Mannas Miles P, Lee Taeweon, Nykopp Timo K, Batista da Costa Jose, Black Peter C
Vancouver Prostate Centre, University of British Columbia, Vancouver, British Columbia, Canada.
Curr Opin Urol. 2018 Nov;28(6):563-569. doi: 10.1097/MOU.0000000000000548.
A bladder-preserving approach for high-grade nonmuscle invasive bladder cancer that has invaded the lamina propria (T1HG) may result in increased recurrence, progression, and even death from bladder cancer in some patients. Initial radical cystectomy does have increased cancer-specific survival (CSS), but represents significant overtreatment for many patients. An evidence-based, risk-stratified approach is required to select patients for immediate radical cystectomy in order to improve CSS.
A restaging transurethral resection aids in optimal staging and treatment of T1HG. Intravesical Bacillus Calmette-Guerin induction followed by 3 years of maintenance is the standard adjuvant management. However, when very high-risk (hydronephrosis, abnormal bimanual examination, variant histology, lymphovascular invasion, or residual disease on re-resection, and Bacillus Calmette-Guerin failure or early recurrence) or multiple high-risk factors (concomitant CIS, size >3 cm, multifocality, unfavorable tumor location, extensive lamina propria invasion, and elderly) are present, the risk of progression often outweighs the risk associated with radical cystectomy. In these cases, an immediate radical cystectomy likely provides an improved opportunity for cure compared to a bladder-preserving strategy.
In order to increase the CSS of patients diagnosed with T1HG bladder cancer, an aggressive approach may benefit those with increased risk of progression.
对于侵犯固有层的高级别非肌层浸润性膀胱癌（T1HG）采用保留膀胱的方法，可能会导致部分患者膀胱癌复发、进展甚至死亡风险增加。初始根治性膀胱切除术确实能提高癌症特异性生存率（CSS），但对许多患者而言属于过度治疗。需要一种基于证据的、风险分层的方法来选择适合立即进行根治性膀胱切除术的患者，以提高CSS。
再次经尿道膀胱肿瘤切除术有助于对T1HG进行最佳分期和治疗。膀胱内卡介苗诱导治疗后维持3年是标准的辅助治疗方法。然而，当存在极高风险因素（肾积水、双合诊异常、组织学变异、淋巴管浸润、再次切除时存在残留病灶以及卡介苗治疗失败或早期复发）或多个高风险因素（合并原位癌、肿瘤大小>3 cm、多灶性、肿瘤位置不佳、固有层广泛浸润以及老年患者）时，进展风险往往超过根治性膀胱切除术的相关风险。在这些情况下，与保留膀胱策略相比，立即进行根治性膀胱切除术可能为治愈提供更好的机会。
为了提高T1HG膀胱癌患者的CSS，积极的治疗方法可能会使进展风险增加的患者受益。
