Clinical and morphological features of 90 cases of squamous cell carcinoma of the bladder have been reviewed. The lesions were solitary in 90 per cent of the patients, developed without a history of vesical malignant disease in 82 per cent and were invasive at the time of diagnosis in all cases. Ureteral obstruction was demonstrated in 42 per cent of the group. The over-all survival rate at 5 years was only 10.6 per cent. There were 17 patients who received no therapy, all of whom were dead before 2 years. Unassisted supervoltage radiation therapy for patients with stages B2 and C lesions yielded a 5-year survival rate only 17.7 per cent. However, preoperative radiotherapy followed by simple total cystectomy and urinary diversion in a small number of patients with stages B2 and C lesions resulted in a 5-year survival rate in excess of 34 per cent. We are encouraged by this finding and believe that combination therapy warrants further clinical trial.
6oCobalt gamma rays or 22 MeV x-rays were used in the radiotherapeutic management of 724 patients treated for bladder cancer at the M.D. Anderson Hospital and Tumor Institute between 1954 and 1970. Cystoscopy and bimanual palpation for clinical stage classification during anesthesia were routinely the joint effort of urologist and radiotherapist. All living patients have been followed at least 5 years; for all who have expired at least the date of death has been established. For patients managed with radiotherapy alone, postoperative irradiation, or with preoperative irradiation and cystectomy, respective major complication rates were: 14%, 25% and 48%; local failure rates 45%, 33% and 16%; 10-year all-stage survival rates 8%, 14% and 20%. Five-year survival rates had only limited prognostic value when management was with radiotherapy alone or with postoperative irradiation, because in these two groups loss rates between the fifth and tenth post radiation years were high; late attrition was due in important part to failure to control cancer within the irradiated tissue volume, a type of failure not yet apparent in the group managed with preoperative irradiation and cystectomy. Among patients managed with radiotherapy alone, there was valid evidence that with increasing dose the incidence of local failure decreased. In the same group, rectal complications increased with higher doses, but the rate of bladder complications was independent of dose within the range studied, suggesting that still higher doses may safely be tolerable if surrounding normal structures can adequately be protected. Because of the higher complication rate (despite a dose smaller than that for radiotherapy alone), the dose for postoperative irradiation probably should be lowered to 5000 rad/25 fractions/5 weeks. Preoperative irradiation (at the 5000 rad level) followed in 6 weeks by cystectomy (node dissection not included, operative mortality rate 3 .3%) was clearly superior to radiotherapy alone for clinical Stages B2 and C. A randomized prospective study resulted in 5-year survival of 46% of such patients managed with the combined modality (53% if patients who failed to undergo the intended cystectomy were excluded) as against 16% for patients managed with radiotherapy alone. For the preoperative group as a whole, there was n o demonstrable residual tumor in 29% of the cystectomy specimens, and of the 26 patients in this category (Stage Bz in 12, Stage C in 14) 54% survived 5 years.Cancer 39:973-980, 1977. HIS REPORT* IS SEQUEL TO AN EARLIERT a n a l y s i s l l of a group of patients who received radiation therapy for carcinoma of the urinary bladder at M.
The clinical and morphological features in 81 cases of carcinoma of the female urethra were reviewed. The over-all 5 and 10-year survival rate for the entire group was 32 per cent. Survival expectations for patients with squamous carcinoma, transitional cell carcinoma and adenocarcinoma were similar when analyzed according to stage and all cell types appeared to respond equally to irradiation. Prognosis was related directly to the clinical stage of the disease. A plea is made for more accurate assessment of the disease status. The high incidence of local recurrence noted for all forms of single modality therapy (46 to 64 per cent) suggests the need for clinical trials with combination preoperative irradiation followed by definitive surgical procedures.
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