Employs maximal TURBT, followed by combined chemotherapy and radiation therapy with curative intent.
Chemotherapy aims to treat micrometastatic disease whilst radiosensitising effect potentiates the radiation efficacy.
2 separate patient populations – fit patients who prefer to not have cystectomy, and older less fit patients who cannot have cystectomy.
There has been no head to head trial comparing TMT with cystectomy.
Overall cancer specific survival seems to favour cystectomy + NAC (about 65 % vs 55 % 5 year CSS), but consider possible selection bias.
Well selected fit patients who elect for TMT may have similar outcomes cf. radical cystectomy in some prospective studies.
Ability to get complete clearance at TURBT is a strong predictor of response.
Those who are not suitable for TMT include:
- Hydronephrosis
- cT3 +
- CIS
- Small, contracted bladders or significantly symptomatic (“bladder not worth saving”)
- Gross residual disease after TURBT
- ? Variant histology
- Contra-indications to chemotherapy or radiation therapy
- ? IBD or severe bowel dysfunction
- ? Bilateral THR
Chemo regime
Various regimes – 5-FU and mitomycin (most studied), weekly cisplatin, cisplatin/5-FU, low dose gemcitabine
Local protocol – either weekly cisplatin or weekly 5-FU/MMC especially if contraindications to cisplatin
No superiority demonstrated for any regime.
Radiation
In TMT – varying doses and regimes – seems about 64 – 66 Gy +/- boost to tumour site +/- nodes.
- e.g., 64 Gy in 32#, also hypofractionation may be used 55 Gy in 20#
Radiation alone without chemotherapy has markedly inferior outcomes and should not be used alone unless not fit for chemotherapy and cystectomy.
It can be used in palliative settings for either ‘local control’ or to palliate symptoms of bleeding.
Major bowel or urinary morbidity reported to be 5 %.
Outcomes
- 10 – 30 % require salvage cystectomy in studies – for local recurrence +/- severe symptoms.
- Majority of local recurrences are non invasive (about 25 % of patients) and can be managed endoscopically.
- 50 – 60 % 5 year overall survival rates.
Follow-up:
- 3-4 monthly cystoscopy / cytology, 6 monthly imaging.
Issues with TMT
- Cystoscopy can be falsely reassuring and patients still have deep or metastatic disease
- May progress during treatment and miss curative window
- Ongoing bladder as site of local recurrence and ongoing need for cystoscopies
- Salvage cystectomy associated with more complications and worse prognosis
- Morbidity of chemotherapy