Radiation therapy-associated invasive bladder tumors

[Medical prevention and treatment of radiation-induced urological and nephrological complications]

Abdominal and pelvic irradiations play a major place in the management of patients with cancer and present a risk of acute and late side effects. Radiation-induced lesions can affect kidney or urological structures. These side effects can have an impact in the quality of life of patients. The aim of this article is to describe the physiopathology, the symptomatology, and the principles of management of radiation-induced nephropathy, uretheritis, cystitis, and urethritis.

Current perspectives in bladder cancer management

More than 350,000 new cases of bladder cancer are diagnosed worldwide each year; the vast majority (> 90%) of these are transitional cell carcinomas (TCC). The most important risk factors for the development of bladder cancer are smoking and occupational exposure to toxic chemicals. Painless visible haematuria is the most common presenting symptom of bladder cancer; significant haematuria requires referral to a specialist urology service. Cystoscopy and urine cytology are currently the recommended tools for diagnosis of bladder cancer. Excluding muscle invasion is an important diagnostic step, as outcomes for patients with muscle invasive TCC are less favourable. For non-muscle invasive bladder cancer, transurethral resection followed by intravesical chemotherapy (typically Mitomycin C or epirubicin) or immunotherapy [bacillus Calmette-Guérin (BCG)] is the current standard of care. For patients failing BCG therapy, cystectomy is recommended; for patients unsuitable for surgery, the choice of treatment options is currently limited. However, novel interventions, such as chemohyperthermia and electromotive drug administration, enhance the effects of conventional chemotherapeutic agents and are being evaluated in Phase III trials. Radical cystectomy (with pelvic lymphadenectomy and urinary diversion) or radical radiotherapy are the current established treatments for muscle invasive TCC. Neoadjuvant chemotherapy is recommended before definitive treatment of muscle invasive TCC; cisplatin-containing combination chemotherapy is the recommended regimen. Palliative chemotherapy is the first-choice treatment in metastatic TCC.

Treatment-related ureteral cancer following stage II testicular seminoma

We report two cases of left ureteral carcinoma that may have been related to prior radiotherapy and anticancer chemotherapy for stage II testicular seminoma. Both patients had undergone radiotherapy (60 Gy) and cisplatin-based chemotherapy, one 17 years before the present presentation and the other 24 years earlier. They underwent retroperitoneoscopy-assisted left nephroureterectomy under a diagnosis of left upper ureteral cancer, established by means of ureteroscopy and brush biopsy. The urologic and radiologic outcomes have been satisfactory after more than 2 years of follow-up. Recently, some investigators have reported that testicular cancer survivors are at significantly increased risk of solid tumors for at least 35 years after treatment. Young patients may have a high risk of cancer when they reach an advanced age.

Secondary cancer after radiotherapy for prostate cancer: should we be more aware of the risk?

OBJECTIVES

As the number of prostate cancer survivors is increasing, the long-term health of prostate cancer patients has become a significant health issue. Radiation is known to induce malignant transformation, and prostate cancer radiotherapy is suggested to induce secondary malignancies. This report reviews the available data regarding the risk of secondary cancer after radiation for prostate cancer.

METHODS

Epidemiological studies of the secondary cancer risk in patients with a history of prostate cancer radiation and the literature regarding radiation-induced carcinogenesis were reviewed.

RESULTS

Prostate cancer is not associated with an increased number of additional malignancies. The data suggests a modest increase in secondary cancers associated with radiation for prostate cancer, as approximately one in 70 patients undergoing radiation and surviving more than 10 yr will develop secondary cancer. The most common sites for secondary cancers are bladder and rectum. In addition to the cancers adjacent to the radiation field, there is also an increase of cancers in distant sites, such as lung. The increased risk for secondary cancers is reported after external radiation, not after brachytherapy. The available data originated from studies of patients undergoing conventional radiotherapy. New treatment methods, such as intensity-modulated radiotherapy, may be associated with a higher risk of secondary cancers.

CONCLUSION

Although the incidence of secondary cancers after prostate cancer radiotherapy is not dramatically different from the overall population, patients should be informed about this risk. Other treatment modalities should be considered for patients with long life expectancy and for patients with additional risk factors.

Urothelial Carcinoma After External Beam Radiation Therapy for Prostate Cancer

PURPOSE

We reviewed the clinical course of patients in whom urothelial carcinoma developed following radiation therapy for prostate cancer.

MATERIALS AND METHODS

A retrospective review of all patients between 1990 and 2005 with the diagnosis of bladder and prostate cancer was performed. Of 125 total patients new onset urothelial carcinoma developed in 11 after undergoing external beam radiation therapy for prostate cancer.

RESULTS

Whole pelvis external beam radiation therapy with a proton boost to the prostate was the radiation modality in 7 of the 11 patients (64%), while the remaining 4 patients received standard external beam radiation only. Urothelial carcinoma was detected a mean of 3.07 years after completion of radiation therapy in the proton group, compared to a mean latency period of 5.75 years in the standard radiation group (p = 0.09). Average patient age at diagnosis was 72 years (range 64 to 84). All patients presented with gross hematuria and had cystoscopic findings of coexisting radiation cystitis. Of the 11 patients 5 (45%) presented with grade 3 carcinoma and eventually 7 (64%) required radical cystectomy. Urothelial tumors with sarcomatoid features (carcinosarcoma and spindle cell sarcomatoid) developed in 2 patients (18%). Of the 11 patients 10 (91%) were nonsmokers at the time of urothelial carcinoma diagnosis.

CONCLUSIONS

Urothelial carcinoma in patients with previous radiation therapy for prostate cancer is often high grade, and the majority of patients have cancer progression requiring cystectomy. A high incidence of urothelial carcinoma with sarcomatoid features was seen in these patients.

Cytogenetic analysis of upper urinary tract transitional cell carcinomas

Ten primary (nine regular and one post-radiation) upper urinary tract transitional cell carcinomas (TCC), i.e., tumors of the renal pelvis and ureter, were obtained from 10 patients following nephroureterectomy and processed for cytogenetic analysis after short-term culturing. Clonal chromosomal aberrations were found in eight tumors. While 10 karyotypically related and/or unrelated clones were detected in the post-radiation tumor, cytogenetic monoclonality was seen in all other tumors. With the exception of two tumors with loss of the Y chromosome as the only change, chromosome 9 was invariably involved, either with loss of the entire chromosome or with partial loss from the short arm. Our findings indicate that the karyotypic profile of upper urinary tract TCC is identical to that of bladder TCC, an indication that the same pathogenetic mechanisms are at work in both regions.

Cytogenetic heterogeneity in a second primary radiation-induced bladder carcinoma: ten karyotypically unrelated clones

Cytogenetic analysis of a transitional cell carcinoma (TCC) of the bladder, the tumor having developed 32 years after the patient received pelvic irradiation and interstitial radium implantation for an endometrial carcinoma, revealed the presence of 10 cytogenetically abnormal, unrelated clones. Although the tumor was poorly differentiated, all clones were pseudo- or near-diploid with rather simple balanced or unbalanced structural rearrangements or both. The chromosomes involved in structural changes more than once were chromosomes 8, 9, and 11, which were rearranged in three clones, and chromosomes 3 and 17, both rearranged in two clones. No previous TCC of the bladder with cytogenetically unrelated clones has been reported, nor has any such radiation-induced tumor with chromosomal abnormalities been described. The distinct karyotypic and clonal pattern of the case presented here is probably indicative of a carcinogenic field effect due to the previous pelvic irradiation. Postradiation bladder carcinomas thus seem to be distinct cytogenetically in addition to their known unique etiological and clinical features.

Second primary bladder cancer following pelvic irradiation for other malignancies

Between 1985 and 1990, five cases of radiation-induced bladder cancer were treated at our center. The first primary neoplasm was uterine cervical cancer in three patients, uterine endometrial cancer in one patient, and Hodgkin's disease in one patient. Additional treatment for the primary neoplasm included panhysterectomy for the patient with endometrial cancer and cyclophosphamide-based combination chemotherapy for the patient with Hodgkin's disease. The mean age at development of bladder cancer was 60.4 years, and the average time interval between irradiation and development of bladder cancer was 14.6 years. All the bladder cancers were invasive. The treatment modalities included anterior pelvic exenteration in one patient, partial cystectomy in one patient, reirradiation in two patients, including the use of intraoperative electron therapy in one patient, and TUR plus endoscopic Nd:YAG laser treatment in one patient. Four patients are alive without disease at a mean follow-up period of 15 months from the diagnosis of bladder cancer.

Transitional cell carcinoma of the ureteral stump 23 years after radical nephrectomy for adenocarcinoma

We report a case of simultaneous invasive transitional cell carcinoma in a ureteral stump and superficial bladder tumor occurring 23 years after ipsilateral radical nephrectomy for adenocarcinoma of the kidney. We review the literature on similar cases and discuss potential etiologies of tumor formation in the ureteral stump.

Invasive bladder cancer following 125iodine implants

We present 2 cases of invasive transitional cell carcinoma of the bladder following implantation of 125iodine seeds for the treatment of localized adenocarcinoma of the prostate. These tumors, which occurred approximately 6 years after radiotherapy, were located in the trigone and prostatic urethra within the previous radiation treatment field. The development of high grade transitional cell carcinoma in these patients may be due to the tumorigenic effects of 125iodine radiation.