Quimioterapia perioperatoria en cáncer de vejiga: más evidencia que realidad

Invasive bladder cancer is an aggressive disease, with higher metastatic and death rates in spite of radical cystectomy and pelvic lymphadenectomy. With the aim of downstaging and eradicating micrometastastic disease, which are the main factors related to recurrence, some trials have shown the usefulness of perioperative or neoadjuvant chemotherapy for patients with stages T2 to T4a. The benefit of this therapy is related to complete disease response, disease free survival, and overall survival. Despite the published evidence and even in high volume medical centres, no more than 5% of the potential candidate patients are offered this therapy, this is possibly because patient related factors and the doubt about tolerability of these chemotherapy regimens. Cisplatin based chemotherapy protocols, particularly a four drugs regimen M-VAC, have the most important data about response rate, but with a poor safety profile. In recent years alternative chemotherapy protocols have been introduced, such as gemcitabine plus cisplatin and M-VAC in dense doses with granulocytic colonies stimulating factor support. These regimens have a similar response rate retrospectively compared to the M-VAC scheme. Currently there are no data about prospective head to head trials comparing these regimens. In non-cisplatin eligible patients the use of a gemcitabine, carboplatin with or without paclitaxel regimen has lower clinical evidence but increasing use rates, although this evidence was obtained in a metastatic setting. Some studies using antiangiogenic agents and directed therapies with kinase inhibitors have shown encouraging results that need confirmation in phase III trials. Invasive bladder cancer is a genomically complex disease, and there are currently no predictive biological or molecular biomarkers of neoadjuvant response. Current trials validating genomic profile expression scores will give us the future possibility for a better choice of the patients who will benefit most from these treatment strategies.