Department of Urology, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland.
Nat Rev Urol. 2017 Jun;14(6):348-358. doi: 10.1038/nrurol.2017.30. Epub 2017 Mar 14.
Administration of neoadjuvant chemotherapy preceding radical cystectomy in patients with bladder cancer remains a matter of debate. Results of prospective, randomized studies have demonstrated an overall absolute survival benefit of 5% at 5 years, provided cisplatin-based combination regimens are used. Owing to the perception of a modest survival benefit, the medical community has been slow to adopt the use of neoadjuvant chemotherapy. Other reasons for the underuse of neoadjuvant chemotherapy range from patient ineligibility to fear of delaying potentially curative surgery in nonresponders. Instead, several institutions have adopted an individualized, risk-adapted approach, in which the decision to administer chemotherapy is based on clinical stage and patient comorbidity profile. The development of new cytotoxic and targeted therapies, in particular immune checkpoint inhibitors, warrants well-designed prospective studies to test their efficacy alone or in combination in the neoadjuvant setting. Moving forward, genomic characterization of muscle-invasive bladder cancer could offer information that aids clinicians in selecting the appropriate chemotherapy regimen. Following neoadjuvant therapy, every effort should be made to ensure optimal surgery, as surgical margins and the number of removed lymph nodes are prognostic factors; thus, radical cystectomy and a meticulous extended pelvic lymph node dissection should be performed by expert surgeons.
在膀胱癌患者中进行新辅助化疗后再进行根治性膀胱切除术仍然存在争议。前瞻性、随机研究的结果表明，在使用基于顺铂的联合方案的情况下，5 年内总体绝对生存获益为 5%。由于认为生存获益适度，医学界迟迟不愿采用新辅助化疗。新辅助化疗使用不足的其他原因包括患者不符合条件以及担心对无反应者延迟潜在的治愈性手术。相反，一些机构已经采用了个体化、风险适应的方法，其中化疗的决定是基于临床分期和患者合并症特征。新的细胞毒性和靶向治疗的发展，特别是免疫检查点抑制剂，需要精心设计的前瞻性研究来单独或联合在新辅助环境中测试它们的疗效。展望未来，肌肉浸润性膀胱癌的基因组特征可能提供有助于临床医生选择合适化疗方案的信息。在新辅助治疗后，应尽一切努力确保最佳手术，因为手术切缘和切除的淋巴结数量是预后因素；因此，根治性膀胱切除术和细致的广泛盆腔淋巴结清扫应由专家外科医生进行。
