浸潤性膀胱癌に対する術前動注療法併用膀胱部分切除術の経験

Abstract

1987年1月から1990年1月の間にneoadjuvant動注療法を行った浸潤性膀胱癌22例のうち, 動注療法の効果が良好でかつ限局性の腫瘍であった4例に対し膀胱部分切除術を施行した.切除標本の病理所見は2例がpT0で他はpT3aとpT3bであり, pT3b例に局所再発がみられ18ヵ月後に癌死したが残りの3例はNED(平均観察期間24ヵ月)である.neoadjuvant動注療法+膀胱部分切除術を選択する際には以下の条件が重要と思われた.1)限局性の浸潤癌で術前動注療法に良く反応したもの(clinical PR以上).2) T3a以下で悪性な浸潤様式(INFγ)を示さない腫瘍.3)切除範囲決定には, 術前に切開予定部のできるだけ深い生検を施行する

From January, 1987 through January, 1990, partial cystectomy was performed for 4 (18%) of 22 patients with invasive bladder cancer who had received neoadjuvant intra-arterial chemotherapy. The criteria of patient selection for partial cystectomy were: 1) invasive bladder cancer showing good response (greater than or equal to PR) to neoadjuvant chemotherapy, 2) solitary or localized tumor that can be eradicated by segmental resection, and 3) tumor of stage T3 or less. As a rule, cisplatinum (100 mg/m2) and THP-adriamycin (40 mg/m2) were administered selectively to the internal iliac artery by one-shot infusion. Concurrently, sodium thiosulfate (10 g/m2), a neutralizing agent against cisplatinum, was administered intravenously. All four patients had achieved clinical complete responses by one or two courses of intra-arterial chemotherapy, and then underwent partial cystectomy with pelvic lymphadenectomy. Pathological examination revealed pTONO in two patients, and the remains were pT3aNO and pT3bN1. After the mean follow-up of 24 months, three of them are alive with no evidence of disease, and also with normal bladder and sexual functions. However, one with pT3bN1 tumor underwent total cystectomy 5 months later for local recurrence (pT4b) and had died of cancer 18 months later. Neoadjuvant intra-arterial chemotherapy followed by partial cystectomy should be the most applicable conservative therapy with high radicality for invasive bladder cancer, when: 1) the patient has localized invasive cancer showing good response (greater than or equal to PR) to neoadjuvant chemotherapy, 2) the tumor is stage T3a or less and without findings of tentacular invasion (INF gamma) by pre-operative biopsy, and 3) pre-operative multiple biopsy is performed as deeply as possible along the prearranged incision line.