of neoadjuvant chemotherapy in this setting?

What factors may influence the decision to use neoadjuvant chemotherapy in this particular patient?

Is adjuvant chemotherapy a reasonable/valid option?

Background

What are the next steps in the diagnostic work-up of this patient?

Image not available. Cytological examination alone may be sufficient to confirm the presence of a neoplastic lesion, although it has low sensitivity for low-grade lesions. Nevertheless, cystoscopy with examination under anaesthesia is essential, to allow for accurate clinical and pathological staging. Biopsies taken from macroscopically normal parts of the bladder surface allow detection of field change, which would influence management. Radiological imaging will demonstrate nodal and/or visceral involvement and allows estimation of the local extent of disease. Computed tomography (CT) is usually adequate, however, small lesions (Image not available.1 cm) especially in the trigone and dome of the bladder may be missed, and sensitivity for low-volume nodal disease is quite low; magnetic resonance imaging (MRI) may be preferable in those circumstances. Finally, full staging should be done, including chest and abdominal CT and, if bone pain is present, a nuclear medicine bone scan.

What treatment options are available?

For patients with localized muscle-invasive disease, the choice of treatment is between radical surgery, with cystectomy and subsequent reconstructive procedures, and a bladder-sparing multimodality approach with salvage cystectomy on recurrence. Neoadjuvant chemotherapy may be given with either of these options. Preoperative radiotherapy has fallen out of favour despite improved local control, as it has not been shown to improve overall survival and makes urological reconstructive procedures more difficult.1

Discussion

Image not available. Unfortunately, no large randomized clinical trials have directly compared the two treatment options (radical surgery versus multimodality treatment). Relatively small (n Image not available.1000) population-based retrospective studies (e.g. see Chahal et al.2) have suggested equivalence in terms of overall survival, but the issue has not been addressed prospectively. A meta-analysis of older trials comparing preoperative radiotherapy followed by radical surgery with upfront radical radiotherapy found a benefit for surgery in terms of overall survival.3 However, it included only three small trials and some radiotherapy was given to both arms thus making extrapolation of the results difficult.

More recent studies have shown that, in carefully ...

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