What are the treatment options for a patient with stage 2 bladder cancer?

Treatment of Stage 2 Bladder Cancer

For stage 2 (T2) bladder cancer, radical cystectomy with bilateral pelvic lymphadenectomy preceded by neoadjuvant cisplatin-based combination chemotherapy is the standard of care and provides the best survival outcomes. 1, 2

Primary Treatment Approach

Neoadjuvant Chemotherapy Followed by Radical Cystectomy (Category 1 Recommendation)

This is the gold standard treatment for T2 bladder cancer based on randomized trials demonstrating survival benefit. 1, 2

• Administer 2-3 cycles of cisplatin-based combination chemotherapy (gemcitabine-cisplatin or MVAC) before surgery 1
• The survival benefit is particularly strong for T2 disease, making neoadjuvant chemotherapy a category 1 recommendation 1, 2
• Following chemotherapy, perform radical cystectomy with extended bilateral pelvic lymphadenectomy that includes common iliac, internal iliac, external iliac, and obturator nodes 2

Critical caveat: If neoadjuvant chemotherapy is administered, do NOT give adjuvant chemotherapy after cystectomy 1

Alternative: Partial Cystectomy (Highly Selected Cases Only)

Partial cystectomy may be considered ONLY when ALL of the following criteria are met 1, 2:

• Single tumor location amenable to segmental resection with adequate margins
• No carcinoma in situ (CIS) present anywhere in the bladder
• T2 disease only (NOT T3 or T4a)
• Consider neoadjuvant chemotherapy before partial cystectomy 1

If partial cystectomy is performed, adjuvant radiotherapy or chemotherapy may be considered based on pathologic risk factors (positive nodes, positive margins, high-grade lesions, pathologic T3-T4), but this is a category 2B recommendation. 1

Bladder-Preservation Strategy (Alternative for Selected Patients)

Bladder preservation with maximal TURBT followed by concurrent chemoradiotherapy is an alternative to cystectomy, but patient selection is critical for success. 1, 3

Ideal Candidates Must Meet ALL Criteria:

• T2 tumor less than 5 cm in size 3
• Solitary lesion 3
• No carcinoma in situ present 3
• No hydronephrosis (this is an absolute contraindication—hydronephrosis consistently predicts treatment failure) 3
• Visibly complete or maximally debulking TURBT achievable 1, 3
• Good performance status and adequate bladder capacity 3
• Negative lymph nodes (N0) 3

Treatment Protocol:

1. Maximal transurethral resection of bladder tumor (TURBT) 1, 3
2. Concurrent chemoradiotherapy with cisplatin-based chemotherapy and radiation to 64-66 Gy 1, 3
   • Only cisplatin alone OR 5-FU plus mitomycin C are proven radiosensitizers superior to radiation alone 1
   • Never substitute carboplatin for cisplatin in bladder preservation—it lacks equivalent efficacy 3
3. Mandatory cystoscopic restaging after treatment to assess response 3
4. Salvage cystectomy if residual invasive disease is found 3

Expected Outcomes with Bladder Preservation:

• Complete response rate after induction: 70-87% 3
• 5-year overall survival: 50-67% 3
• Bladder-intact survival at 5 years: 40-54% 3
• Up to 25% of patients who initially respond will develop new lesions requiring additional treatment 1

Common pitfall: Up to 45% of bladders may be clinically understaged after TURBT, with residual disease found at cystectomy 3. This underscores the importance of strict patient selection criteria.

Treatment for Patients Unfit for Standard Therapy

For patients with extensive comorbidities or poor performance status who cannot tolerate cystectomy or intensive trimodality therapy 1, 3:

• TURBT alone
• Radiotherapy with concurrent chemotherapy (if renal function permits cisplatin)
• Chemotherapy alone
• For patients with low or moderate renal function who cannot receive cisplatin, concurrent 5-FU and mitomycin C can be used with radiation 1

Follow-Up After Treatment

After Radical Cystectomy:

• Urine cytology, liver function tests, creatinine, and electrolytes every 3-6 months for 2 years, then as clinically indicated 1, 2
• Imaging of chest, abdomen, and pelvis every 3-12 months for 2 years based on recurrence risk 1, 2

After Bladder Preservation:

• Intensive monitoring is mandatory: cystoscopy with cytology every 3 months for first 2 years, then every 6 months thereafter 1, 2, 3
• Upper tract imaging every 1-2 years for high-grade tumors 2
• Imaging of chest, abdomen, and pelvis every 3-12 months based on risk 3

Critical Pitfalls to Avoid

• Never attempt bladder preservation in patients with any degree of hydronephrosis 3
• Never substitute carboplatin for cisplatin in bladder preservation settings, even with borderline renal function 3
• Avoid bladder preservation in patients with diffuse CIS—concurrent extensive CIS significantly reduces success rates 3
• Do not give adjuvant chemotherapy after cystectomy if neoadjuvant chemotherapy was already administered 1
• Partial cystectomy is NOT an option for T3 or T4a disease 1