1
|
Murthy V, Maitre P, Singh M, Pal M, Arora A, Pujari L, Kapoor A, Pandey H, Sharma R, Gudipudi D, Joshi A, Prabhash K, Noronha V, Menon S, Mehta P, Bakshi G, Prakash G. Study Protocol of the Bladder Adjuvant RadioTherapy (BART) Trial: A Randomised Phase III Trial of Adjuvant Radiotherapy Following Cystectomy in Bladder Cancer. Clin Oncol (R Coll Radiol) 2023; 35:e506-e515. [PMID: 37208232 DOI: 10.1016/j.clon.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/10/2023] [Accepted: 04/28/2023] [Indexed: 05/21/2023]
Abstract
AIMS To assess the efficacy and safety of adjuvant radiotherapy in patients with high-risk muscle-invasive bladder cancer (MIBC) following radical cystectomy (RC) and chemotherapy. MATERIALS AND METHODS The BART (Bladder Adjuvant RadioTherapy) trial is an ongoing multicentric, randomised, phase III trial comparing the efficacy and safety of adjuvant radiotherapy versus observation in patients with high-risk MIBC. The key eligibility criteria include ≥pT3, node-positive (pN+), positive margins and/or nodal yield <10, or, neoadjuvant chemotherapy for cT3/T4/N+ disease. In total, 153 patients will be accrued and randomised, in a 1:1 ratio, to either observation (standard arm) or adjuvant radiotherapy (test arm) following surgery and chemotherapy. Stratification parameters include nodal status (N+ versus N0) and chemotherapy (neoadjuvant chemotherapy versus adjuvant chemotherapy versus no chemotherapy). For patients in the test arm, adjuvant radiotherapy to cystectomy bed and pelvic nodes is planned with intensity-modulated radiotherapy to a dose of 50.4 Gy in 28 fractions using daily image guidance. All patients will follow-up with 3-monthly clinical review and urine cytology for 2 years and subsequently 6 monthly until 5 years, with contrast-enhanced computed tomography abdomen pelvis 6 monthly for 2 years and annually until 5 years. Physician-scored toxicity using Common Terminology Criteria for Adverse Events version 5.0 and patient-reported quality of life using the Functional Assessment of Cancer Therapy - Colorectal questionnaire is recorded pre-treatment and at follow-up. ENDPOINTS AND STATISTICS The primary endpoint is 2-year locoregional recurrence-free survival. The sample size calculation was based on the estimated improvement in 2-year locoregional recurrence-free survival from 70% in the standard arm to 85% in the test arm (hazard ratio 0.45) using 80% statistical power and a two-sided alpha error of 0.05. Secondary endpoints include disease-free survival, overall survival, acute and late toxicity, patterns of failure and quality of life. CONCLUSION The BART trial aims to evaluate whether contemporary radiotherapy after standard-of-care surgery and chemotherapy reduces pelvic recurrences safely and also potentially affects survival in high-risk MIBC.
Collapse
Affiliation(s)
- V Murthy
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
| | - P Maitre
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - M Singh
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - M Pal
- Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - A Arora
- Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - L Pujari
- Department of Radiation Oncology, HBCH & MPMMMC, Varanasi, India
| | - A Kapoor
- Department of Medical Oncology, HBCH & MPMMMC, Varanasi, India
| | - H Pandey
- Department of Surgical Oncology, HBCH & MPMMMC, Varanasi, India
| | - R Sharma
- Department of Uro-Oncology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, India
| | - D Gudipudi
- Department of Uro-Oncology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, India
| | - A Joshi
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - K Prabhash
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - V Noronha
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - S Menon
- Department of Pathology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - P Mehta
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - G Bakshi
- Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - G Prakash
- Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| |
Collapse
|
2
|
Brown JT, Narayan VM, Joshi SS, Harik L, Jani AB, Bilen MA. Challenges and opportunities in the management of non-urothelial bladder cancers. Cancer Treat Res Commun 2023; 34:100663. [PMID: 36527979 DOI: 10.1016/j.ctarc.2022.100663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/20/2022] [Indexed: 12/12/2022]
Abstract
Urothelial carcinoma accounts for approximately 90% of all bladder cancer diagnoses. Localized, muscle-invasive disease is often managed with a multidisciplinary approach including either neoadjuvant chemotherapy (NAC) followed by radical cystectomy or concurrent chemoradiation, whereas multiple immunotherapies and novel antibody drug conjugates have recently joined platinum-based chemotherapy as standard of care therapy for metastatic disease. However, the clinical trials leading to these standards often require majority if not complete urothelial histology for eligibility. As many as one quarter of patients diagnosed with bladder cancer will have either divergent differentiation of their urothelial carcinoma or an alternate epithelial tumor such as squamous cell carcinoma, adenocarcinoma, or small cell carcinoma; even more rare are non-epithelial tumors such as sarcoma. The rarity of these diseases and their general exclusion from treatment within prospective clinical trials has created a challenging situation where treatment plans are often derived from case series or extrapolated from other disease types and outcomes are poor compared to pure urothelial carcinoma. In this review, we summarize the existing data on the diagnosis and treatment of epithelial, non-urothelial bladder cancers including adenocarcinoma, squamous cell carcinoma, and small cell carcinoma in their localized and advances stages. We will also review the current clinical trial landscape investigating novel approaches to these diseases.
Collapse
Affiliation(s)
- Jacqueline T Brown
- Winship Cancer Institute, Emory University, Atlanta, GA, United States; Emory University School of Medicine, Department of Hematology and Medical Oncology, Atlanta, GA, United States.
| | - Vikram M Narayan
- Winship Cancer Institute, Emory University, Atlanta, GA, United States; Emory University School of Medicine, Department of Urology, Atlanta, GA, United States
| | - Shreyas S Joshi
- Winship Cancer Institute, Emory University, Atlanta, GA, United States; Emory University School of Medicine, Department of Urology, Atlanta, GA, United States
| | - Lara Harik
- Winship Cancer Institute, Emory University, Atlanta, GA, United States; Emory University School of Medicine, Department of Pathology and Laboratory Medicine, Atlanta, GA, United States
| | - Ashesh B Jani
- Winship Cancer Institute, Emory University, Atlanta, GA, United States; Emory University School of Medicine, Department of Radiation Oncology, Atlanta, GA, United States
| | - Mehmet Asim Bilen
- Winship Cancer Institute, Emory University, Atlanta, GA, United States; Emory University School of Medicine, Department of Hematology and Medical Oncology, Atlanta, GA, United States
| |
Collapse
|
3
|
Ernandez J, Kaul S, Fleishman A, Korets R, Chang P, Wagner A, Kim S, Bellmunt J, Kaplan I, Olumi AF, Gershman B. Adjuvant chemotherapy plus radiotherapy versus chemotherapy alone for locally advanced bladder cancer after radical cystectomy. Bladder Cancer 2022. [DOI: 10.3233/blc-220031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: Survival with locally advanced bladder cancer (LABC) following radical cystectomy (RC) remains poor. Although adjuvant chemotherapy (AC) is standard of care, one small, randomized trial has suggested a potential survival benefit when combined with post-operative radiotherapy (PORT). OBJECTIVE: We examined the association of AC + PORT with overall survival (OS) in patients with LABC after RC. METHODS: Using a prior phase 2 trial to inform design, we conducted observational analyses to emulate a hypothetical target trial of patients aged 18–79 years with pT3-4 Nany M0 or pTany N1-3 M0 urothelial bladder carcinoma following RC who were treated with AC (multiagent chemotherapy within 3 months of RC) with or without PORT (≥45 Gy to the pelvis) from 2006–2015 in the NCDB. Patients who received preoperative chemotherapy or radiotherapy were excluded. The associations of treatment with OS were evaluated using multivariable Cox regression. RESULTS: 1,684 patients were included, with 66 receiving AC + PORT and 1,618 AC alone. Compared to patients treated with AC alone, those treated with AC + PORT were more likely to have pT4 disease (52% vs 26% ; p < 0.01), positive surgical margins (44% vs 17% ; p < 0.01), and be treated at a non-academic facility (75% vs 53% ; p < 0.01). Crude 5-year OS was 19% for AC + PORT versus 36% for AC alone (p = 0.01). Adjusted 5-year OS was 33% for AC + PORT versus 36% for AC alone (p = 0.49). After adjusting for baseline characteristics including pathologic features, AC + PORT was not associated with improved OS compared to AC alone (HR 1.11; 95% CI 0.82–1.51). CONCLUSIONS: Although infrequently utilized, the addition of radiotherapy to AC is not associated with improved OS in LABC. These results highlight the need for prospective trials to better define the potential benefits from PORT with regard to symptomatic progression and oncologic outcomes.
Collapse
Affiliation(s)
| | - Sumedh Kaul
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Aaron Fleishman
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ruslan Korets
- Division of Urologic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Peter Chang
- Division of Urologic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Andrew Wagner
- Division of Urologic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Simon Kim
- Division of Urology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Joaquim Bellmunt
- Department of Medicine, Division of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Irving Kaplan
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, MA, 02215, USA
| | - Aria F. Olumi
- Division of Urologic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Boris Gershman
- Division of Urologic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| |
Collapse
|
4
|
Fonteyne V, Dirix P, Van Praet C, Berghen C, Albersen M, Junius S, Liefhooghe N, Noé L, De Meerleer G, Ost P, Villeirs G, Verbeke S, De Maeseneer D, Rammant E, Verghote F, Elhaseen E, De Man K, Decaestecker K. Adjuvant Radiotherapy After Radical Cystectomy for Patients with High-risk Muscle-invasive Bladder Cancer: Results of a Multicentric Phase II Trial. Eur Urol Focus 2022; 8:1238-1245. [PMID: 34893458 DOI: 10.1016/j.euf.2021.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/27/2021] [Accepted: 11/18/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND High-risk muscle-invasive bladder cancer (MIBC) has a poor prognosis. Old trials showed that external beam radiotherapy (EBRT) after radical cystectomy (RC) decreases the incidence of local recurrences but induces severe toxicity. OBJECTIVE To evaluate the toxicity and local control rate after adjuvant EBRT after RC delivered with volumetric arc radiotherapy. DESIGN, SETTING, AND PARTICIPANTS This is a multicentric phase 2 trial. From August 2014 till October 2020, we treated 72 high-risk MIBC patients with adjuvant EBRT after RC. High-risk MIBC is defined as ≥pT3-MIBC ± lymphovascular invasion, fewer than ten lymph nodes removed, pathological positive lymph nodes, or positive surgical margins. INTERVENTION Patients received 50 Gy in 25 fractions with intensity-modulated radiotherapy to the pelvic lymph nodes ± cystectomy bed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome is acute toxicity. We report on local relapse-free rate (LRFR), clinical relapse-free survival (CRFS), overall survival (OS), and bladder cancer-specific survival (BCSS). RESULTS AND LIMITATIONS The median follow-up is 18 mo. Forty-two patients (61%) developed acute grade 2 gastrointestinal (GI) toxicity. Four patients (6%) had acute grade 3 GI toxicity. One patient had grade 5 diarrhea and vomiting due to obstruction at 1 mo. Two-year probabilities of developing grade ≥3 and ≥2 GI toxicity were 17% and 76%, respectively. Urinary toxicity, assessed in 17 patients with a neobladder, was acceptable with acute grade 2 and 3 urinary toxicity reported in 53% (N = 9) and 18% (N = 3) of the patients, respectively. The 2-yr LRFR is 83% ± 5% and the 2-yr CRFS rate is 43% with a median CRFS time of 12 mo (95% confidence interval: 3-21 mo). Two-year OS and BCSS are 52% ± 7% and 62% ± 7%, respectively. Shortcomings are the nonrandomized study design and limited follow-up. CONCLUSIONS Adjuvant EBRT after RC can be administered without excessive severe toxicity. PATIENT SUMMARY In this report, we looked at the incidence of toxicity and local control after adjuvant external beam radiotherapy (EBRT) following radical cystectomy (RC) in high-risk muscle-invasive bladder cancer patients. We found that adjuvant EBRT was feasible and resulted in good local control. We conclude that these data support further enrollment of patients in ongoing trials to evaluate the place of adjuvant EBRT after RC.
Collapse
Affiliation(s)
- Valérie Fonteyne
- Department of Radiotherapy-Oncology, Ghent University Hospital, Ghent, Belgium.
| | - P Dirix
- Department of Radiation-Oncology, Iridium Network, Antwerp, Belgium
| | - C Van Praet
- Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - C Berghen
- Department of Radiotherapy-Oncology, University Hospitals Leuven, Leuven, Belgium
| | - M Albersen
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - S Junius
- Department of Radiotherapy-Oncology, CH-M/AMPR, Mouscron, Belgium
| | - N Liefhooghe
- Department of Radiotherapy-Oncology, AZ Groeninge, Kortrijk, Belgium
| | - L Noé
- Department of Radiotherapy-Oncology, Limburg Oncology Center, Jessa Hospital, Hasselt, Belgium
| | - G De Meerleer
- Department of Radiotherapy-Oncology, University Hospitals Leuven, Leuven, Belgium
| | - P Ost
- Department of Human structure and Repair, Ghent University, Ghent, Belgium
| | - G Villeirs
- Department of Medical Imaging, Ghent University Hospital, Ghent, Belgium
| | - S Verbeke
- Department of Pathology, Ghent University Hospital, Ghent, Belgium
| | - D De Maeseneer
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - E Rammant
- Department of Radiotherapy-Oncology, Ghent University Hospital, Ghent, Belgium
| | - F Verghote
- Department of Radiotherapy-Oncology, Ghent University Hospital, Ghent, Belgium
| | - E Elhaseen
- Department of Radiotherapy-Oncology, Ghent University Hospital, Ghent, Belgium
| | - K De Man
- Department of Medical Imaging, Ghent University Hospital, Ghent, Belgium
| | - K Decaestecker
- Department of Urology, Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
5
|
Kamal M, Navai N, Bree KK, Williams LA, Cleeland CS, Shen SE, Wang XS. Validation and Application of MD Anderson Symptom Inventory Module for Patients with Bladder Cancer in the Perioperative Setting. Cancers (Basel) 2022; 14:cancers14163896. [PMID: 36010890 PMCID: PMC9405694 DOI: 10.3390/cancers14163896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/08/2022] [Accepted: 08/10/2022] [Indexed: 12/24/2022] Open
Abstract
Objectives: We developed and validated a disease-specific tool for perioperative patient-reported outcomes assessment for bladder cancer (BLC) patients undergoing radical cystectomy, The MD Anderson Symptom Inventory (the MDASI-PeriOp-BLC). Methods: Patients who underwent radical cystectomy were recruited. We used qualitative interviews and experts’ input to generate disease/treatment-specific items of the MDASI-PeriOp-BLC module; conducted item reduction; examined the psychometric properties of the resultant items for reliability, validity, and clinical interpretability; and conducted cognitive debriefing interviews to assess the tool’s performance. Results: A total of 150 BLC patients contributed to psychometric validation. We identified and defined eight BLC-specific module items (blood in urine, leaking urine, frequent urination, urinary urgency, burning with urination, constipation, changes in sexual function, and stomal problems). We included those 8 items in addition to 13 MDASI core symptoms and 6 interference items to form the MDASI-PeriOp-BLC module. Cronbach alphas were 0.89 and 0.90 for the 21 severity items and the 6 interference items, respectively. Test−retest reliability (intra-class correlation) was 0.92 for the 21 severity items. The MDASI-PeriOp-BLC module significantly differentiated the patients by performance status (p < 0.0001). Conclusions: The MDASI-PeriOp-BLC is a valid, reliable, and concise tool for monitoring symptom burden during perioperative care in BLC patients undergoing radical cystectomy.
Collapse
Affiliation(s)
- Mona Kamal
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1450, Houston, TX 77030, USA
| | - Neema Navai
- Department of Urology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1450, Houston, TX 77030, USA
| | - Kelly K. Bree
- Department of Urology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1450, Houston, TX 77030, USA
| | - Loretta A. Williams
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1450, Houston, TX 77030, USA
| | - Charles S. Cleeland
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1450, Houston, TX 77030, USA
| | - Shu-En Shen
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1450, Houston, TX 77030, USA
| | - Xin Shelley Wang
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1450, Houston, TX 77030, USA
- Correspondence: ; Tel.: +1-713-745-3504; Fax: +1-713-745-3475
| |
Collapse
|
6
|
Verghote F, Sargos P, Christodouleas JP, Murthy V, Baumann BC, Dirix P, Berghen C, Paelinck L, Vercauteren T, Fonteyne V. International Consensus Guidelines for Adjuvant Radiation Therapy for Bladder Cancer After Radical Cystectomy: Update From an IBIS Workgroup. Pract Radiat Oncol 2022; 12:524-532. [PMID: 35691550 DOI: 10.1016/j.prro.2022.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 05/26/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE In 2016, international consensus clinical target volume (CTV) guidelines for adjuvant radiation treatment (ART) after radical cystectomy (RC) in muscle-invasive bladder cancer patients with high risk for locoregional failure (LRF) were published. A subsequent external validation study recommended several CTV optimizations (CTV-OPT). This study aimed to update international consensus guidelines based on new clinical experiences. METHODS AND MATERIALS Phase 1 (delineation interobserver variability): 4 observers delineated the CTV of 9 patients post-RC, as in clinical practice. Interobserver agreement in contouring was evaluated using volume- and kappa-statistics. Phase 2 (pattern of failure analysis): Among a prospective cohort of 72 patients treated with ART, 11 developed LRF (10 available for review). LRFs were mapped in predefined pelvic subsites (i.e. common, external and internal iliac, obturator and presacral node regions and cystectomy bed) and their distance to CTV-OPT was measured. The actual delivered dose at each relapse site was calculated. Phase 3 (review CTV): Based on the results of phase 1 and 2, 5 senior radiation-oncologists (XXXX) reviewed the published CTV borders and provided an update when indicated. RESULTS Phase 1: The mean overall kappa-value was 0.66 (range: 0.60-0.70), indicating substantial overall agreement per Landis-Koch criteria. Specific kappa-values per area indicated for the common iliac and obturator node regions only slight and moderate variability, respectively. Phase 2: 13 out of 16 LRFs centers were not included in the CTV-OPT. 10 LRF sites received a median dose <45Gy, of which 6 were located in the cystectomy bed that was not included in the CTV because of negative RC margins. Phase 3: Key recommendations by the panel were to include the entire common iliac node region and the cystectomy bed regardless of surgical margin status and re-affirmed to not crop the CTV out of bowel. CONCLUSION International consensus guidelines were updated.
Collapse
Affiliation(s)
- Flor Verghote
- Department of Radiotherapy-Oncology, Ghent University Hospital, Ghent, Belgium.; Department of Human Structure and Repair, Ghent University, Ghent, Belgium..
| | - Paul Sargos
- Department of Radiotherapy, Institut Bergonié, Bordeaux, France
| | - John P Christodouleas
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Vedang Murthy
- Department of Radiation Oncology, ACTREC, Tata Memorial Centre, HBNI, Mumbai, India
| | - Brian C Baumann
- Department of Radiation Oncology, Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri
| | - Piet Dirix
- Department of Radiation-Oncology, Iridium Network, Antwerp, Belgium
| | - Charlien Berghen
- Department of Radiation-Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Leen Paelinck
- Department of Radiotherapy-Oncology, Ghent University Hospital, Ghent, Belgium
| | - Tom Vercauteren
- Department of Radiotherapy-Oncology, Ghent University Hospital, Ghent, Belgium
| | - Valérie Fonteyne
- Department of Radiotherapy-Oncology, Ghent University Hospital, Ghent, Belgium.; Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| |
Collapse
|
7
|
Bladder-Sparing Approaches to Treatment of Muscle-Invasive Bladder Cancer. Urol Oncol 2022. [DOI: 10.1007/978-3-030-89891-5_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
8
|
Sargos P, Supiot S, Créhange G, Fromont-Hankard G, Barret E, Beauval JB, Brureau L, Dariane C, Fiard G, Gauthé M, Mathieu R, Roubaud G, Ruffion A, Renard-Penna R, Neuzillet Y, Rouprêt M, Ploussard G. Oncologic Impact and Safety of Pre-Operative Radiotherapy in Localized Prostate and Bladder Cancer: A Comprehensive Review from the Cancerology Committee of the Association Française d'Urologie. Cancers (Basel) 2021; 13:cancers13236070. [PMID: 34885179 PMCID: PMC8656987 DOI: 10.3390/cancers13236070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/26/2021] [Accepted: 11/28/2021] [Indexed: 11/23/2022] Open
Abstract
Simple Summary Radiotherapy may have an interesting role of reinforcing the loco-regional control of cancer, in addition to surgery, when used as a preoperative treatment. This sequence has demonstrated its efficacy and safety in various malignancies, but no strong data exist in the era of uro-oncology. In this review article, we aim to highlight the potential usefulness of preoperative radiotherapy in prostate and muscle-invasive bladder cancer, aiming to enhance pathological response and local control and to prevent intraoperative tumor seeding. We also emphasize the need for further clinical studies assessing the functional safety of subsequent surgical procedures in a competitive context of new systemic agents that have proven to demonstrate a survival benefit in locally advanced urologic cancers. Abstract Preoperative radiotherapy (RT) is commonly used for the treatment of various malignancies, including sarcomas, rectal, and gynaecological cancers, but it is preferentially used as a competitive treatment to radical surgery in uro-oncology or as a salvage procedure in cases of local recurrence. Nevertheless, preoperative RT represents an attractive strategy to prevent from intraoperative tumor seeding in the operative field, to sterilize microscopic extension outside the organ, and to enhance the pathological and/or imaging tumor response rate. Several clinical works support this research field in uro-oncology. In this review article, we summarized the oncologic impact and safety of preoperative RT in localized prostate and muscle-invasive bladder cancer. Preliminary studies suggest that both modalities can be complementary as initial primary tumor treatments and that a pre-operative radiotherapy strategy could be beneficial in a well-defined population of patients who are at a very high-risk of local relapse. Future prospective trials are warranted to evaluate the oncologic benefit of such a combination of local treatments in addition to new life-prolonging systemic therapies, such as immunotherapy, and new generation hormone therapies. Moreover, the safety and the feasibility of salvage surgical procedures due to non-response or local recurrence after pelvic RT remain poorly evaluated in that context.
Collapse
Affiliation(s)
- Paul Sargos
- Department of Radiotherapy, Institut Bergonié, 33000 Bordeaux, France;
| | - Stéphane Supiot
- Department of Radiotherapy, Insitut de Cancérologie de l’Ouest, 44800 St-Herblain, France;
| | - Gilles Créhange
- Department of Radiotherapy, Institut Curie, 75005 Paris, France;
| | | | - Eric Barret
- Department of Urology, Institut Mutualiste Montsouris, 75014 Paris, France;
| | | | - Laurent Brureau
- Department of Urology, CHU de Pointe-à-Pitre, University of Antilles, University of Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)—UMR_S 1085, 97110 Pointe-à-Pitre, France;
| | - Charles Dariane
- Department of Urology, Hôpital Européen Georges-Pompidou, APHP, Paris—Paris University—U1151 Inserm-INEM, Necker, 75015 Paris, France;
| | - Gaëlle Fiard
- Department of Urology, Grenoble Alpes University Hospital, Université Grenoble Alpes, CNRS, Grenoble INP, TIMC-IMAG, 38000 Grenoble, France;
| | - Mathieu Gauthé
- Unité de Recherche Clinique en Économie de la Santé, CRESS METHODS INSERM UMR 1153, 75000 Paris, France;
| | - Romain Mathieu
- Department of Urology, CHU Rennes, 35033 Rennes, France;
| | - Guilhem Roubaud
- Department of Medical Oncology, Institut Bergonié, 33000 Bordeaux, France;
| | - Alain Ruffion
- Service d’Urologie Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 69002 Lyon, France;
- Equipe 2, Centre d’Innovation en Cancérologie de Lyon (EA 3738 CICLY), Faculté de Médecine Lyon Sud, Université Lyon 1, 69002 Lyon, France
| | - Raphaële Renard-Penna
- Department of Radiology, Sorbonne University, AP-HP, Pitie-Salpetriere Hospital, 75013 Paris, France;
| | - Yann Neuzillet
- Department of Urology, Hôpital Foch, 92151 Suresnes, France;
| | - Morgan Rouprêt
- Department of Urology, Sorbonne University, GRC 5 Predictive Onco-Uro, AP-HP, Pitie-Salpetriere Hospital, 75013 Paris, France;
| | - Guillaume Ploussard
- Department of Urology, La Croix du Sud Hôpital, 31130 Quint Fonsegrives, France;
- Correspondence: ; Tel.: +33-5-32027202; Fax: +33-5-32027203
| |
Collapse
|
9
|
Press RH, Shelton JW, Zhang C, Dang Q, Tian S, Shu T, Seldon CS, Hasan S, Jani AB, Zhou J, McDonald MW. Bone Marrow Suppression during Postoperative Radiation for Bladder Cancer and Comparative Benefit of Proton Therapy—Phase 2 Trial Secondary Analysis. Int J Part Ther 2021; 8:1-10. [PMID: 35127970 PMCID: PMC8768898 DOI: 10.14338/ijpt-21-00003.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 05/06/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose For patients with high-risk bladder cancer (pT3+ or N+), local regional failure remains a challenge after chemotherapy and cystectomy. An ongoing prospective phase 2 trial (NCT01954173) is examining the role of postoperative photon radiation therapy for high-risk patients using volumetric modulated arc therapy. Proton beam therapy (PBT) may be beneficial in this setting to reduce hematologic toxicity. We evaluated for dosimetric relationships with pelvic bone marrow (PBM) and changes in hematologic counts before and after pelvic radiation therapy and explored the potential of PBT treatment plans to achieve reductions in PBM dose. Materials and Methods All enrolled patients were retrospectively analyzed after pelvic radiation per protocol with 50.4 to 55.8 Gy in 28 to 31 fractions. Comparative PBT plans were generated using pencil-beam scanning and a 3-beam multifield optimization technique. Changes in hematologic nadirs were assessed using paired t test. Correlation of mean nadirs and relative PBM dose levels were assessed using the Pearson correlation coefficient (CC). Results Eighteen patients with a median age of 70 were analyzed. Mean cell count values after radiation therapy decreased compared with preradiation therapy values for white blood cells (WBCs), absolute neutrophil count (ANC), absolute lymphocyte count (all P < .001), and platelets (P = .03). Increased mean PBM dose was associated with lower nadirs in WBC (Pearson CC −0.593, P = .02), ANC (Pearson CC −0.597, P = .02), and hemoglobin (Pearson CC −0.506, P = .046), whereas the PBM V30 to V40 correlated with lower WBC (Pearson CC −0.512 to −0.618, P < .05), and V20 to V30 correlated with lower ANC (Pearson CC −0.569 to −0.598, P < .04). Comparative proton therapy plans decreased the mean PBM dose from 26.5 Gy to 16.1 Gy (P < .001) and had significant reductions in the volume of PBM receiving doses from 5 to 40 Gy (P < .001). Conclusion Increased PBM mean dose and V20 to V40 were associated with lower hematologic nadirs. PBT plans reduced PBM dose and may be a valuable strategy to reduce the risk of hematologic toxicity in these patients.
Collapse
Affiliation(s)
| | - Joseph W. Shelton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Chao Zhang
- Biostatistics Core of Department Pediatrics, Emory University, Atlanta, GA, USA
| | - Quang Dang
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Sibo Tian
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Timothy Shu
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Crystal S. Seldon
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | | | - Ashesh B. Jani
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Jun Zhou
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Mark W. McDonald
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| |
Collapse
|
10
|
Kim HJ, Chun J, Kim TH, Yang G, Shin SJ, Kim JS, Yang J, Ham WS, Koom WS. Patterns of Locoregional Recurrence after Radical Cystectomy for Stage T3-4 Bladder Cancer: A Radiation Oncologist's Point of View. Yonsei Med J 2021; 62:569-576. [PMID: 34164953 PMCID: PMC8236349 DOI: 10.3349/ymj.2021.62.7.569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/02/2021] [Accepted: 04/23/2021] [Indexed: 12/05/2022] Open
Abstract
PURPOSE Adjuvant radiotherapy (RT) has been performed to reduce locoregional failure (LRF) following radical cystectomy for locally advanced bladder cancer; however, its efficacy has not been well established. We analyzed the locoregional recurrence patterns of post-radical cystectomy to identify patients who could benefit from adjuvant RT and determine the optimal target volume. MATERIALS AND METHODS We retrospectively reviewed 160 patients with stage ≥ pT3 bladder cancer who were treated with radical cystectomy between January 2006 and December 2015. The impact of pathologic findings, including the stage, lympho-vascular invasion, perineural invasion, margin status, nodal involvement, and the number of nodes removed on failure patterns, was assessed. RESULTS Median follow-up period was 27.7 months. LRF was observed in 55 patients (34.3%), 12 of whom presented with synchronous local and regional failures as the first failure. The most common failure pattern was distant metastasis (40%). Among LRFs, the most common recurrence site was the cystectomy bed (15.6%). Patients with positive resection margins had a significantly higher recurrence rate compared to those without (28% vs. 10%, p=0.004). The pelvic nodal recurrence rate was < 5% in pN0 patients; the rate of recurrence in the external and common iliac nodes was 12.5% in pN+ patients. The rate of recurrence in the common iliac nodes was significantly higher in pN2-3 patients than in pN0-1 patients (15.2% vs. 4.4%, p=0.04). CONCLUSION Pelvic RT could be beneficial especially for those with positive resection margins or nodal involvement after radical cystectomy. Radiation fields should be optimized based on the patient-specific risk factors.
Collapse
Affiliation(s)
- Hyun Ju Kim
- Department of Radiation Oncology, Gachon University Gil Medical Center, Incheon, Korea
| | - Jaehee Chun
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Hyung Kim
- Department of Radiation Oncology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
| | - Gowoon Yang
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Joon Shin
- Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Sung Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jaemoon Yang
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Won Sik Ham
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea.
| | - Woong Sub Koom
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea.
| |
Collapse
|
11
|
Baumann BC, Zaghloul MS, Sargos P, Murthy V. Adjuvant and Neoadjuvant Radiation Therapy for Locally Advanced Bladder Cancer. Clin Oncol (R Coll Radiol) 2021; 33:391-399. [PMID: 33972025 DOI: 10.1016/j.clon.2021.03.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/09/2021] [Accepted: 03/26/2021] [Indexed: 01/06/2023]
Abstract
Local-regional failure for patients with ≥pT3 urothelial carcinoma after radical cystectomy is a significant clinical challenge. Prospective randomised trials have failed to show that chemotherapy reduces the risk of local-regional recurrences. Salvage treatment for local failures is difficult and often unsuccessful. There is promising evidence, particularly from a recent Egyptian National Cancer Institute trial, that radiation therapy plus chemotherapy can significantly reduce local recurrences compared with chemotherapy alone, and that this improvement in local-regional control may translate to meaningful improvements in disease-free and overall survival with acceptable toxicity. In light of the high rates of local failure following cystectomy for locally advanced disease and the progress that has been made in identifying patients at high risk of failure and the patterns of failure in the pelvis, the National Comprehensive Cancer Network guidelines were revised to include postoperative radiotherapy as an option to consider for patients with ≥pT3 disease. Here we review the problem of local-regional failure after cystectomy, identify patients who would probably benefit from adjuvant radiotherapy, review the patterns of pelvic failure after cystectomy, discuss technical details of radiation treatment and review the modern literature on this topic. Adjuvant radiotherapy should be considered as a treatment option for patients with locally advanced disease, especially those with positive margins or squamous cell carcinoma.
Collapse
Affiliation(s)
- B C Baumann
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO, USA; Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - M S Zaghloul
- National Cancer Institute, Cairo, Egypt; Children's Cancer Hospital, Cairo, Egypt
| | - P Sargos
- Department of Radiotherapy, Institut Bergonié, Bordeaux, France
| | - V Murthy
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India.
| |
Collapse
|
12
|
Murthy V, Bakshi G, Manjali JJ, Prakash G, Pal M, Joshi A, Dholakia K, Bhattacharjee A, Talole S, Puppalwar A, Srinivasan S, Panigrahi G, Salunkhe R, Menon S, Noronha V, Prabhash K, Krishnatry R. Locoregional recurrence after cystectomy in muscle invasive bladder cancer: Implications for adjuvant radiotherapy. Urol Oncol 2021; 39:496.e9-496.e15. [PMID: 33573998 DOI: 10.1016/j.urolonc.2021.01.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/23/2020] [Accepted: 01/11/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE We report the patterns of locoregional recurrence (LRR) in muscle invasive bladder cancer (MIBC), and propose a risk stratification to predict LRR for optimizing the indication for adjuvant radiotherapy. MATERIALS AND METHODS The study included patients of urothelial MIBC who underwent radical cystectomy with standard perioperative chemotherapy between 2013 and 2019. Recurrences were classified into local and/or cystectomy bed, regional, systemic, or mixed. For risk stratification modelling, T stage (T2, T3, T4), N stage (N0, N1/2, N3) and lymphovascular invasion (LVI positive or negative) were given differential weightage for each patient. The cohort was divided into low risk (LR), intermediate risk (IR) and high risk (HR) groups based on the cumulative score. RESULTS Of the 317 patients screened, 188 were eligible for the study. Seventy patients (37.2%) received neoadjuvant chemotherapy (NACT) while 128 patients (68.1%) had T3/4 disease and 66 patients (35.1%) had N+ disease. Of the 55 patients (29%) who had a recurrence, 31 (16%) patients had a component of LRR (4% cystectomy bed, 11.5% regional 0.5% locoregional). The median time to LRR was 8.2 (IQR 3.3-18.8) months. The LR, IR and HR groups for LRR based on T, N and LVI had a cumulative incidence of 7.1%, 21.6%, and 35% LRR, respectively. The HR group was defined as T3, N3, LVI positive; T4 N1/2, LVI positive; and T4, N3, any LVI. The odds ratio for LRR was 3.37 (95% CI 1.16-9.73, P = 0.02) and 5.27 (95% CI 1.87-14.84, P = 0.002) for IR and HR respectively, with LR as reference. CONCLUSION LRR is a significant problem post radical cystectomy with a cumulative incidence of 35% in the HR group. The proposed risk stratification model in our study can guide in tailoring adjuvant radiotherapy in MIBC.
Collapse
Affiliation(s)
- Vedang Murthy
- Department of Radiation Oncology, Tata Memorial Centre (TMH/ACTREC), Mumbai, India; Homi Bhabha National Institute (HBNI), Anushakti Nagar, Mumbai, India.
| | - Ganesh Bakshi
- Department of Surgery, Tata Memorial Centre (TMH/ACTREC), Mumbai, India; Homi Bhabha National Institute (HBNI), Anushakti Nagar, Mumbai, India
| | - Jifmi Jose Manjali
- Department of Radiation Oncology, Tata Memorial Centre (TMH/ACTREC), Mumbai, India; Homi Bhabha National Institute (HBNI), Anushakti Nagar, Mumbai, India
| | - Gagan Prakash
- Department of Surgery, Tata Memorial Centre (TMH/ACTREC), Mumbai, India; Homi Bhabha National Institute (HBNI), Anushakti Nagar, Mumbai, India
| | - Mahendra Pal
- Department of Surgery, Tata Memorial Centre (TMH/ACTREC), Mumbai, India; Homi Bhabha National Institute (HBNI), Anushakti Nagar, Mumbai, India
| | - Amit Joshi
- Department of Medical Oncology, Tata Memorial Centre (TMH/ACTREC), Mumbai, India; Homi Bhabha National Institute (HBNI), Anushakti Nagar, Mumbai, India
| | - Kunal Dholakia
- Department of Surgery, Tata Memorial Centre (TMH/ACTREC), Mumbai, India; Homi Bhabha National Institute (HBNI), Anushakti Nagar, Mumbai, India
| | - Atanu Bhattacharjee
- Department of Biostatistics, Centre for Cancer Epidemiology, Tata Memorial Centre (TMH/ACTREC), Mumbai, India; Homi Bhabha National Institute (HBNI), Anushakti Nagar, Mumbai, India
| | - Sanjay Talole
- Department of Biostatistics, Centre for Cancer Epidemiology, Tata Memorial Centre (TMH/ACTREC), Mumbai, India; Homi Bhabha National Institute (HBNI), Anushakti Nagar, Mumbai, India
| | - Abhinav Puppalwar
- Department of Radiation Oncology, Tata Memorial Centre (TMH/ACTREC), Mumbai, India; Homi Bhabha National Institute (HBNI), Anushakti Nagar, Mumbai, India
| | - Shashank Srinivasan
- Department of Radiation Oncology, Tata Memorial Centre (TMH/ACTREC), Mumbai, India; Homi Bhabha National Institute (HBNI), Anushakti Nagar, Mumbai, India
| | - Gitanjali Panigrahi
- Department of Radiation Oncology, Tata Memorial Centre (TMH/ACTREC), Mumbai, India
| | - Rohan Salunkhe
- Department of Radiation Oncology, Tata Memorial Centre (TMH/ACTREC), Mumbai, India; Homi Bhabha National Institute (HBNI), Anushakti Nagar, Mumbai, India
| | - Santosh Menon
- Department of Pathology, Tata Memorial Centre (TMH/ACTREC), Mumbai, India; Homi Bhabha National Institute (HBNI), Anushakti Nagar, Mumbai, India
| | - Vanita Noronha
- Department of Medical Oncology, Tata Memorial Centre (TMH/ACTREC), Mumbai, India; Homi Bhabha National Institute (HBNI), Anushakti Nagar, Mumbai, India
| | - Kumar Prabhash
- Department of Medical Oncology, Tata Memorial Centre (TMH/ACTREC), Mumbai, India; Homi Bhabha National Institute (HBNI), Anushakti Nagar, Mumbai, India
| | - Rahul Krishnatry
- Department of Radiation Oncology, Tata Memorial Centre (TMH/ACTREC), Mumbai, India; Homi Bhabha National Institute (HBNI), Anushakti Nagar, Mumbai, India
| |
Collapse
|
13
|
Regmi SK, Konety BR. Variant Histology: Management Pearls. Bladder Cancer 2021. [DOI: 10.1007/978-3-030-70646-3_27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
14
|
Pignot G, Sargos P. [Adjuvant radiotherapy after radical cystectomy for muscle-invasive bladder cancer]. Prog Urol 2020; 31:158-168. [PMID: 33358467 DOI: 10.1016/j.purol.2020.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/02/2020] [Accepted: 12/04/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Locoregional relapse (LRR) after cystectomy is a common early event associated with poor prognosis. The role of radiotherapy as an adjunct to radical cystectomy is not well-defined. The aim of this critical literature review is to provide an overview of the elements in favor of adjuvant radiation for patients treated for muscle-invasive bladder cancer. MATERIAL AND METHODS An exhaustive review of the literature was carried out using the Pubmed search tool with the following keywords: "radiotherapy" [Mesh], "adjuvant" [Mesh], "local recurrence" [Mesh], "Bladder cancer" [Mesh]. RESULTS Several recent publications have led to the development of a nomogram that predicts the risk of LRR, in order to identify patients for which adjuvant radiotherapy could be beneficial. Several randomized trials seem to suggest a benefit of radiotherapy, in particular when combined with chemotherapy, in terms of reducing LRR, and may even improve overall survival, with good safety profile. However, there are many biases and the interest of adjuvant radiotherapy in urothelial carcinomas remains debated. CONCLUSION Prospective trials evaluating adjuvant radiotherapy with current techniques should be undertaken.
Collapse
Affiliation(s)
- G Pignot
- Service de chirurgie oncologique 2, institut Paoli-Calmettes, Marseille, France.
| | - P Sargos
- Département de radiothérapie, institut Bergonié, Bordeaux, France
| |
Collapse
|
15
|
Iwata T, Kimura S, Abufaraj M, Janisch F, Karakiewicz PI, Seebacher V, Rouprêt M, Nasu Y, Shariat SF. The role of adjuvant radiotherapy after surgery for upper and lower urinary tract urothelial carcinoma: A systematic review. Urol Oncol 2019; 37:659-671. [DOI: 10.1016/j.urolonc.2019.05.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/23/2019] [Accepted: 05/29/2019] [Indexed: 01/20/2023]
|
16
|
Sargos P, Baumann BC, Eapen L, Christodouleas J, Bahl A, Murthy V, Efstathiou J, Fonteyne V, Ballas L, Zaghloul M, Roubaud G, Orré M, Larré S. Risk factors for loco-regional recurrence after radical cystectomy of muscle-invasive bladder cancer: A systematic-review and framework for adjuvant radiotherapy. Cancer Treat Rev 2018; 70:88-97. [PMID: 30125800 DOI: 10.1016/j.ctrv.2018.07.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 07/18/2018] [Accepted: 07/19/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Radical cystectomy (RC) associated with pelvic lymph node dissection (PLND) is the most common local therapy in the management of non-metastatic muscle invasive bladder cancer (MIBC). Loco-regional recurrence (LRR), however, remains a common and important therapeutic challenge associated with poor oncologic outcomes. We aimed to systematically review evidence regarding factors associated with LRR and to propose a framework for adjuvant radiotherapy (RT) in patients with MIBC. METHODS We performed this systematic review in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. We searched the PubMed database for articles related to MIBC and associated treatments, published between January 1980 and June 2015. Articles identified by searching references from candidate articles were also included. We retrieved 1383 publications from PubMed and 34 from other sources. After an initial screening, a review of titles and abstracts, and a final comprehensive full text analysis of papers assessed for eligibility, a final consensus on 32 studies was obtained. RESULTS LRR is associated with specific patient-, tumor-, center- or treatment-related variables. LRR varies widely, occurring in as many as 43% of the cases and is strongly related to survival outcomes. While perioperative treatment does not impact on LRR, pathological factors such as pT, pN, positive margins status, extent of PLND, number of lymph nodes removed and/or invaded are correlated with LRR. Patients with pT3-T4a and/or positive lymph-nodes and/or limited pelvic lymph-node dissection and/or positive surgical margins have been distributed in LRR risk groups with accuracy. CONCLUSIONS LRR patterns are well-known and for selected patients, adjuvant treatments could target this event. Intrinsic tumor subtype may guide future criteria to define a personalized treatment strategy. Prospective trials evaluating safety and efficacy of adjuvant RT are ongoing in several countries.
Collapse
Affiliation(s)
- Paul Sargos
- Department of Radiation Oncology, Institut Bergonié, F-33076 Bordeaux Cedex, France.
| | - Brian C Baumann
- Department of Radiation Oncology, Washington University, St. Louis, Washington, MO 63110, United States
| | - Libni Eapen
- Department of Radiation Oncology, Ottawa Hospital, K1H 8L6 Ottawa, ON, Canada
| | - John Christodouleas
- Department of Radiation Oncology, Perelman Center for Advanced Medicine, 19104-6021 Philadelphia, PA, United States
| | - Amhit Bahl
- Department of Radiation Oncology, University Hospitals Bristol, Bristol BS2 8HW, United Kingdom
| | - Vedang Murthy
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra 400012, India
| | - Jason Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Valérie Fonteyne
- Department of Radiotherapy, Ghent University Hospital, 9000 Ghent, Belgium
| | - Leslie Ballas
- Department of Radiation Oncology, USC Norris Comprehensive Cancer Center, Keck School of Medicine, Los Angeles, CA 90033, United States
| | - Mohamed Zaghloul
- Children's Cancer Hospital Egypt, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Guilhem Roubaud
- Department of Medical Oncology, Institut Bergonié, F-33076 Bordeaux Cedex, France
| | - Mathieu Orré
- Department of Radiation Oncology, Institut Bergonié, F-33076 Bordeaux Cedex, France
| | - Stéphane Larré
- Department of Urology, Centre Hospitalier Universitaire de Reims, F-51092 Reims, France
| |
Collapse
|
17
|
Nadal R, Apolo AB. Overview of Current and Future Adjuvant Therapy for Muscle-Invasive Urothelial Carcinoma. Curr Treat Options Oncol 2018; 19:36. [DOI: 10.1007/s11864-018-0551-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
|
18
|
Zaghloul MS, Christodouleas JP, Smith A, Abdallah A, William H, Khaled HM, Hwang WT, Baumann BC. Adjuvant Sandwich Chemotherapy Plus Radiotherapy vs Adjuvant Chemotherapy Alone for Locally Advanced Bladder Cancer After Radical Cystectomy: A Randomized Phase 2 Trial. JAMA Surg 2018; 153:e174591. [PMID: 29188298 DOI: 10.1001/jamasurg.2017.4591] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Importance Locoregional failure for patients with locally advanced bladder cancer (LABC) after radical cystectomy (RC) is common even with chemotherapy and is associated with high morbidity and mortality. Adjuvant radiotherapy (RT) can decrease locoregional failure but has not been studied in the chemotherapy era. Objective To investigate if adjuvant sequential RT plus chemotherapy can improve locoregional recurrence-free survival (LRFS) compared with adjuvant chemotherapy alone. Design, Setting, and Participants A randomized phase 3 trial was opened to compare adjuvant RT vs sequential chemotherapy plus RT after RC for LABC, but a third arm was added later as a randomized phase 2 trial to compare chemotherapy plus RT vs adjuvant chemotherapy alone, an emerging standard. The intent-to-treat phase 2 trial reported herein enrolled patients from December 2002 to July 2008. Data were analyzed from August 3, 2015, to January 6, 2016. Routine follow-up and surveillance pelvic computed tomographic (CT) scans every 6 months during the first 2 years were performed. The setting was an academic center. Patients with bladder cancer 70 years or younger having 1 or more risk factors (≥pT3b, grade 3, or positive nodes) with negative margins after radical cystectomy plus pelvic lymph node dissection were eligible. Patients had Eastern Cooperative Oncology Group performance status of 0 to 2, no evidence of distant metastases on CT scan of the abdomen and pelvis or on chest imaging, and adequate renal, hepatic, and hematologic function. Ninety-one percent (109 of 120) had ≥ pT3 disease. Interventions Chemotherapy plus RT included 2 cycles of gemcitabine (1000 mg/m2 intravenously on days 1, 8, and 15) and cisplatin (70 mg/m2 intravenously on day 2) before and after RT to 4500 cGy in 150 cGy twice-daily fractions over 3 weeks using 3-dimensional conformal techniques. Chemotherapy alone included 4 cycles of gemcitabine and cisplatin. Main Outcome and Measure Locoregional recurrence-free survival. Results The chemotherapy plus RT arm accrued 75 patients, and the chemotherapy-alone arm accrued 45 patients, with a weighted randomization to speed accrual. Fifty-three percent (64 of 120) had urothelial carcinoma, and 46.7% (56 of 120) had squamous cell carcinoma or other. The arms were balanced except for age (median, 52 vs 55 years; P = .04) and tumor size (mean, 4.9 vs 5.8 cm; P < .01), both favoring chemotherapy plus RT. Two-year outcomes and overall adjusted hazard ratios (HRs) for chemotherapy plus RT vs chemotherapy alone were 96% vs 69% (HR, 0.08; 95% CI, 0.02-0.39; P < .01) for LRFS, 68% vs 56% (HR, 0.53; 95% CI, 0.27-1.06; P = .07) for disease-free survival, and 71% vs 60% (HR, 0.61; 95% CI, 0.33-1.11; P = .11) for overall survival (OS). Five patients (7%) had RT-associated late grade 3 gastrointestinal tract adverse effects in the chemotherapy plus RT arm. Conclusions and Relevance Adjuvant chemotherapy plus RT was reasonably well tolerated and was associated with significant improvements in LRFS and marginal improvements in disease-free survival vs chemotherapy alone in LABC. The addition of adjuvant RT should be considered for LABC. This regimen warrants further study in phase 3 trials. Trial Registration clinicaltrials.gov Identifier: NCT01734798.
Collapse
Affiliation(s)
- Mohamed S Zaghloul
- National Cancer Institute, Cairo University, Cairo, Egypt.,Children's Cancer Hospital, Cairo, Egypt
| | - John P Christodouleas
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia
| | - Andrew Smith
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia
| | - Ahmed Abdallah
- National Cancer Institute, Cairo University, Cairo, Egypt
| | - Hany William
- Department of Oncology, Ahmed Maher Teaching Hospital, Cairo, Egypt
| | | | - Wei-Ting Hwang
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia
| | - Brian C Baumann
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia.,Department of Radiation Oncology, Washington University in St Louis, St Louis, Missouri
| |
Collapse
|
19
|
Moschini M, Shariat SF, Abufaraj M, Foerster B, D′Andrea D, Soria F, Dell′Oglio P, Mattei A, Montorsi F, Colombo R, Briganti A, Gallina A. Predicting local failure after radical cystectomy in patients with bladder cancer: Implications for the selection of candidates at adjuvant radiation therapy. Urol Oncol 2017; 35:672.e1-672.e6. [DOI: 10.1016/j.urolonc.2017.08.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 06/26/2017] [Accepted: 08/14/2017] [Indexed: 10/18/2022]
|
20
|
Tolerance of Orthotopic Ileal Neobladders to Radiotherapy: A Multi-institutional Retrospective Study. Clin Genitourin Cancer 2017; 15:711-716. [DOI: 10.1016/j.clgc.2017.05.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 04/21/2017] [Accepted: 05/01/2017] [Indexed: 11/22/2022]
|
21
|
Chua KLM, Kusumawidjaja G, Murgic J, Chua MLK. Adjuvant treatment following radical cystectomy for muscle-invasive urothelial carcinoma and variant histologies: Is there a role for radiotherapy? ESMO Open 2017; 1:e000123. [PMID: 28848661 PMCID: PMC5569989 DOI: 10.1136/esmoopen-2016-000123] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 11/24/2016] [Accepted: 12/01/2016] [Indexed: 12/22/2022] Open
Abstract
Comprehensive molecular characterisation of muscle-invasive urothelial carcinoma and variant histological subtypes has led to the identification of recurrent driver mutations that are distinct in these aggressive subgroups of bladder cancer. While distant metastasis dominates as a pattern of relapse following radical cystectomy or chemoradiotherapy, loco-regional control rates are also suboptimal with single modality local treatment, and likewise, harbour equivocal implications on the long-term prognosis of patients. The role of adjuvant radiotherapy for optimising disease control within the pelvis is controversial, with limited evidence to support its efficacy. Herein, we present a stepwise review on adjuvant radiotherapy post-cystectomy; first, discussing the evidence to date supporting the concept that adjuvant radiotherapy is effective in targeting occult metastases within the pelvis, and adds to the benefits of adjuvant chemotherapy. Next, we outlined the principles underlying the definition of radiotherapy target volumes. To conclude, we addressed the need for appropriate patient stratification for treatment intensification, based on existing clinical models and novel molecular indices of aggression in muscle-invasive urothelial cancers and variant histological subtypes.
Collapse
Affiliation(s)
- Kevin L M Chua
- Division of Radiation Oncology,National Cancer Centre Singapore,Singapore
| | | | - Jure Murgic
- Department of Oncology and Nuclear Medicine,University Hospital Center Sisters of Charity Zagreb School of Medicine,Zagreb,Croatia
| | - Melvin L K Chua
- Division of Radiation Oncology,National Cancer Centre Singapore,Singapore; Duke-NUS Graduate Medical School,National University of Singapore,Singapore.
| |
Collapse
|
22
|
Fonteyne V, Dirix P, Junius S, Rammant E, Ost P, De Meerleer G, Swimberghe M, Decaestecker K. Adjuvant radiotherapy after radical cystectomy for patients with muscle invasive bladder cancer: a phase II trial. BMC Cancer 2017; 17:308. [PMID: 28464906 PMCID: PMC5414216 DOI: 10.1186/s12885-017-3302-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 04/25/2017] [Indexed: 11/10/2022] Open
Abstract
Background Neo-adjuvant chemotherapy followed by radical cystectomy with extended pelvic lymph node dissection is considered to be the treatment of choice for patients with muscle invasive bladder cancer (MIBC). Despite this aggressive treatment the outcome is poor and ultimately, 30% of the patients with ≥pT3 tumors develop a pelvic recurrence. We hypothesize that postoperative adjuvant external beam radiotherapy (EBRT) might prevent local and lymph node recurrence and improve disease free- and overall survival as loco-regional recurrence is linked to the development of distant metastasis. Methods We plan to perform a multicentric prospective phase two study including 76 patients. Eligible patients are patients with MIBC, treated with radical cystectomy and presenting with ≥1 of the following characteristics:Pathological (p)T3 stage + presence of lymphovascular invasion on pathological examination pT4 stage <10 lymph nodes removed positive lymph nodes positive surgical margins
Patients will have a 18F–FDG PET-CT to rule out the presence of distant metastasis prior to EBRT. A median dose of 50 Gy in 25 fractions is prescribed to the pelvic lymph node regions with inclusion of the operative bladder bed in case of a positive surgical margin. Patients with suspected lymph nodes on PET- CT can still be included in the trial, but a simultaneous integrated boost to 74Gy to the positive lymph nodes will be delivered. Blood and urine samples will be collected on day-1 and last day of EBRT for evaluation of biomarkers. The primary endpoint is evaluation of acute ≥Grade 3 intestinal or grade 4 urinary toxicity, in case of a neo-bladder reconstruction, within 12 weeks after EBRT. Secondary endpoints are: assessment of QOL, late RTOG toxicity, local control, disease free survival and overall survival. Biomarkers in urine and blood will be correlated with secondary survival endpoints. Discussion This is a prospective phase 2 trial re-assessing the feasibility of adjuvant radiotherapy in high-risk MIBC. Trial registration The Ethics committee of the Ghent University Hospital (EC2014/0630) approved this study on 31/07/2014. Trial registration on Clinicaltrials.gov (NCT02397434) on November 19, 2014.
Collapse
Affiliation(s)
- Valérie Fonteyne
- Department of Radiation-Oncology, Ghent University Hospital, De Pintelaan 185, Ghent, Belgium.
| | - Piet Dirix
- Department of Radiation-Oncology, Iridium Cancer Network, Ghent, Belgium
| | - Sara Junius
- Department of Radiation-Oncology CH-M/AMPR, Mouscron, Belgium
| | - Elke Rammant
- Department of Radiation-Oncology, Ghent University Hospital, De Pintelaan 185, Ghent, Belgium
| | - Piet Ost
- Department of Radiation-Oncology, Ghent University Hospital, De Pintelaan 185, Ghent, Belgium
| | - Gert De Meerleer
- Department of Radiotherapy and Experimental Cancer Research, Ghent University, Ghent, Belgium
| | - Martijn Swimberghe
- Department of Radiation-Oncology, Ghent University Hospital, De Pintelaan 185, Ghent, Belgium
| | | |
Collapse
|
23
|
Orré M, Latorzeff I, Fléchon A, Roubaud G, Brouste V, Gaston R, Piéchaud T, Richaud P, Chapet O, Sargos P. Adjuvant radiotherapy after radical cystectomy for muscle-invasive bladder cancer: A retrospective multicenter study. PLoS One 2017; 12:e0174978. [PMID: 28384195 PMCID: PMC5383060 DOI: 10.1371/journal.pone.0174978] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 03/19/2017] [Indexed: 12/03/2022] Open
Abstract
Objectives Radical cystectomy (RC) and pelvic lymph-node dissection (LND) is standard treatment for non-metastatic muscle-invasive urothelial bladder cancer (MIBC). However, loco-regional recurrence (LRR) is a common early event associated with poor prognosis. We evaluate 3-year LRR-free (LRRFS), metastasis-free (MFS) and overall survivals (OS) after adjuvant radiotherapy (RT) for pathological high-risk MIBC. Material and methods We retrospectively reviewed data from patients in 3 institutions. Inclusion criteria were MIBC, histologically-proven urothelial carcinoma treated by RC and adjuvant RT. Patients with conservative surgery were excluded. Outcomes were evaluated by Kaplan-Meier method. Acute toxicities were recorded according to CTCAE V4.0 scale. Results Between 2000 and 2013, 57 patients [median age 66.3 years (45–84)] were included. Post-operative pathological staging was ≤pT2, pT3 and pT4 in 16%, 44%, and 39%, respectively. PLND revealed 28% pN0, 26% pN1 and 42% pN2. Median number of lymph-nodes retrieved was 10 (2–33). Forty-eight patients (84%) received platin-based chemotherapy. For RT, clinical target volume 1 (CTV 1) encompassed pelvic lymph nodes for all patients. CTV 1 also included cystectomy bed for 37 patients (65%). CTV 1 median dose was 45 Gy (4–50). A boost of 16 Gy (5–22), corresponding to CTV 2, was administered for 30 patients, depending on pathological features. One third of patients received intensity-modulated RT. With median follow-up of 40.4 months, 8 patients (14%) had LRR. Three-year LRRFS, MFS and OS were 45% (95%CI 30–60), 37% (95%CI 24–51) and 49% (95%CI 33–63), respectively. Five (9%) patients had acute grade ≥3 toxicities (gastro-intestinal, genito-urinary and biological parameters). One patient died with intestinal fistula in a septic context. Conclusions Because of poor prognosis, an effective post-operative standard of care is needed for pathological high-risk MIBC. Adjuvant RT is feasible and may have oncological benefits. Prospective trials evaluating this approach with current RT techniques should be undertaken.
Collapse
Affiliation(s)
- Mathieu Orré
- Department of Radiotherapy, Institut Bergonié, Bordeaux,France
| | - Igor Latorzeff
- Department of Radiotherapy, Groupe Oncorad Garonne, Clinique Pasteur, Toulouse, France
| | - Aude Fléchon
- Department of Medical Oncology, Centre Léon-Bérard, Lyon, France
| | - Guilhem Roubaud
- Department of Medical Oncology, Institut Bergonié, Bordeaux, France
| | - Véronique Brouste
- Clinical and Epidemiological Research Unit, Institut Bergonié, Bordeaux, France
| | - Richard Gaston
- Department of Urology, Clinique Saint-Augustin, Bordeaux, France
| | - Thierry Piéchaud
- Department of Urology, Clinique Saint-Augustin, Bordeaux, France
| | - Pierre Richaud
- Department of Radiotherapy, Institut Bergonié, Bordeaux,France
| | - Olivier Chapet
- Department of Radiotherapy, CHU de Lyon-Sud, Lyon, France
| | - Paul Sargos
- Department of Radiotherapy, Institut Bergonié, Bordeaux,France
- * E-mail:
| |
Collapse
|
24
|
Solanki AA, Martin B, Korpics M, Small C, Harkenrider MM, Mitin T. Adjuvant Radiotherapy Use by US Radiation Oncologists After Radical Cystectomy for Muscle-invasive Bladder Cancer. Clin Oncol (R Coll Radiol) 2017; 29:429-435. [PMID: 28242163 DOI: 10.1016/j.clon.2017.02.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 01/30/2017] [Accepted: 01/31/2017] [Indexed: 10/20/2022]
Abstract
AIMS Historic trials suggested significant toxicity with adjuvant radiotherapy (ART) after radical cystectomy for muscle-invasive bladder cancer (MIBC). However, recent trials have found improved locoregional control and the 2016 National Comprehensive Cancer Network (NCCN) guidelines recommend ART consideration for select patients at high risk of local recurrence. ART practice patterns among US radiation oncologists are unknown and we carried out a survey to explore current trends. MATERIALS AND METHODS We conducted a survey of US radiation oncologists regarding the management of patients with cT2-3N0M0 transitional cell MIBC. Responses were reported using descriptive statistics. Chi-square and univariate logistic regression of clinical and demographic covariates were conducted, followed by multivariable logistic regression analysis to identify factors predicting for ART use. RESULTS In total, 277 radiation oncologists completed our survey. Nearly half (46%) have used ART for MIBC at least once in the past. In ART users, indications for ART include gross residual disease (93%), positive margins (92%), pathological nodal involvement (64%), pT3 or T4 disease (46%), lymphovascular invasion (16%) and high-grade disease (13%). On univariate logistic regression, ART use was associated with the number of years in practice (P=0.04), pre-cystectomy radiation oncology consultation (P=0.004), primarily treating MIBC patients fit for cystectomy (P=0.01) and intensity-modulated radiotherapy use (P=0.01). On multivariable logistic regression analysis, routine pre-cystectomy radiation oncology consultation (odds ratio 1.91, 95% confidence interval 1.04-3.51; P=0.04) and intensity-modulated radiotherapy use (odds ratio 2.77, 95% confidence interval 1.48-5.22; P=0.002) remained associated with ART use. CONCLUSIONS ART use is controversial in bladder cancer, yet unexpectedly has commonly been used among US radiation oncologists treating patients with MIBC after radical cystectomy. NRG-GU001 was a randomised trial in the US randomizing patients with high-risk pathological findings for observation or ART after cystectomy. However, due to poor accrual it recently closed and thus it will be up to other international trials to clarify the role of ART and identify patients benefiting form this adjuvant therapy.
Collapse
Affiliation(s)
- A A Solanki
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA.
| | - B Martin
- Clinical Research Office, Health Sciences Division, Loyola University Chicago, Maywood, IL, USA
| | - M Korpics
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - C Small
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - M M Harkenrider
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - T Mitin
- Department of Radiation Medicine, Oregon Health and Science University, Portland, OR, USA
| |
Collapse
|
25
|
Sargos P, Larré S, Chapet O, Latorzeff I, Fléchon A, Roubaud G, Orré M, Belhomme S, Richaud P. [Adjuvant radiotherapy for bladder cancer in patients with risk of locoregional recurrence: Who, what and how?]. Cancer Radiother 2017; 21:67-72. [PMID: 28187997 DOI: 10.1016/j.canrad.2016.08.131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 07/26/2016] [Accepted: 08/03/2016] [Indexed: 01/22/2023]
Abstract
Radical cystectomy with extended pelvic lymph node dissection remains the standard of care for non-metastatic muscle-invasive bladder cancer. Locoregional control is a key factor in the outcome of patients since it is related to overall survival, metastasis-free survival and specific survival. Locoregional recurrence rate is directly correlated to pathological results and the quality of lymphadenectomy. In addition, while pre- or postoperative chemotherapy improved overall survival, it showed no impact on locoregional recurrence-free survival. Several recent publications have led to the development of a nomogram that predicts the risk of locoregional recurrence, in order to identify patients for which adjuvant radiotherapy could be beneficial. International cooperative groups have then come together to provide the rational for adjuvant radiotherapy, reinforced by recent technical developments limiting toxicity, and to develop prospective studies to reduce the risk of relapse. The aim of this critical literature review is to provide an overview of the elements in favor of adjuvant radiation for patients treated for muscle-invasive bladder cancer.
Collapse
Affiliation(s)
- P Sargos
- Département de radiothérapie, institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France.
| | - S Larré
- Service d'urologie, CHU de Reims, 45, rue Cognacq-Jay, 51100 Reims, France
| | - O Chapet
- Département de radiothérapie, CHU Lyon Sud, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France
| | - I Latorzeff
- Département de radiothérapie, groupe Oncorad Garonne, clinique Pasteur, bâtiment Atrium, 1, rue de la Petite-Vitesse, 31300 Toulouse, France
| | - A Fléchon
- Département d'oncologie médicale, centre Léon-Bérard, 28, promenade Léa-et-Napoléon-Bullukian, 69008 Lyon, France
| | - G Roubaud
- Département d'oncologie médicale, institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France
| | - M Orré
- Département de radiothérapie, institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France
| | - S Belhomme
- Département de physique médicale, institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France
| | - P Richaud
- Département de radiothérapie, institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France
| |
Collapse
|
26
|
Baumann BC, Sargos P, Eapen LJ, Efstathiou JA, Choudhury A, Bahl A, Murthy V, Ballas LK, Fonteyne V, Richaud PM, Zaghloul MS, Christodouleas JP. The Rationale for Post-Operative Radiation in Localized Bladder Cancer. Bladder Cancer 2017; 3:19-30. [PMID: 28149931 PMCID: PMC5271478 DOI: 10.3233/blc-160081] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Local-regional recurrence for patients with ≥pT3 disease after radical cystectomy is a significant problem. Chemotherapy has not been shown to reduce the risk of local-regional recurrences in randomized prospective trials, and salvage therapies for local-regional failure are rarely successful. There is promising evidence, particularly from a recent Egyptian NCI trial, that radiation therapy plus chemotherapy can significantly reduce local recurrences compared to chemotherapy alone, and that this improvement in local-regional control may translate to meaningful improvements in disease-free and overall survival with acceptable toxicity. In light of the high rates of local failure following cystectomy for locally advanced disease and the progress that has been made in identifying patients at high risk of failure and the patterns of failure in the pelvis, the NCCN guidelines were revised in 2016 to include post-operative radiotherapy as an option to consider for patients with ≥pT3 disease. Despite advances in our understanding of the problem of local-regional failure after cystectomy and the potential role of adjuvant radiotherapy, the question of whether adjuvant radiotherapy should have a defined role for patients with locally advanced urothelial carcinoma has not yet been determined. The results of the NRG, European, Indian, and Egyptian trials on adjuvant radiotherapy are eagerly awaited. While none of these trials on their own may provide definitive conclusions, their aggregate outcomes will help clarify whether this treatment should have a role in the management of patients with locally advanced bladder cancer.
Collapse
Affiliation(s)
- Brian C Baumann
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA; Washington University in Saint Louis, Saint Louis, MO, USA
| | | | | | | | - Ananya Choudhury
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK; The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Amit Bahl
- University Hospitals Bristol NHS Foundation Trust , Bristol, UK
| | | | | | | | | | - Mohamed S Zaghloul
- National Cancer Institute, Cairo University, Cairo, Egypt; Children's Cancer Hospital, Cairo, Egypt
| | | |
Collapse
|
27
|
Sargos P, Baumann BC, Eapen LJ, Bahl A, Murthy V, Roubaud G, Orré M, Efstathiou JA, Shariat S, Larré S, Richaud P, Christodouleas JP. Adjuvant radiotherapy for pathological high-risk muscle invasive bladder cancer: time to reconsider? Transl Androl Urol 2016; 5:702-710. [PMID: 27785427 PMCID: PMC5071208 DOI: 10.21037/tau.2016.08.18] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Radical cystectomy with extended pelvic lymph-node dissection, associated with neo-adjuvant chemotherapy, remains the standard of care for advanced, non-metastatic muscle-invasive bladder cancer (MIBC). Loco-regional control is a key factor in the outcome of patients since it is related to overall survival (OS), disease-free survival (DFS) and cause-specific survival. The risk of loco-regional recurrence (LRR) is correlated to pathological factors as well as the extent of the lymphadenectomy. In addition, neither pre- nor post-operative chemotherapy have shown a clear impact on LRR-free survival. Several recent publications have led to the development of a nomogram predicting the risk of LRR, in order to identify patients most likely to benefit from adjuvant radiotherapy. Given the high risk of LRR for selected patients and improvements in radiation techniques that can reduce toxicity, there is a growing interest in adjuvant radiotherapy; international cooperative groups have come together to provide the rationale in favor of adjuvant radiotherapy. Clinical trials in order to reduce the risk of pelvic relapse are opened based on this optimizing patient selection. The aim of this critical literature review is to provide an overview of the rationale supporting the studies of adjuvant radiation for patients with pathologic high-risk MIBC.
Collapse
Affiliation(s)
- Paul Sargos
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
| | - Brian C Baumann
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Libni J Eapen
- Department of Radiation Oncology, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Amit Bahl
- Department of Radiation Oncology, University Hospitals Bristol, Bristol, UK
| | - Vedang Murthy
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | - Guilhem Roubaud
- Department of Medical Oncology, Institut Bergonié, Bordeaux, France
| | - Mathieu Orré
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Shahrokh Shariat
- Department of Urology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Stephane Larré
- Department of Urology, Reims University Hospital, Reims, France
| | - Pierre Richaud
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
| | - John P Christodouleas
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| |
Collapse
|
28
|
Pouessel D, Bastuji-Garin S, Houédé N, Vordos D, Loriot Y, Chevreau C, Sevin E, Beuzeboc P, Taille ADL, Le Thuaut A, Allory Y, Culine S. Adjuvant Chemotherapy After Radical Cystectomy for Urothelial Bladder Cancer: Outcome and Prognostic Factors for Survival in a French Multicenter, Contemporary Cohort. Clin Genitourin Cancer 2016; 15:e45-e52. [PMID: 27554584 DOI: 10.1016/j.clgc.2016.07.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 07/01/2016] [Accepted: 07/13/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND In the past decade, adjuvant chemotherapy (AC) after radical cystectomy (RC) was preferred worldwide for patients with muscle-invasive urothelial bladder cancer. In this study we aimed to determine the outcome of patients who received AC and evaluated prognostic factors associated with survival. PATIENTS AND METHODS We retrospectively analyzed 226 consecutive patients treated in 6 academic hospitals between 2000 and 2009. Multivariate Cox proportional hazards regression adjusted for center to estimate adjusted hazard ratios (HRs) with 95% confidence intervals were used. RESULTS The median age was 62.4 (range, 35-82) years. Patients had pT3/pT4 and/or pN+ in 180 (79.6%) and 168 patients (74.3%), respectively. Median lymph node (LN) density was 25% (range, 3.1-100). Median time between RC and AC was 61.5 (range, 18-162) days. Gemcitabine with cisplatin, gemcitabine with carboplatin, and MVAC (methotrexate, vinblastine, doxorubicin, and cisplatin) regimens were delivered in 161 (71.2%), 49 (21.7%), and 12 patients (5.3%) of patients, respectively. The median number of cycles was 4 (range, 1-6). Thirteen patients (5.7%) with LN metastases also received adjuvant pelvic radiotherapy (ART). After a median follow-up of 4.2 years, 5-year overall survival (OS) was 40.7%. In multivariate analysis, pT ≥3 stage (HR, 1.73; P = .05), LN density >50% (HR, 1.94; P = .03), and number of AC cycles <4 (HR, 4.26; P = .001) were adverse prognostic factors for OS. ART (HR, 0.30; P = .05) tended to provide survival benefit. CONCLUSION Classical prognostic features associated with survival are not modified by the use of AC. Patients who derived benefit from AC had a low LN density and received at least 4 cycles of treatment.
Collapse
Affiliation(s)
- Damien Pouessel
- Inserm U955 Hôpital Henri Mondor, Team 7 Translational Research of Genito-Urinary Oncogenesis, Créteil, France; Department of Medical Oncology, Hôpital Saint-Louis, AP-HP, Paris, France.
| | - Sylvie Bastuji-Garin
- CEpiA (Clinical Epidemiology and Ageing), Unit EA 4393, Paris Est University, Créteil, France; Public Health Department, Hôpital Henri-Mondor, AP-HP, Créteil, France
| | - Nadine Houédé
- Department of Medical Oncology, Institut Bergonié, Bordeaux, France
| | - Dimitri Vordos
- Department of Urology, Hôpital Henri Mondor, AP-HP, Créteil, France
| | - Yohann Loriot
- Department of Cancer Medicine and INSERM U981, Gustave Roussy, Cancer Campus, Grand Paris, Villejuif, France
| | - Christine Chevreau
- Département d'Oncologie Médicale, Institut Claudius Regaud, IUCT-O, Toulouse, France
| | - Emmanuel Sevin
- Department of Medical Oncology, Centre François Baclesse, Caen, France
| | | | - Alexandre de la Taille
- Inserm U955 Hôpital Henri Mondor, Team 7 Translational Research of Genito-Urinary Oncogenesis, Créteil, France; Department of Urology, Hôpital Henri Mondor, AP-HP, Créteil, France; Paris Est University, Créteil, France
| | - Aurélie Le Thuaut
- CEpiA (Clinical Epidemiology and Ageing), Unit EA 4393, Paris Est University, Créteil, France; Public Health Department, Hôpital Henri-Mondor, AP-HP, Créteil, France
| | - Yves Allory
- Inserm U955 Hôpital Henri Mondor, Team 7 Translational Research of Genito-Urinary Oncogenesis, Créteil, France; Paris Est University, Créteil, France; Department of Pathology and Tissue Biobank Unit, Hôpital Henri Mondor, AP-HP, Créteil, France
| | - Stéphane Culine
- Department of Medical Oncology, Hôpital Saint-Louis, AP-HP, Paris, France; Paris Diderot University, Paris, France
| |
Collapse
|
29
|
Leow JJ, Fay AP, Mullane SA, Bellmunt J. Perioperative therapy for muscle invasive bladder cancer. Hematol Oncol Clin North Am 2015; 29:301-18, ix. [PMID: 25836936 DOI: 10.1016/j.hoc.2014.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Muscle invasive bladder cancer (MIBC) is an aggressive disease associated with poor survival rates. High rates of relapse, despite radical cystectomy, suggest that administration of systemic therapy in the perioperative period may improve clinical outcomes. Neoadjuvant treatment with cisplatin-based combination regimens is an established standard of care and has improved long-term survival in MIBC. As the use of neoadjuvant chemotherapy steadily increases, clinicians still need to decide about administering adjuvant chemotherapy to patients with high-risk disease. This review examines in detail the latest evidence available for both neoadjuvant and adjuvant chemotherapy, and highlights pertinent studies.
Collapse
Affiliation(s)
- Jeffrey J Leow
- Bladder Cancer Center, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02215, USA; Department of Urology, Tan Tock Seng Hospital, Singapore.
| | - André P Fay
- Bladder Cancer Center, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02215, USA
| | - Stephanie A Mullane
- Bladder Cancer Center, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02215, USA
| | - Joaquim Bellmunt
- Bladder Cancer Center, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02215, USA; University Hospital del Mar-IMIM, Barcelona, Spain
| |
Collapse
|
30
|
|
31
|
Orré M, Latorzeff I, Fléchon A, Xylinas E, Roubaud G, Chapet O, Richaud P, Sargos P. Radiothérapie périopératoire dans la prise en charge des tumeurs urothéliales infiltrantes de la vessie (TVIM) : une indication à reconsidérer ? ONCOLOGIE 2015. [DOI: 10.1007/s10269-015-2504-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
32
|
Bayoumi Y, Heikal T, Darweish H. Survival benefit of adjuvant radiotherapy in stage III and IV bladder cancer: results of 170 patients. Cancer Manag Res 2014; 6:459-65. [PMID: 25506244 PMCID: PMC4259260 DOI: 10.2147/cmar.s69055] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: Radical cystectomy (RC) with or without neoadjuvant chemotherapy is the standard treatment for muscle-invasive bladder cancers. However, the locoregional recurrence rate is still significantly higher for locally advanced cases post-RC. The underuse of postoperative radiotherapy (PORT) in such cases after RC is related mainly to a lack of proven survival benefit. Here we are reporting our long-term Egyptian experience with bladder cancer patients treated with up-front RC with or without conformal PORT. Patients and methods: This retrospective study included 170 locally advanced bladder cancer (T3–T4, N0/N1, M0) patients who had RC performed with or without PORT at Damietta Cancer Institute during the period of 1998–2006. The treatment outcomes and toxicity profile of PORT were evaluated and compared with those of a non-PORT group of patients. Results: Ninety-two patients received PORT; 78 did not. At median follow-up of 47 months (range, 17–77 months), 33% locoregional recurrences were seen in the PORT group versus 55% in the non-PORT group (P<0.001). The overall distant metastasis rate in the whole group was 39%, with no difference between the two groups. The 5-year disease-free survival for the whole group of patients was 53%±11%, which was significantly affected by additional PORT, and 65%±13% compared with 40%±9% for the non-PORT group (P=0.04). The pathological subtypes did not affect 5-year disease-free survival significantly (P=0.9). The 5-year overall survival was 44%±10%. Using multivariate analysis, PORT, stage, and extravesical extension (positive surgical margins) were found to be important prognostic factors for locoregional control. Stage and lymph node status were important prognosticators for distant metastasis control. Conclusion: PORT was found to be a safe and effective tool in decreasing local recurrence rates and improving disease-free survival.
Collapse
Affiliation(s)
- Yasser Bayoumi
- Radiation Oncology, National Cancer Institute, Cairo University, Giza, Egypt
| | - Tarek Heikal
- Medical Oncology, Damietta Cancer Institute, Ministry of Health, Damietta, Egypt
| | - Hossam Darweish
- Medical Oncology, Damietta Cancer Institute, Ministry of Health, Damietta, Egypt
| |
Collapse
|
33
|
[Radiation therapy in locally advanced and/or relapsed urological tumors]. Urologia 2014; 80:212-24. [PMID: 24526598 DOI: 10.5301/ru.2013.11501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2013] [Indexed: 11/20/2022]
Abstract
Radiation therapy (RT) plays a fundamental role in the treatment of locally advanced and/or relapsed urological tumors, as well as in palliation, or as definitive treatment, and even where integrated into a multi-modal approach. In operated renal tumors, positive margins or extracapsular extension show a positive impact of postoperative RT, with a reduction of relapses between 100% and 30%, while, in the case of palliation, treatments with RT at high doses are preferred. In advanced cancers of the upper urinary tract, RT plays a limited role, even if it seems to increase the level of disease control locally and, with the combination of cisplatin, survival rates too. An important reduction in the recurrence is also observed in locally advanced tumors of the urethra, with a recurrence of 60% after surgery, 36% after RT and 25% after pairing of the two. In locally advanced tumors of the penis, RT shows poorer results than surgery, and the addition of postoperative RT does not seem to add any further outcome, except where, in the presence of a positive inguinal dissection, the postoperative RT reduces lymph node recurrences by 60%-11%. Interesting data for the preservation of the organ are reported with reference to the combination with chemotherapy. In the tumors of the testis, it is still disputable whether the treatment of residual masses after chemotherapy may be appropriate, with a view to a possible salvage radiotherapy. In the treatment of the prostate, the role of RT is consolidated and evolving with the progress of dose escalation, the association with hormonal therapy, new technologies, new possibilities of IMRT and proton therapy and various studies on multi-modal approaches (hormone therapy, surgery, radiotherapy, chemotherapy). Cystectomy is the gold standard for the treatment of locally advanced bladder cancer, even though there is a revived interest in multimodal treatments (transurethral resection, chemotherapy, RT) that may allow the organ preservation. Postoperative radiotherapy, which can reduce by 50% to 20%-5% local recurrences that are highly correlated with distance failure and with survival, should be revised in the light of modern RT techniques that can further increase local control levels and reduce the toxicity significantly.
Collapse
|
34
|
Zaghloul MS, Gouda I. Schistosomiasis and bladder cancer: similarities and differences from urothelial cancer. Expert Rev Anticancer Ther 2014; 12:753-63. [DOI: 10.1586/era.12.49] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
|
35
|
Christodouleas JP, Baumann BC, He J, Hwang WT, Tucker KN, Bekelman JE, Tangen CM, Lerner SP, Guzzo TJ, Malkowicz SB. Optimizing bladder cancer locoregional failure risk stratification after radical cystectomy using SWOG 8710. Cancer 2014; 120:1272-80. [DOI: 10.1002/cncr.28544] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 11/21/2013] [Accepted: 11/22/2013] [Indexed: 11/05/2022]
Affiliation(s)
| | - Brian C. Baumann
- Department of Radiation Oncology; University of Pennsylvania; Philadelphia Pennsylvania
| | - Jiwei He
- Department of Biostatistics and Epidemiology; University of Pennsylvania; Philadelphia Pennsylvania
| | - Wei-Ting Hwang
- Department of Biostatistics and Epidemiology; University of Pennsylvania; Philadelphia Pennsylvania
| | - Kai N. Tucker
- Department of Radiation Oncology; University of Pennsylvania; Philadelphia Pennsylvania
| | - Justin E. Bekelman
- Department of Radiation Oncology; University of Pennsylvania; Philadelphia Pennsylvania
| | | | - Seth P. Lerner
- Department of Urology; Baylor College of Medicine; Houston Texas
| | - Thomas J. Guzzo
- Department of Urology; University of Pennsylvania; Philadelphia Pennsylvania
| | - S. Bruce Malkowicz
- Department of Urology; University of Pennsylvania; Philadelphia Pennsylvania
| |
Collapse
|
36
|
Baumann BC, Guzzo TJ, He J, Vaughn DJ, Keefe SM, Vapiwala N, Deville C, Bekelman JE, Tucker K, Hwang WT, Malkowicz SB, Christodouleas JP. Bladder Cancer Patterns of Pelvic Failure: Implications for Adjuvant Radiation Therapy. Int J Radiat Oncol Biol Phys 2013; 85:363-9. [DOI: 10.1016/j.ijrobp.2012.03.061] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Revised: 03/25/2012] [Accepted: 03/28/2012] [Indexed: 10/27/2022]
|
37
|
A Novel Risk Stratification to Predict Local-Regional Failures in Urothelial Carcinoma of the Bladder After Radical Cystectomy. Int J Radiat Oncol Biol Phys 2013; 85:81-8. [DOI: 10.1016/j.ijrobp.2012.03.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Revised: 02/19/2012] [Accepted: 03/02/2012] [Indexed: 11/21/2022]
|
38
|
Zaghloul MS. Bladder cancer and schistosomiasis. J Egypt Natl Canc Inst 2012; 24:151-9. [PMID: 23159285 DOI: 10.1016/j.jnci.2012.08.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Revised: 08/11/2012] [Accepted: 08/25/2012] [Indexed: 10/27/2022] Open
Abstract
Schistosoma-associated bladder cancer was believed, for several decades, to be a completely unique entity of disease, different from urothelial cancer. This was probably due to its distinct clinicopathologic and demographic features that varied from those of urothelial entity. The carcinogenesis is an extremely complex process resulting from the accumulation of many genetic and epigenetic changes leading to alterations in the cell proliferation regulation process. In bladder cancer, many of these carcinogenic cascades were not fully documented or somewhat conflicting. Inspite of the efforts performed, much is still needed to explore the presence or absence of the carcinogenic difference with a different etiology. The control of schistosomiasis in certain countries and the subsequent decrease in the intensity of infestation showed changing of features approaching that of urothelial tumors. However the schistosoma-associated bladder cancer presented in more advanced stages than schistosoma-non associated urothelial cancer. More recently, data are gathered that, upon applying the same treatment protocol and management care, stage by stage comparison of the treatment end-results were found to be similar in bladder cancer patients with a different etiology. All treatment options; including radical cystectomy with or without adjuvant or neoadjuvant chemo- or radiotherapy or trimodality bladder preserving treatment seem to lead to similar end-results regardless of etiologic factor(s) implicated in bladder cancer development.
Collapse
Affiliation(s)
- Mohamed S Zaghloul
- Radiation Oncology Department, Children's Cancer Hospital and National Cancer Institute, Cairo University, Cairo, Egypt.
| |
Collapse
|
39
|
Abstract
Background: There is a significant variation in the treatment strategies adopted for the treatment of locally advanced T3b, T4a, N1-3 and metastatic bladder cancer. There is increasing evidence that we would be able to offer them some benefit in terms of disease-free survival and improving the quality of life. This article is aimed at reviewing the current literature on the treatment strategies in locally advanced and metastatic bladder cancer. Materials and Methods: Extensive literature search was done on Medline/Pubmed from 1980-2007 using the key words - treatment of locally advanced, metastatic bladder cancer. Standard textbooks on urology, urologic oncology and monograms were reviewed. Guidelines such as National Comprehensive Cancer Network guidelines, European Urology Association guidelines and American Urology Association guidelines were also studied. Results and Conclusions: There is a place for radical cystectomy in locally advanced T3b-T4 and N1-3 bladder cancer. Radical cystectomy alone rarely cures this subgroup of patients. There is increasing evidence that meticulous surgical clearance and extended lymphadenectomy has significant impact on disease-free survival. Adjuvant chemotherapy has been found to be effective in terms of recurrence-free survival and better than cystectomy alone. Neoadjuvant chemotherapy followed by radical cystectomy also has beneficial effects in terms of downstaging the disease and improving recurrence-free survival. This perioperative chemotherapy (adjuvant/neoadjuvant) has 5-7% survival benefit and 10% reduction in the death due to cancer disease. Excellent five-year survival rates have been achieved in patients achieving pT0 stage at surgery following chemotherapy (around 80%) and overall 40% five-year survival in node positive patients, which is promising. Though practiced widely, perioperative chemotherapy is not considered as a standard of care as yet. Current ongoing trials are likely to help us in reaching a consensus over this. There is no role of preoperative or postoperative radiotherapy in locally advanced/metastatic bladder cancer except in non TCC bilharzial/squamous cell carcinoma of bladder. Use of nomograms and prognostic factor evaluation may help us in the future in predicting the disease relapse and may help us in tailoring the treatment accordingly. Newer and more effective chemotherapeutic drugs and ongoing trials will have a significant impact on the treatment strategies and outcome of these patients in the future.
Collapse
Affiliation(s)
- Makarand V Khochikar
- Department of Uro-Oncology, Siddhi Vinayak Ganapati Cancer Hospital, Miraj, India
| |
Collapse
|
40
|
El-Monim HA, El-Baradie MM, Younis A, Ragab Y, Labib A, El-Attar I. A prospective randomized trial for postoperative vs. preoperative adjuvant radiotherapy for muscle-invasive bladder cancer. Urol Oncol 2011; 31:359-65. [PMID: 21353794 DOI: 10.1016/j.urolonc.2011.01.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2010] [Revised: 01/07/2011] [Accepted: 01/09/2011] [Indexed: 11/29/2022]
Abstract
PURPOSE Although radical cystectomy is considered to be the primary treatment for muscle-invasive bladder cancer, it is associated with unfavorable outcome. Local recurrence is still a major problem. Survival rates as well as quality of live are far from being satisfactory. Postoperative radiotherapy is considered the standard adjuvant treatment in the NCI-Egypt. This is a prospective randomized study conducted to compare preoperative with postoperative radiotherapy as regard the survival and complication rates. PATIENTS AND METHODS In the period from May, 2004 to June 2007, 100 eligible patients were included into the study, 50 patients in each treatment arm. Pelvic irradiation was identical in both groups aiming at 50 Gy/25 Fs/5 wk. Radical cystectomy was the standard surgery. Locoregional control, survival rates, and complications rates were compared in both arms. RESULTS Patients had a median follow-up period of 32 months (range 0-69 months). Patients had an average age of 54.8 ± 9.5 years with a male/female ratio 3:1. In the present study, transitional cell carcinoma constitutes (51%), while squamous cell carcinoma was reported in 46% of cases. Grades II and III pathology were 81% and 17%, respectively. Pathological stage P2b was encountered in 39.5% of the patients followed by P3b (33.3%) and P3a (14.6%). For the preoperative group, the 3-year overall survival, disease-free survival, locoregional control, and metastases-free survival rates were 53.4%, 47.4%, 89.3%, and 61.5%, respectively. The corresponding figures for the postoperative group were 51.8%, 34.1%, 80.6%, and 55.7% for the postoperative group. None of the patients had serious radiation reactions. CONCLUSION In our study, preoperative radiotherapy was almost equivalent to postoperative radiation therapy as regard OS, DFS, as well as complication rates. Given the recent physical developments in radiation therapy techniques and the biological rationale for treating the pelvis after cystectomy, adjuvant radiotherapy should be re-evaluated world wide. Preoperative radiotherapy may re-emerge as a useful tool for adjuvant treatment.
Collapse
Affiliation(s)
- Hassan Abd El-Monim
- Department of Radiation, National Cancer Institute, Cairo University, Cairo, Egypt
| | | | | | | | | | | |
Collapse
|
41
|
Abdel Raheem AM, Hameed DA, ElGanainy EO, Mosad E, Abdelwanis ME, Kamel NA, Hammouda HM, Abdelaziz MA, Hemeyda K. Can Bcl-XL expression predict the radio sensitivity of bilharzial-related squamous bladder carcinoma? A prospective comparative study. BMC Cancer 2011; 11:16. [PMID: 21226954 PMCID: PMC3033850 DOI: 10.1186/1471-2407-11-16] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2010] [Accepted: 01/12/2011] [Indexed: 12/20/2022] Open
Abstract
Background Local pelvic recurrence after radical cystectomy for muscle invasive bilharzial related squamous cell carcinoma accounts for 75% of treatment failures even in organ confined tumors. Despite the proven value of lymphadenectomy, up to 60% of patients undergoing cystectomy do not have it. These factors are in favor of adjuvant radiotherapy reevaluation. objectives: to evaluate the effect of adjuvant radiotherapy on disease free survival in muscle invasive bilharzial related squamous cell carcinoma of the urinary bladder and to test the predictability of radio-sensitivity using the anti apoptotic protein Bcl-XL. Methods The study prospectively included 71 patients, (47 males, 24 females) with muscle invasive bilharzial related squamous cell carcinoma of the bladder (Stage pT2a-T3N0-N3M0) who underwent radical cystectomy in Assiut university hospitals between January 2005 and December 2006. Thirty eight patients received adjuvant radiotherapy to the pelvis in the dose of 50Gy/25 fractions/5 weeks (Group 1), while 33 patients did not receive adjuvant radiotherapy (group 2). Immunohistochemical characterization for bcl-xL expression was done. Follow up was done every 3 months for 12 to 36 months with a mean of 16 ± 10 months. All data were analyzed using SPSS version 16. Three years cumulative disease free survival was calculated and adjusted to Bcl-XL expression and side effects of the treatment were recorded. Results The disease free cumulative survival was 48% for group 1 and 29% for group 2 (log rank p value 0.03). The multivariate predictors of tumor recurrence were the positive Bcl-XL expression (odd ratio 41.1, 95% CI 8.4 - 102.3, p < 0.0001) and radiotherapy (odd ratio 0.19, 95% CI 0.05 - 0.78, p < 0.02). With Cox regression, the only independent multivariate predictor of radio-sensitivity was the Bcl-XL expression with odd ratio 4.6 and a p value < 0.0001. All patients tolerated the treatment with no life threatening or late complications during the period of follow up. Conclusions Adjuvant radiotherapy for muscle invasive bilharzial related squamous cell carcinoma of the urinary bladder has potential effectiveness and minor side effects. Moreover, Bcl-XL expression is a valuable tool for predicting those who might not respond to this adjuvant treatment.
Collapse
|
42
|
Zaghloul MS. Adjuvant and neoadjuvant radiotherapy for bladder cancer: revisited. Future Oncol 2010; 6:1177-91. [DOI: 10.2217/fon.10.82] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
To date, radical cystectomy has continued to be the treatment of choice for muscle-invasive bladder cancer. It is associated with a 5-year disease-free survival rate ranging from 27–55%. This outcome is significantly worse when reporting upon locally advanced cases. The independent prognostic factors include: tumor stage, grade, pelvic nodal involvement and some other additional factors. Beside the higher reported incidence of distant metastasis, local recurrence either alone or combined with systemic relapse has been shown to be experienced by 23–50% of locally advanced patients – a rate that was much more frequent than previously believed. Nonrandomized trials of preoperative radiotherapy have suggested improved survival rates. However, only one out of the six randomized preoperative trials in the literature published in English has proved to be significant. On the other hand, the only randomized trial and most retrospective studies dealing with postoperative radiotherapy revealed a significant increase in disease-free survival. Late complications of post operative radiotherapy, contrary to former belief, were acceptable and generally depended upon the volume of the irradiated normal tissues and the radiotherapy techniques used. Most of these adjuvant or neoadjuvant reports were performed in the 1970s and 1980s using conventional radiation techniques. Modern radiotherapy, delivering higher doses to the tumor while saving a significant amount of the surrounding normal structure, has not been rigorously tested. However, these techniques have already succeeded in improving treatment end results in other pelvic tumors.
Collapse
Affiliation(s)
- Mohamed Saad Zaghloul
- Radiation Oncology Department, Children’s Cancer Hospital (57357), Egypt & National Cancer Institute, Cairo University, 1 Sekket El Emam, Sayeda Zainab, Cairo, Egypt
| |
Collapse
|
43
|
Kim YB, Hong SJ, Yang SC, Cho JH, Choi YD, Kim GE, Rha KH, Han WK, Cho NH, Oh YT. Pattern of failure in bladder cancer patients treated with radical cystectomy: rationale for adjuvant radiotherapy. J Korean Med Sci 2010; 25:835-40. [PMID: 20514302 PMCID: PMC2877228 DOI: 10.3346/jkms.2010.25.6.835] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2009] [Accepted: 11/30/2009] [Indexed: 11/20/2022] Open
Abstract
Thus far, the role of adjuvant radiotherapy (RT) after radical cystectomy (RC) in urinary bladder cancer patients has yet to be defined. The purpose of this study is to analyze patterns of failure, and suggest the rationale for RT. Between 1986 and 2005, a total of 259 patients treated with RC and pelvic lymph node dissection was enrolled. The age range was 27-82 yr (median, 62 yr). Node positivity increased according to tumor staging. Patients were divided into the following two groups based on pathologic analysis: organ-confined disease group (n=135) and extravesical/lymph node-positive disease group (n=80). Pelvic failures (PF) were observed in 8 (4.9%) in organ-confined disease group, and 21 (21.7%) in extravesical/lymph node-positive disease group. Five-year PF-free survival rates were 91.2% in organ-confined disease group and 68.0% in extravesical/lymph node-positive disease group. Five-year cancer-specific survival rates were 86.2% in organ-confined disease group and 53.9% in extravesical/lymph node-positive disease group. In conclusion, a relatively high PF rate was observed in extravesical lymph node-negative and lymph node-positive disease patients in this study. Adjuvant pelvic RT may be considered to reduce pelvic failures in extravesical lymph node-positive bladder cancer. Future prospective trials are required to test the clinical benefit of adjuvant RT.
Collapse
Affiliation(s)
- Yong Bae Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Joon Hong
- Department of Urology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Cheol Yang
- Department of Urology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Ho Cho
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Young Deuk Choi
- Department of Urology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Gwi Eon Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Koon Ho Rha
- Department of Urology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Woong Kyu Han
- Department of Urology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Nam Hoon Cho
- Department of Pathology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Young Taek Oh
- Department of Diagnostic Radiology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
44
|
Troiano M, Corsa P, Raguso A, Cossa S, Piombino M, Guglielmi G, Parisi S. Radiation therapy in urinary cancer: state of the art and perspective. Radiol Med 2008; 114:70-82. [PMID: 19082788 DOI: 10.1007/s11547-008-0347-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Accepted: 04/10/2008] [Indexed: 12/19/2022]
Abstract
Invasive urinary tumours are relatively rare, and their treatment may cause important changes in urinary, sexual and social functions. A systematic review of external radiation therapy studies in urinary cancers was performed. This synthesis of the literature is based on data from meta-analyses, randomised and prospective trials and retrospective studies. There are few controlled clinical trials using adjuvant or radical radiotherapy with or without chemotherapy in cancer of the kidney, ureter and urethra. There are several reports on multimodality treatment in invasive bladder cancer: intravesical surgery and neoadjuvant chemotherapy to radiotherapy or concomitant radiochemotherapy with organ preservation. The conclusions reached for renal cancer are controversial, and data on cancers of the urethra and ureter are few and inconclusive. Sufficient data now exist in the literature to demonstrate that conservative management with organ preservation is a valuable alternative to radical cystectomy, the traditional gold standard, in invasive bladder cancer.
Collapse
Affiliation(s)
- M Troiano
- Department of Radiation Oncology, Scientific Institute Hospital Casa Sollievo della Sofferenza, and University of Foggia, Department of Radiology, San Giovanni Rotondo, 71013, Foggia, Italy
| | | | | | | | | | | | | |
Collapse
|
45
|
Murthy V, Zaghloul MS. Adjuvant radiotherapy in bladder cancer: time to take a fresh look? Urol Oncol 2007; 25:353-4. [PMID: 17628309 DOI: 10.1016/j.urolonc.2007.02.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2007] [Accepted: 02/27/2007] [Indexed: 10/23/2022]
|
46
|
Parisi S, Troiano M, Corsa P, Raguso A, Cossa S, Piazzolla EE, Munafò T, Sanpaolo G, Natuno A, Maiello E. Role of external radiation therapy in urinary cancers. Ann Oncol 2007; 18 Suppl 6:vi157-61. [PMID: 17591812 DOI: 10.1093/annonc/mdm247] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Invasive urinary tumors are relatively rare and their treatment may cause important changes in urinary, sexual, and social functions. A systematic review of external radiation therapy studies in urinary cancers has been carried out. This synthesis of the literature is based on data from meta-analysis, randomized and prospective trials, and retrospective studies. There are few controlled clinical trials using adjuvant or radical radiotherapy +/- chemotherapy in kidney, ureter, and urethra cancers; there are several reports of muscle-invasive bladder cancer using multimodality treatment: intravesical surgery and neo-adjuvant chemotherapy to radiotherapy or concomitant radiochemotherapy with organ preservation. The conclusions reached for renal cancer are controversial; urethra and ureter cancers data are few and inconclusive; sufficient data now exist in literature to demonstrate that conservative management with organ preservation, for muscle-invasive bladder cancer, is a valid alternative to radical cystectomy, viewed as the gold standard.
Collapse
Affiliation(s)
- S Parisi
- Department of Radiation Oncology, Istituti di ricovero e cura a carattere scientifico Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Cohen SM, Goel A, Phillips J, Ennis RD, Grossbard ML. The Role of Perioperative Chemotherapy in the Treatment of Urothelial Cancer. Oncologist 2006; 11:630-40. [PMID: 16794242 DOI: 10.1634/theoncologist.11-6-630] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Cancer of the urothelium is the fourth most common malignancy in men in the U.S. and the ninth most common in women. More than 63,000 Americans will be diagnosed with bladder cancer this year (47,010 men and 16,200 women), and more than 13,000 (8,970 men and 4,210 women) can expect to die of their disease. The approximate 5:1 ratio of incidence to mortality roughly parallels the frequency of superficial to invasive disease. Efforts to improve this ratio have generated a potential paradigm shift in the treatment of urothelial cancer, incorporating increasingly active chemotherapy into treatment regimens for high-risk tumors in both the pre-and postoperative settings. This review summarizes the evolution of chemotherapeutic treatment of urothelial cancer and the rationale for its perioperative administration and addresses the future directions of clinical research in this field.
Collapse
Affiliation(s)
- Seth M Cohen
- Department of Medicine, Division of Hematology/Oncology, St. Luke's-Roosevelt Hospital Center, New York, New York 10019, USA.
| | | | | | | | | |
Collapse
|
48
|
Zaghloul MS, Nouh A, Nazmy M, Ramzy S, Zaghloul AS, Sedira MA, Khalil E. Long-term results of primary adenocarcinoma of the urinary bladder: A report on 192 patients. Urol Oncol 2006; 24:13-20. [PMID: 16414487 DOI: 10.1016/j.urolonc.2005.05.027] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2005] [Revised: 05/23/2005] [Accepted: 05/27/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To evaluate the clinical presentation and treatment end results of primary adenocarcinoma of the urinary bladder, and to determine the significant independent prognostic factors that determine this outcome. PATIENTS AND METHODS Of 3659 patients who underwent cystectomy, 192 had adenocarcinoma of the urinary bladder, with a relative frequency of 5.2%. Most of these patients (68.2%) presented in late stages (P3 + P4). The incidence of pelvic lymph nodes involvement was 25.5%. Mucinous adenocarcinoma was reported in 28 patients (14.6%), papillary in 20 (10.4%), signet ring in 14 (7.3%), while not otherwise specified was reported in 130 (67.7%) in the cystectomy specimens. RESULTS Mucinous and signet-ring histologic subtypes showed increased frequency of high stages and high grades, and more nodal involvement than the papillary and not otherwise specified. All patients were treated with radical cystectomy and pelvic lymphadenectomy with (69 patients) or without (123) postoperative radiotherapy. The 5-year disease-free survival rate was 46 +/- 4% for all patients with adenocarcinoma. Postoperative radiotherapy improved the disease-free survival significantly. The 5-year disease-free survival rate for the postoperative radiotherapy group was 61 +/- 6% compared to 37 +/- 5% for the cystectomy alone group (P = 0.002). Local control rate was significantly improved from 53 +/- 7% for cystectomy alone to 96 +/- 3% for postoperative radiotherapy patients (P = 0.00001). Distant metastases were the leading cause of death in the postoperative radiotherapy group. CONCLUSIONS Within the limitations provided by retrospective studies, it could be concluded that postoperative radiotherapy improved the disease-free survival through its effect on local control. The disease-free survival independent prognostic variables were tumor stage, postoperative radiotherapy, nodal involvement, and adenocarcinoma subclassification. These factors, except the adeno-subclassification, were also found to determine the local control rate. On the other hand, the independent prognostic factors for distant metastasis were lymph nodal involvement, stage, and adeno-subclassification.
Collapse
Affiliation(s)
- Mohamed S Zaghloul
- Department of Radiation Oncology, National Cancer Institute, Cairo, Egypt.
| | | | | | | | | | | | | |
Collapse
|
49
|
Aparicio AM, Elkhouiery AB, Quinn DI. The Current and Future Application of Adjuvant Systemic Chemotherapy in Patients with Bladder Cancer Following Cystectomy. Urol Clin North Am 2005; 32:217-30, vii. [PMID: 15862619 DOI: 10.1016/j.ucl.2005.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Urothelial transitional cell cancer has a high rate of response to combination cytotoxic therapy. Approximately 50% of patients with high-grade bladder cancer and deep muscle invasion ultimately die of disseminated disease. Translating the high response seen in locally advanced disease into long-term survival in the metastatic setting and to improved survival in the advanced setting has proved difficult. This article reviews the use of adjuvant chemotherapy in localized or locally advanced transitional cell cancer. The chemotherapy of urological malignancies, including bladder cancer, has recently been reviewed in detail; this article does not contain an extensive review of the drugs used.
Collapse
Affiliation(s)
- Ana M Aparicio
- Division of Medical Oncology and Kenneth J. Norris Comprehensive Cancer Center, University of Southern California Keck School of Medicine, 1441 Eastlake Avenue, Los Angeles, CA 90089, USA
| | | | | |
Collapse
|
50
|
Pernot M, Hubert J, Guillemin F, Six A, Hoffstetter S, Peiffert D, Verhaeghe J, Luporsi E. Combined surgery and brachytherapy in the treatment of some cancers of the bladder (partial cystectomy and interstitial iridium-192). Radiother Oncol 1996; 38:115-20. [PMID: 8966223 DOI: 10.1016/0167-8140(96)82354-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Eighty-five bladder cancers were treated at the Urology Clinic of Nancy and the Centre Alexis Vautrin from 1975 to 1992 with short course preoperative radiation therapy (3 x 3.5 Gy), conservative surgery and brachytherapy by iridium-192. The tumours were classified according to the 1979 UICC pTNM classification. There were 27 pT1, 31 pT2 and 22 pT3, two pT4 and three pTx. The pT1-pT2 cases received only one brachytherapy (50 Gy at least) after the short course preoperative irradiation. The pT3 cases received only 30 Gy of brachytherapy and an external irradiation boost (generally 40 Gy to the node areas and 30 Gy to the tumour, but the dose varied during the time course). Surgery was often preceded by an endoscopic resection consisting of a tumoral resection or a partial cystectomy according to the localisation. The plastic vector tubes were put into place at the time of partial cystectomy. Until 1983 the radioactive wires were loaded into the vector tubes on the day following surgery, thereafter it was done one week later. The 85 patients were classified into two groups: 63 patients who were untreated previously and 22 patients who had received one or more endoscopic resections for recurrences. The median follow-up was 84 months. The local controls at 5 years were 78% in the first group versus 56% in the second group (p = 0.005) with an overall survival of 73 and 65%, respectively. The local control did not vary according to the differentiation (grade 1/2 vs. grade 3). The local control for pT1, pT2, pT3 was 85, 64 and 70% with a specific survival of 85, 76 and 72%, and an overall survival of 78, 66 and 66%. Among early complications, delay in healing of the bladder wall with subsequent vesico-cutaneous fistula depends mainly on the loading time of radioactive wires after surgery and is rare if the loading is delayed by one week. The late complications depend mostly on dosimetric factors. We found 24 grade 1, three grade 2, four grade 3 and one grade 4. The following factors are significant: the surface treated (> 14 cm2), a distance between the sources of more than 2 cm and, especially, activity of the wires of more than 2 mCi/cm (this factor was found in the five complications of grade 3 and 4), the other factors were not significant in univariate analyses.
Collapse
Affiliation(s)
- M Pernot
- Centre Alexis Vautrin, Vandoeuvre les Nancy, France
| | | | | | | | | | | | | | | |
Collapse
|