Chemotherapy agents in transitional cell carcinoma: the old and the new

Transitional cell carcinoma is a malignancy in which a number of single agents with different mechanisms of action are effective. Most older agents have limited activity, but several combinations are quite active. The most common regimens over the past 15 years were cyclophosphamide, doxorubicin, and cisplatin (CAP, CISCA); cisplatin, methotrexate, and vinblastine (CMV, MCV); and (methotrexate, vinblastine, doxorubicin, and cisplatin (M-VAC). Several new agents have been identified recently, including docetaxel, paclitaxel, gemcitabine, and ifosfamide. Combinations using these new agents now provide alternatives to the M-VAC combination that have much less toxicity and, in some instances, are used as multimodality therapy in patients with unresectable primary tumors without the degree of toxicity associated with older combinations of chemotherapy. Phase II and Phase III trials evaluating these new combinations are reviewed.