ABSTRACT
Introduction Approximately 19% of patients with bladder cancer will present with locally advanced disease, 3% with distant metastases, and about 25% with unsuspected positive regional nodes discovered at the time of cystectomy.1-9 Although radical cystectomy with pelvic lymphadenectomy cures the majority of patients with invasive tumors confined to the bladder (stage pT1-2), and about half of those with microscopic extravesical tumor spread (stage pT3a), it cures only a minority of those with low-volume pelvic nodal (N1) or locally advanced disease (stage pT3b-4), and rarely cures those with extensive node-positive (N2-3) or metastatic (M+) bladder cancer.2-9
The 5-year survival of non-organ-confined bladder cancer following cystectomy alone is reported in the vicinity of 43% for node-negative patients and 23% in node-positive patients, even in series in which an extended pelvic nodal dissection is standard practice (Table 15.1).3-9
These findings indicate that the most important cause of surgical failure is the presence of occult metastasis outside the field of surgery, and, therefore, surgery alone in the treatment of locally advanced unresectable bladder cancer, gross regional nodal disease, and/or limited metastatic disease is destined to failure.2-9,10
Similarly, combination chemotherapy (methotrexate, vinblastine, adriamycin (doxorubicin), and cisplatin: MVAC) used alone will result in a major response in 39% to 72% of patients and a complete response in 20% to 36% of patients; however, the response is rarely durable, with the median survival approximately 1 year and only 4% to 9% of patients surviving more than 5 years.11,12 These findings indicate that the use of either surgery or chemotherapy alone in advanced disease is unlikely to be curative. Therefore, both local tumor control and eradication of systemic disease are important treatment issues in terms of improved long-term survival and as a secondary goal in palliation of symptoms when cure is not possible.
