Valderrama Begoña P, González-Del-Alba Aránzazu, Morales-Barrera Rafael, Peláez Fernández Ignacio, Vázquez Sergio, Caballero Díaz Cristina, Domènech Montserrat, Fernández Calvo Ovidio, Gómez de Liaño Lista Alfonso, Arranz Arija José Ángel
Medical Oncology Department, Hospital Universitario Virgen del Rocío, Av. Manuel Siurot, s/n, 41013, Sevilla, Spain.
Medical Oncology Department, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain.
Clin Transl Oncol. 2022 Apr;24(4):613-624. doi: 10.1007/s12094-022-02815-w. Epub 2022 Mar 26.
Most muscle-invasive bladder cancer (BC) are urothelial carcinomas (UC) of transitional origin, although histological variants of UC have been recognized. Smoking is the most important risk factor in developed countries, and the basis for prevention. UC harbors high number of genomic aberrations that make possible targeted therapies. Based on molecular features, a consensus classification identified six different MIBC subtypes. Hematuria and irritative bladder symptoms, CT scan, cystoscopy and transurethral resection are the basis for diagnosis. Radical cystectomy with pelvic lymphadenectomy is the standard approach for muscle-invasive BC, although bladder preservation is an option for selected patients who wish to avoid or cannot tolerate surgery. Perioperative cisplatin-based neoadjuvant chemotherapy is recommended for cT2-4aN0M0 tumors, or as adjuvant in patients with pT3/4 and or pN + after radical cystectomy. Follow-up is particularly important after the availability of new salvage therapies. It should be individualized and adapted to the risk of recurrence. Cisplatin-gemcitabine is considered the standard first line for metastatic tumors. Carboplatin should replace cisplatin in cisplatin-ineligible patients. According to the EMA label, pembrolizumab or atezolizumab could be an option in cisplatin-ineligible patients with high PD-L1 expression. For patients whose disease respond or did not progress after first-line platinum chemotherapy, maintenance with avelumab prolongs survival with respect to the best supportive care. Pembrolizumab also increases survival versus vinflunine or taxanes in patients with progression after chemotherapy who have not received avelumab, as well as enfortumab vedotin in those progressing to first-line chemotherapy followed by an antiPDL1/PD1. Erdafitinib may be considered in this setting in patients with FGFR alterations. An early onset of supportive and palliative care is always strongly recommended.
大多数肌层浸润性膀胱癌（BC）是移行来源的尿路上皮癌（UC），不过UC的组织学变异型也已得到确认。在发达国家，吸烟是最重要的风险因素，也是预防的基础。UC存在大量基因组畸变，这使得靶向治疗成为可能。基于分子特征，一种共识分类法确定了六种不同的肌层浸润性膀胱癌亚型。血尿和膀胱刺激症状、CT扫描、膀胱镜检查及经尿道切除术是诊断的基础。根治性膀胱切除术加盆腔淋巴结清扫术是肌层浸润性BC的标准治疗方法，不过对于希望避免手术或无法耐受手术的特定患者，膀胱保留也是一种选择。对于cT2-4aN0M0肿瘤，推荐围手术期基于顺铂的新辅助化疗，或在根治性膀胱切除术后用于pT3/4和/或pN+的患者作为辅助治疗。在有新的挽救治疗方法可用后，随访尤为重要。随访应个体化并根据复发风险进行调整。顺铂-吉西他滨被认为是转移性肿瘤的标准一线治疗方案。在不符合顺铂治疗条件的患者中，卡铂应替代顺铂。根据欧洲药品管理局（EMA）的标签，帕博利珠单抗或阿替利珠单抗可作为不符合顺铂治疗条件且PD-L1高表达患者的一种选择。对于一线铂类化疗后疾病有反应或未进展的患者，与最佳支持治疗相比，阿维鲁单抗维持治疗可延长生存期。在化疗后进展且未接受阿维鲁单抗治疗的患者中，帕博利珠单抗与长春氟宁或紫杉烷相比也可提高生存率，在一线化疗后进展且接受抗PDL1/PD1治疗的患者中，与恩杂鲁胺相比也可提高生存率。在这种情况下，对于有FGFR改变的患者可考虑使用厄达替尼。始终强烈建议尽早开始支持性和姑息性治疗。
