SEOM clinical guideline for treatment of muscle-invasive and metastatic urothelial bladder cancer (2018)

Abstract

The goal of this article is to provide recommendations about the management of muscle-invasive (MIBC) and metastatic bladder cancer. New molecular subtypes of MIBC are associated with specific clinical–pathological characteristics. Radical cystectomy and lymph node dissection are the gold standard for treatment and neoadjuvant chemotherapy with a cisplatin-based combination should be recommended in fit patients. The role of adjuvant chemotherapy in MIBC remains controversial; its use must be considered in patients with high-risk who are able to tolerate a cisplatin-based regimen, and have not received neoadjuvant chemotherapy. Bladder-preserving approaches are reasonable alternatives to cystectomy in selected patients for whom cystectomy is not contemplated either for clinical or personal reasons. Cisplatin-based combination chemotherapy is the standard first-line protocol for metastatic disease. In the case of unfit patients, carboplatin–gemcitabine should be considered the preferred first-line chemotherapy treatment option, while pembrolizumab and atezolizumab can be contemplated for individuals with high PD-L1 expression. In cases of progression after platinum-based therapy, PD-1/PD-L1 inhibitors are standard alternatives. Vinflunine is another option when anti-PD-1/PD-L1 therapy is not possible. There are no data from randomized clinical trials regarding moving on to immuno-oncology agents.

Atezolizumab in locally advanced or metastatic urothelial cancer: a pooled analysis from the Spanish patients of the IMvigor 210 cohort 2 and 211 studies

“…For more than three decades, no progress has been made in advanced UC therapeutics [ 8 ]. Yet, the recent incorporation of immunotherapy with the arrival to the clinic of the check-point inhibitors has reshaped the treatment scenario, and both atezolizumab (an anti-PD-L1) and pembrolizumab (an anti-PD-1) have become standard options for patients with advanced UC with either progression beyond first-line chemotherapy or treatment naïve and unfit to receive cisplatin [ 19 ]. Immunotherapy has demonstrated substantial benefit in this patient population and a better toxicity profile across different trials [ 15 , 16 , 20 , 21 ].…”

Latin American Consensus for the Evaluation and Treatment of Patients With Metastatic/Locally Advanced Urothelial Carcinoma

“…6 Advanced metastatic involvement in urothelial cancer requires a therapeutic approach focused on maintaining the quality of life and prolonging survival. Currently, most of the clinical practice guidelines available on the evaluation and systemic treatment of patients with locally advanced and metastatic urothelial carcinoma come from developed countries in Asia, 7 Europe, [8][9][10] and North America. 11 However, there are few recommendations on this for developing countries, such as Latin America, specifically considering the limited resources and significant barriers to access for timely diagnosis and treatment.…”

Prognostic Impact of CD36 Immunohistochemical Expression in Patients with Muscle-Invasive Bladder Cancer Treated with Cystectomy and Adjuvant Chemotherapy

“…The goal of perioperative chemotherapy is to treat micrometastatic disease and thus avoid patient relapse. However, the role of adjuvant chemotherapy remains controversial [10][11][12][13][14][15]. Clinical guidelines recommend a cisplatin-based regimen for patients with high-risk MIBC (pT3-pT4 and/or lymph node involvement) who are fit for this treatment and who have not received neoadjuvant chemotherapy [12,16].…”