Zietman A L, Shipley W U, Kaufman D S
Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston 02114.
Int J Radiat Oncol Biol Phys. 1993 Sep 1;27(1):161-70. doi: 10.1016/0360-3016(93)90434-w.
Radical cystectomy is the standard of care for patients with muscle-invading transitional cell carcinoma of the bladder. More limited surgery is only useful in highly selected patients and radiation therapy alone gives overall local-control rates under 40%. Phase II studies have shown that when radiation and trans-urethral surgery are combined with cis-platin based chemotherapy local-control rates increase such that the majority of patients preserve a tumor-free functional bladder. Up to 85% of patients selected for bladder sparing therapy on the basis of their initial response to chemo-radiation may keep their bladders. This figure could increase further when other powerful prognostic factors such as the presence of hydronephrosis, the presence of carcinoma in situ, and DNA ploidy are also taken into account in initial patient selection. The activity of cisplatin combinations in metastatic disease is not in doubt with up to 50% response rates generally reported. The hope that this will translate into the eradication of micrometastatic disease (known to be present in up to 40% of patients at diagnosis) has yet to be borne out. Those randomized trials so far reported have not shown any survival advantage when combined-modality therapy is compared to radiation alone. The addition of combination chemotherapy to radiation does not increase bladder morbidity but carries a considerable systemic penalty. Thus, despite promising Phase II studies, until local control and survival benefit is proven in a randomized trial it should continue to be regarded as experimental.
根治性膀胱切除术是肌层浸润性膀胱移行细胞癌患者的标准治疗方法。更有限的手术仅对经过严格筛选的患者有用，单纯放疗的总体局部控制率低于40%。II期研究表明，当放疗和经尿道手术与基于顺铂的化疗联合使用时，局部控制率会提高，从而使大多数患者保留无肿瘤的功能性膀胱。在接受化疗放疗初始反应的基础上选择膀胱保留治疗的患者中，高达85%的人可以保留膀胱。如果在初始患者选择中还考虑其他有力的预后因素，如是肾积水、原位癌的存在和DNA倍体等，这一数字可能会进一步提高。顺铂联合化疗在转移性疾病中的活性是毋庸置疑的，一般报道的缓解率高达50%。但这种联合化疗能否消除微转移疾病（已知在诊断时高达40%的患者中存在）的希望尚未得到证实。迄今为止报道的那些随机试验并未显示联合治疗与单纯放疗相比有任何生存优势。放疗联合化疗不会增加膀胱发病率，但会带来相当大的全身不良反应。因此，尽管II期研究前景乐观，但在随机试验中证明局部控制和生存获益之前，它仍应被视为试验性治疗。
