新辅助动脉化疗在肌层浸润性大体积膀胱癌保留膀胱治疗中的价值

Efficacy of neo-adjuvant intra-arterial chemotherapy in bladder preservation treatment for large size muscle-invasive bladder cancer

目的评估术前新辅助动脉化疗联合经尿道手术在直径超过3cm的肌层浸润性膀胱癌保留膀胱治疗的临床价值。方法对于较大体积（直径〉3cm）的28例肌层浸润性膀胱肿瘤（T2NoM。～T4。N。M。）采用新辅助动脉化疗联合手术治疗，观察动脉化疗效果，分析肿瘤降期率、保留膀胱率、肿瘤复发率，Kaplar-Meier法计算总体生存率、无肿瘤复发生存率，并绘制生存曲线。结果26例（92．9％）患者动脉化疗有效，肿瘤可见明显缩小，经3～5次动脉介入治疗后行经尿道切除术＋膀胱灌注完成保留膀胱治疗；动脉化疗无效2例，立即行根治性全膀胱切除术。26例完成保留膀胱治疗的患者，术后肿瘤病理分期降低19例（73．1％），无变化为7例。肿瘤复发8例（复发率为30．8％），其中，浅表性复发5例，局部浸润性复发2例，远处转移1例。28例患者总体生存率：3年69％，5年62．1％。无肿瘤复发生存率：5年44．07％。最终25例患者得到保留膀胱（保留膀胱率89．3％）。结论直径〉3cm的较大体积浸润性膀胱肿瘤采用术前新辅助动脉化疗治疗，可使肿瘤降期降级及体积缩小，有利于经尿道完全切除，可有效提高患者生存率，同时保留了膀胱，大大提高患者生存质量，对不愿或不宜行膀胱全切的患者是一个理想的选择。

Objective To evaluate the clinical value of neo-adjuvant intra-arterial chemotherapy combined with transure- thral surgery in the bladder preservation therapy of muscle-invasive bladder cancer with tumor size larger than 3cm. Methods A total of 28 patients with large size muscle-invasive bladder cancer （clinical stage： T2 N. M.-T4aN. M., tumor size：〉3 cm） were treated with neo-adjuvant intra-arterial chemotherapy combined with surgery. The effect of inter-arterial chemotherapy, the rates of clinical down-staging, bladder preservation, and recurrence of the tumors were observed. Kaplan-Meier analysis was used to calculate the overall survival and cancer-specific survival rates, and then a survival curve was drawn. Results 26 （92.9%） patients were responsive to treatment and tumor size was significantly reduced. After 3 to 5 courses of intra-arterial chemotherapy and embolization, these patients received bladder preservation therapy with transurethral resection of tumor and intravesical instillation; while the other 2 patients underwent radical cystectomy immediately after intra-arterial chemotherapy because the treatment was ineffective. Tumor down-staging was observed in 19 of the patients （73.1%）. During the follow-up, 8 patients （30.8%） experienced tumor recurrence, with 3 superficial recurrence, 2 local invasive recurrence, and 1 distant me- tastasis. The overall survival rate in 3 and 5 years was 69% and 62.1%, respectively. The recurrence-free survival rate in 5 years was 44.07%. Eventually the bladder was preserved in 25 patients （89.3%）. Conclusions Neo-adjuvant inter-arterial chemotherapy in the treatment of muscle-invasive bladder cancer with tumor size larger than 3cm often results in clinical down- staging and decreases in tumor size. This treatment is conducive for radical transurethral resection of bladder tumor, which can improve the survival rate, and preserve the bladder to improve the quality of life. It is a treatment option for patients who are unwilling or unsuitable for radical cystectomy.