Shariat Shahrokh F, Chade Daher C, Karakiewicz Pierre I, Scherr Douglas S, Dalbagni Guido
Urology Service, Memorial Sloan-Kettering Cancer Center, NY, USA.
Immunotherapy. 2010 May;2(3):381-92. doi: 10.2217/imt.10.1.
Major controversies still exist with regard to the indication, type and regimen of intravesical therapy for non-muscle-invasive bladder cancer. Other areas of controversy are the criteria for response/failure of treatment and for decisions regarding secondary intravesical therapy versus radical cystectomy. In this article, we analyze the different intravesical therapeutic strategies and compare their safety and efficacy. Well-designed clinical trials have found that the addition of bacillus Calmette-Guerin (BCG) to transurethral resection (TUR) decreases the risk for both disease recurrence and progression. These encouraging results are sustained even in patients with recurrent or aggressive disease, including patients whose prior intravesical chemotherapy has failed. Most investigators believe that the efficacy of BCG therapy can be maximized with maintenance therapy. Mitomycin C (MMC), the most commonly used intravesical chemotherapy to date, decreases the risk of disease recurrence but not disease progression when used after TUR compared with TUR alone. The oncologic efficacy of intravesical MMC can be optimized by increasing its concentration in addition to alkalinizing and reducing urine production. For patients at high risk of disease progression, BCG with maintenance therapy should be the preferred primary intravesical therapeutic strategy. However, MMC can be considered as a viable alternative for patients with papillary tumors (no carcinoma in situ) that are at low or intermediate risk of disease progression. Combination intravesical therapy may be more successful than single-agent strategies. Intravesical therapy failures indicate the need to include radical cystectomy as an option in the management decision.
对于非肌层浸润性膀胱癌的膀胱内治疗的适应证、类型和治疗方案，目前仍存在重大争议。其他存在争议的领域包括治疗反应/失败的标准以及关于二次膀胱内治疗与根治性膀胱切除术决策的标准。在本文中，我们分析了不同的膀胱内治疗策略，并比较了它们的安全性和有效性。精心设计的临床试验发现，在经尿道切除术（TUR）后加用卡介苗（BCG）可降低疾病复发和进展的风险。即使在复发或侵袭性疾病患者中，包括先前膀胱内化疗失败的患者，这些令人鼓舞的结果依然存在。大多数研究者认为，维持治疗可使BCG治疗的疗效最大化。丝裂霉素C（MMC）是迄今为止最常用的膀胱内化疗药物，与单纯TUR相比，TUR后使用MMC可降低疾病复发风险，但不能降低疾病进展风险。除了碱化尿液和减少尿量外，通过增加MMC的浓度可优化其膀胱内肿瘤治疗效果。对于疾病进展风险高的患者，BCG维持治疗应作为首选的原发性膀胱内治疗策略。然而，对于疾病进展风险低或中等的乳头状肿瘤（无原位癌）患者，MMC可被视为一种可行的替代方案。联合膀胱内治疗可能比单药治疗策略更成功。膀胱内治疗失败表明在管理决策中需要将根治性膀胱切除术作为一种选择。
