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.