Torti F M, Lum B L
J Clin Oncol. 1984 May;2(5):505-31. doi: 10.1200/JCO.1984.2.5.505.
Management of the superficial bladder cancer patient consists of two complementary but separate therapeutic goals: treatment of the existing tumor(s) and prevention of tumor recurrence. At present, the stage, grade, and multicentricity are the major determinants in the natural and therapeutic history of the disease. Although intravesical instillation of chemotherapeutic agents has been used for greater than 20 years, neither its exact role nor the optimal dose or schedule of administration have been established. To date, no dramatic differences in efficacy between the agents commonly used for intravesical chemotherapy, either as definitive therapy or prophylaxis, have been appreciated. These agents do appear to lower the recurrence rate as well as extend the disease-free interval. Since the most thorough experience is with thiotepa, it is the drug against which other agents should be compared in terms of both efficacy and toxicologic evaluation. Different administration schedules and methodologies need further study, such as the utility of continuous bladder irrigation, the use of sequential chemotherapeutic agents to gain cell synchronization, and the use of multiple drug regimens. Because there are multiple factors that influence the occurrence and recurrence of bladder cancer, combined modality therapy deserves testing. Modes of therapy that could be used together because they act through different mechanisms are intravesical chemotherapy, radioactive needle implants, carcinogen modifiers such as pyridoxine, chemoprotective agents such as retinoic acid, and immune stimulants such as BCG. These studies should be performed in a randomized prospective controlled fashion, which may require cooperative multi-institutional involvement to accrue adequate numbers of patients. At this time there are a number of important questions that remain to be answered concerning the treatment of superficial bladder cancer: (1) does this mode of therapy affect overall survival, (2) does prophylactic intravesical chemotherapy alter the incidence of subsequent muscle invasive disease, (3) does intravesical chemotherapy alter the sites, incidence, or responsiveness to systemic chemotherapy of subsequent metastatic disease, and (4) and what is the optimal timing and duration of prophylactic therapy from a cost-effectiveness standpoint?
治疗现有的肿瘤以及预防肿瘤复发。目前，疾病的分期、分级和多中心性是其自然病程和治疗史的主要决定因素。尽管膀胱内灌注化疗药物已使用超过20年，但其确切作用、最佳剂量或给药方案均未确定。迄今为止，无论是作为确定性治疗还是预防措施，常用的膀胱内化疗药物在疗效上均未发现显著差异。这些药物似乎确实能降低复发率并延长无病间期。由于对噻替派的经验最为丰富，在疗效和毒理学评估方面，其他药物都应与之进行比较。不同的给药方案和方法需要进一步研究，例如持续膀胱冲洗的效用、使用序贯化疗药物以实现细胞同步化，以及使用联合药物方案。由于有多种因素影响膀胱癌的发生和复发，联合治疗模式值得一试。可以一起使用的治疗模式，因为它们通过不同机制起作用，包括膀胱内化疗、放射性针植入、致癌物修饰剂如吡哆醇、化学保护剂如视黄酸，以及免疫刺激剂如卡介苗。这些研究应以随机前瞻性对照方式进行，这可能需要多机构合作以积累足够数量的患者。目前，关于浅表性膀胱癌的治疗仍有许多重要问题有待解答：（1）这种治疗模式是否会影响总生存期，（2）预防性膀胱内化疗是否会改变后续肌肉浸润性疾病的发生率，（3）膀胱内化疗是否会改变后续转移性疾病的部位、发生率或对全身化疗的反应性，以及（4）从成本效益的角度来看，预防性治疗的最佳时机和持续时间是什么？
