What is the best treatment approach for an elderly male patient with a 5 cm muscle-invasive bladder cancer and Carcinoma In Situ (CIS)?

Treatment of Muscle-Invasive Bladder Cancer with CIS in an Elderly Male

Radical cystectomy with bilateral pelvic lymph node dissection preceded by neoadjuvant cisplatin-based chemotherapy is the definitive treatment for this patient, provided he is medically fit for surgery. 1

Primary Treatment Approach: Radical Cystectomy with Neoadjuvant Chemotherapy

Neoadjuvant Chemotherapy (Category 1 Recommendation)

• Administer 2-3 cycles of cisplatin-based combination chemotherapy before surgery (such as dose-dense MVAC or gemcitabine/cisplatin), as this provides a survival benefit in muscle-invasive disease. 1
• Neoadjuvant chemotherapy is strongly preferred over adjuvant therapy because it improves overall survival and allows treatment while the patient has better performance status. 1
• Assess renal function (creatinine clearance) before initiating cisplatin; adequate renal function is required for cisplatin-based regimens. 1, 2

Radical Cystectomy with Lymph Node Dissection

• Perform radical cystectomy with bilateral pelvic lymph node dissection extending to at minimum the common iliac, internal iliac, external iliac, and obturator nodes bilaterally. 1
• The presence of concomitant CIS is an adverse prognostic factor but does not change the primary surgical approach; it reinforces the need for complete bladder removal rather than partial cystectomy. 1
• Do not offer orthotopic neobladder reconstruction if there is invasive tumor in the urethra or at the urethral dissection margin. 1
• Perform at least 10, and preferably >20, radical cystectomy cases per hospital per year for optimal outcomes. 1

Perioperative Care Considerations

• Do not offer preoperative bowel preparation. 1
• Use "fast track" enhanced recovery protocols to reduce time to bowel recovery. 1
• Provide pharmacological VTE prophylaxis with low-molecular-weight heparin starting the first day after surgery for at least 4 weeks. 1

Alternative: Bladder-Preserving Multimodal Therapy

If the patient is medically unfit for cystectomy, refuses surgery, or strongly desires bladder preservation, offer multimodal bladder-preserving treatment as an alternative. 1

Patient Selection Criteria for Bladder Preservation

This approach is contraindicated in this patient due to the presence of CIS. The ideal candidate for bladder preservation must have: 1, 2

• Solitary tumor (not multifocal)
• No extensive or multifocal CIS (this patient has CIS, making him a poor candidate)
• No tumor-related hydronephrosis
• Good pretreatment bladder function
• Ability to undergo complete or near-complete transurethral resection

Critical Caveat About CIS

The presence of CIS is specifically listed as an exclusion criterion for bladder-preserving approaches because it indicates field change disease and significantly increases the risk of treatment failure. 1

If Bladder Preservation is Still Pursued Despite CIS (Against Guidelines)

• Perform maximal transurethral resection of all visible tumor with examination under anesthesia. 1
• Administer 60-66 Gy external beam radiotherapy with concurrent cisplatin-based chemotherapy (cisplatin plus 5-FU, or cisplatin plus paclitaxel, or 5-FU plus mitomycin C as radiosensitizers). 1
• Reassess tumor status 2-3 months after completing chemoradiotherapy with cystoscopy, examination under anesthesia, and biopsy. 1
• If residual disease is present at reassessment, proceed immediately to salvage cystectomy. 1
• Long-term lifelong bladder monitoring is essential, as the bladder remains a potential source of recurrence. 1

Frailty Assessment in Elderly Patients

Base the treatment decision on tumor stage and frailty assessment, not chronological age alone. 1, 3

• Assess comorbidity using a validated score such as the Charlson Comorbidity Index. 1
• Use frailty screening tools such as the G8 instrument or Clinical Frailty Scale with multidisciplinary input including geriatric consultation. 1, 3
• Do not use the American Society of Anesthesiologists (ASA) score alone for treatment decisions in this setting. 1
• Healthy elderly patients can tolerate radical cystectomy with outcomes comparable to younger patients; functional age matters more than chronological age. 3, 4, 5

What NOT to Do

• Do not offer transurethral resection alone as curative treatment for this 5 cm muscle-invasive tumor with CIS, as most patients will not benefit. 1
• Do not offer radiotherapy alone as primary therapy; it is inferior to surgery or multimodal treatment. 1
• Do not offer chemotherapy alone as primary therapy; it rarely leads to durable complete remission. 1
• Do not offer partial cystectomy for this patient due to the presence of CIS (field change disease) and the 5 cm tumor size. 1
• Do not proceed with bladder-preserving therapy in the presence of CIS unless the patient absolutely refuses or cannot tolerate cystectomy, as CIS is a specific contraindication. 1

Adjuvant Therapy Considerations

If neoadjuvant chemotherapy was not given, consider adjuvant platinum-based chemotherapy for high-risk pathological features (pT3/4 and/or lymph node-positive disease). 1

Surveillance After Treatment

• Intensive cystoscopic surveillance every 3 months for 2 years, then every 6 months, is mandatory if bladder preservation is attempted. 1, 2
• Imaging of chest, abdomen, and pelvis every 3-12 months for 2 years based on recurrence risk. 1
• Upper tract imaging every 1-2 years. 1