Transitional cell carcinoma medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Suveenkrishna Pothuru, M.B,B.S. [2]

Overview

The predominant therapy for transitional cell carcinoma is surgical resection. Adjunctive chemotherapy, radiation therapy, and immunotherapy may be required. Patients with superficial tumors of bladder are treated with intravescical injection of BCG, whereas patients with local spread and distant metastasis are treated with systemic chemotherapy. External beam radiation therapy may be the treatment for people who can’t have surgery.

Medical Therapy

Transitional Cell Carcinoma of Bladder

Immunotherapy

• Immunotherapy is a type of biological therapy that uses the immune system to help destroy cancer cells.
• Bacillus Calmette-Guérin (BCG)

• Immunotherapy by intravesicular delivery of Bacillus Calmette–Guérin (BCG) is often used to treat and prevent the recurrence of superficial tumors.
• BCG is a vaccine against tuberculosis that is prepared from attenuated live Mycobacterium bovis, that has lost its virulence in humans.
• BCG immunotherapy is effective in up to 2/3 of the cases at this stage, and in randomized trials has been shown to be superior to standard chemotherapy.
• The mechanism by which BCG prevents recurrence is unknown, but the presence of bacteria in the bladder may trigger a localized immune reaction which clears residual cancer cells.

Chemotherapy

• Chemotherapy may be given to patients with stage II and III disease either before or after surgery to help prevent the tumor from returning.
• For early disease (stages 0 and I), chemotherapy is usually given directly into the bladder.
• Intravesical chemotherapy

• During intravesical chemotherapy, the drugs are placed into the bladder through a urinary catheter.
• Intravesical chemotherapy may be given instead of BCG or if the bladder cancer doesn’t respond to BCG.
• Mitomycin is the drug most often used in intravesical chemotherapy.

• Systemic chemotherapy

• During systemic chemotherapy, the drugs are given intravenously.
• Systemic chemotherapy may be a treatment option for bladder cancer that has spread to other tissues near the bladder and bladder cancer that has spread to other parts of the body.
• Chemotherapy is recommended before a radical cystectomy (called neoadjuvant chemotherapy) for many people with bladder cancer that has grown into the muscle layer of the bladder wall. It is also often given after a radical cystectomy (called adjuvant chemotherapy) to people with high-risk features such as cancer that has spread to lymph nodes.

Radiation therapy

• Radiation therapy may be the main treatment for people who can’t have surgery.
• External beam radiation therapy is the type of radiation treatment that is most often used to treat bladder cancer.
• Palliative radiation therapy may be given to relieve symptoms caused by advanced bladder cancer.

Transitional Cell Carcinoma of Renal Pelvis and Ureter

Chemotherapy

• Chemotherapy is used to treat cancer of the renal pelvis or ureter that has spread to the lymph nodes or to other parts of the body.
• In patients with metastatic transitional cell carcinoma, combination chemotherapy has produced high response rates and occasional complete responses.
• It may be offered after surgery (called adjuvant chemotherapy) if cancer is found in the lymph nodes removed during surgery.
• Sometimes it is also given before surgery (called neoadjuvant chemotherapy) if the cancer appears more advanced.
• The most common chemotherapy drug combinations used are:

Regimens
GemCIS: Gemcitabine (Gemzar) and cisplatin (Platinol AQ)
MVAC: Methotrexate, vinblastine (Velbe), doxorubicin (Adriamycin), and cisplatin

• GemCIS is used most often because it causes less severe side effects than the other combination.
• Other chemotherapy agents that have shown activity in metastatic transitional cell cancer include the following:

• Paclitaxel
• Ifosfamide
• Gallium nitrate
• Pemetrexed

• Ifosfamide, gallium, and pemetrexed have shown limited activity in patients previously treated with cisplatin.
• Increasing the dose intensity of MVAC by administering treatment every two weeks with granulocyte-colony stimulating factor (G-CSF) support has also been evaluated in an effort to improve long-term survival.