Urothelial Carcinoma: Role of Perioperative Systemic Chemotherapy

Abstract

In the bladder, the vast majority of patients with urothelial carcinoma (UCC) initially present with superficial disease at diagnosis, although approximately one-third will have muscle-invasive disease. Of these, greater than 60 % will eventually develop metastatic disease. In 2009, the American Cancer Society estimated that more than 14,000 patients in the USA died as a result of metastatic bladder cancer [1]. Worldwide, surgery and radiation therapy (RT) are considered standard of care for patients with muscle-invasive disease [2,3]. Despite the lack of prospective randomized data comparing surgery to RT in muscle-invasive disease, radical cystectomy, with an extended lymph node dissection and urinary diversion, represents a standard approach at many academic centers in North America. Survival after radical cystectomy is a function of pathologic stage, with several series indicating that patients with pT4 lesions (tumor-penetrating adjacent structures) have a long-term survival rate of 33 % compared with 72 % for patients with pT2 lesions (tumor invading either the superficial muscularis propria pT2a or the deep muscularis propria pT2b) [4–8]. Similarly, lymph-node involvement at the time of surgery remains a strong predictor of both local and systemic relapses. The 5-year median overall survival after radical cystectomy for patients with lymph node positive disease is less than 30 % [7,9].