الفهرس 
Epidemiology of bladder cancer globally (worldwideOnly 14 pages are availabe for public view
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Abstract
The treatment of muscle-invasive bladder cancer (MIBC) is complex and requires a multi-disciplinary collaboration among surgery, radiation, and medical oncology. Although neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC) and lymph node dissection has been considered the standard treatment for MIBC, many patients are unfit for surgery or cisplatin-ineligible, and considerations for bladder-preservation strategies not only are increasingly recognized as optimal treatment alternatives, but also should feature in the range of management options presented to patients at the time of diagnosis. Bladder preservation employing the combination of maximal TURBT, sensitizing chemotherapy, and radiation is now an established part of the therapeutic landscape in MIBC. The basic principles of organ conservation are that (1) the organ can be preserved in a functional state and with little residual impact on quality of life, (2) the organ-preserving strategy does not preclude salvage surgery, and (3) overall survival is not compromised by an attempt at initial organ preservation. Bladder cancer diagnosis and management begins with a highquality transurethral resection of bladder tumor (TURBT). Inadequate resection can lead to considerable under staging and misdiagnosis, with patients receiving intravesical therapy for presumed non-MIBC when in fact they have muscle-invasive disease. Aggressive TURBT appears to improve the rates of complete response by chemoradiation by as much as 47%. Bladder preservation therapy with tri modality treatment is a safe treatment that achieves response rates and survival benefit in MIBC similar to those achieved in modern cystectomy series. Tumor colonogenic repopulation is a major concern that limits the effectiveness of conventional radiation treatment. To overcome tumor colonogenic repopulation, accelerated hyper fractionated radiotherapy with concomitant boost and concurrent cisplatin allows delivery of two fractions per day with shortening of the overall treatment time without a rise in acute and late toxicity. The results observed in our study are equivalent to previous studies in terms of toxicity, both acute and late, and treatment results. In our study, the use of concomitant boost radiotherapy schedule results in a CR rate of 50 %, objective response rate of 75%. Patients with cT2 and T3a tumors, low grade, those with unifocal disease, lack of serious co-morbidities and at least good performance status are those for whom good local control can be anticipated. In part, this is because they can be readily debulked. Large multi focal tumors and those with tumorrelated hydronephrosis have lower rates of local control. These patients may be better served by RC. Chemotherapy has an established role in the treatment of MIBC, either in the perioperative setting or concurrently as radio sensitizing agents with radiation. Concurrent chemotherapy improved the complete response rate by 42%. Acute and late bowel and genitourinary toxicities were mild to moderate. No patients suffered Grade 3acute or late toxicity. Late toxicities are influenced by acute toxicities. Close surveillance after multimodality bladder preservation therapy with salvage cystectomy for non-responders or recurrence is an integral and important part of this treatment. The complication rate after salvage cystectomy is only very modestly higher than that seen after an initial cystectomy. In an ideal world, biomarkers would be used to refine the selection of patients for chemoradiation. In the past couple of years, there has been a rapid evolution in bladder cancer treatment with immuno-oncology, especially checkpoint inhibitors as single agents and/or in combination therapy in the first- and second-line metastatic bladder cancer settings. There are now plans afoot by the cooperative groups to test PD-L1 inhibitors as a component of organ-preserving strategies for MIBC. Close co-operation between urologic surgeons, pathologists, radiation oncologists, and medical oncologists seems to be most important in order to succeed in organ preservation therapy for muscleinvasive bladder cancer.