肌层浸润性膀胱癌肌层浸润性膀胱癌保留膀胱的治疗策略保留膀胱的治疗策略 TNM staging classification from UICC 非浸润性膀胱癌（表浅性）非浸润性膀胱癌（表浅性） Ta, T1, Tis 局限于固有层内局限于固有层内 浸润性膀胱癌浸润性膀胱癌 T2-T4 肿瘤侵犯至肌层以上肿瘤侵犯至肌层以上 组织病理学组织病理学 分期分期 TNM staging classification from UICC 2009 (7th)n n浸润性肿瘤浸润性肿瘤浸润性肿瘤浸润性肿瘤 (T2-4a N0-x M0)(T2-4a N0-x M0)Indications for cystectomy肌层浸润性肿瘤肌层浸润性肿瘤Do not delay cystectomy more than 3 months since it increases the risk of progression and cancer specific death.Chang SS, et al. Delaying radical cystectomy for muscle invasive bladder cancer results in worse pathological stage. J Urol 2003 ;170:1085保留膀胱的治疗保留膀胱的治疗v 保留膀胱手术保留膀胱手术 TUR： T2a？ 部分切除部分切除 无手术条件（全身状态、尿道狭窄、憩室等）无手术条件（全身状态、尿道狭窄、憩室等） v 强调综合治疗强调综合治疗 5年总生存率年总生存率45%-73% 10年总生存率年总生存率29%-49% 单纯单纯TURBT TURBT联合外放疗联合外放疗 TURBT联合化疗联合化疗 TURBT联合放、化疗联合放、化疗 （Multimodality or Trimodality） 膀胱部分切除联合化疗膀胱部分切除联合化疗目前保留膀胱的治疗方法有以下几种目前保留膀胱的治疗方法有以下几种CUAguidelines2014推荐意见：推荐意见：特特殊殊情情况况下下需需选选择择保保留留膀膀胱胱的的治治疗疗方方法法时时，须须与与患患者者充充分分沟沟通通并告知风险，应辅以联合放、化疗，并密切随访。并告知风险，应辅以联合放、化疗，并密切随访。 CUAguidelines2014EAUguidelines2015EAUguidelines2015BLADDER-SPARING TREATMENTS FOR LOCALISED DISEASEFeasibility of Radical Transurethral Resection as Monotherapy for Selected Patients With Muscle Invasive Bladder CancerEduardo Solsona, et al. J Urol., 2010, 184:475Conclusions: Radical transurethral bladder tumor resection is a reliable therapeutic approach for patients with muscle invasive bladder cancer after complete tumor resection and with negative biopsies of the tumor bed.Five-, 10-, and 15-yr cumulative DSS rates were 64%, 59%, and 57%, respectivelyFive-, 10-, and 15-yr cumulative OS rates were 52%, 35%, and 22%, respectivelyT2, Five-, 10-, and 15-yr 74%, 67%, and 63% T34 Five-, 10-, and 15-yr 53%, 49%, and 49%, T2, Five-, 10-, and 15-yr 61%, 43%, and 28% T34 Five-, 10-, and 15-yr 41%, 27%, and 16%72% of all patients (78% with T2 disease) achieved CR to induction chemoradiation. Among patients achieving CR, 10-yr rates of noninvasive, invasive, pelvic (nodal or sidewall), and distant recurrences were 29%, 16%, 11%, and 32%, respectively. One hundred two patients (29%) ultimately required a cystectomy 60 (17%) immediately for less than CR and 42 (12%) in a prompt salvage fashion for recurrent invasive tumors identified during follow-up with close cystoscopic surveillance. Median time to cystectomy in the salvage group was 1.1 yr (95% CI, 0.751.5). No patient required cystectomy resulting from treatment related toxicity.Outcomes与根治性膀胱全切相比生存率相当CMT achieves a CR and preserves the native bladder in 70% of patients while offering long-term survival rates comparable to contemporary cystectomy series. These results support modern bladder-sparing therapy as a proven alternative for selected patients.Bladder-sparing therapy offers a unique opportunity for urologic surgeons, radiation oncologists, and medical oncologists to work hand-in-hand in a truly multidisciplinary effort for the benefit of patients with invasive BCa. ConclusionsFig. 7. CR and 5-year OS rates in patients receiving neoadjuvant chemotherapy (NADCT+) or not (NADCT). A growing body of accumulated data suggests that TMT(with prompt cystectomy reserved for tumour recurrenceor nonresponders) leads to acceptable outcomes and maytherefore be considered a reasonable treatment option inwell-selected patients. TMT can be discussed not only inpatients unfit for surgery but also for those patients whohave MIBC and are not willing to undergo surgery.ConclusionsThe results of this overview seem to indicate that TMT is able to produce excellent 5-year OS rates, no matter how it is done (continuous or split). No significant difference in 5-year OS rates could be observed between the two treatment regimens, although the continuous may offer some advantage compared to split treatment in terms of higher CR and, likely lower SC rates. ConclusionsFrom 1997 2010, 183 consecutive patients with cT2-4aN0M0 bladder cancer (median age 70 years, women/men =46/137, T2/3/4a = 100/69/14) underwent debulking transurethral resection followed by LCRT (radiation at 40Gy to the small pelvis concurrently with two cycles of i.v. cisplatin at 20 mg/day for 5 days).(i) Essentially solitary MIBC or intravesically circumscribed tumours ( 25% or less of the bladder in area, excluding the bladder neck and trigone); (ii) no involvement of bladder neck or trigone; and (iii) clinically, no residual disease or minimal amounts of non-invasive disease in the original MIBC site after LCRT; otherwise, radical cystectomy (RC) is recommended.Criteria for PC include: Histological examination of the 46 PC specimens showed residual muscle-invasive disease in three (7%). In the 46 PC patients, neither MIBC, norpelvic recurrence was observed; 5-year CSSand MRFS rates were both 100%. In the current selective bladder-sparing protocol, one-third of MIBC patients met the PC criteria; when patients from this group underwent PC with pelvic lymph node dissection, their oncological outcomes were excellent. Consolidative PC potentially reduces MIBC recurrence in the preserved bladder, eventually improving survival in properly selected MIBC patients.Conclusionsl保留膀胱治疗是肌层浸润性膀胱癌可选择的手段保留膀胱治疗是肌层浸润性膀胱癌可选择的手段l对选择性患者可以达到与根治手术相似的结果对选择性患者可以达到与根治手术相似的结果l强调手术结合放化疗的联合治疗强调手术结合放化疗的联合治疗l选择部分切除的指证有待进一步明确选择部分切除的指证有待进一步明确l应充分患者告知并密切随访应充分患者告知并密切随访小结小结