A comparison of preoperative radiotherapy regimens for bladder carcinoma.The university of Pennsylvania experience

Abstract

Between 1976 and 1985, 155 patients from the Hospital of the University of Pennsylvania, the Philadelphia Veterans Administration Hospital, and the Fox Chase Cancer Center were divided into groups, each of which was treated with one of three preoperative radiotherapy regimens to be followed by cystectomy. Patients initially were treated with 4000 cGy during 4 weeks followed by cystectomy (16 patients). Beginning in 1978, patients received 2000 cGy in 1 week prior to surgery (70 patients). Since 1982, 40 patients were treated with 500 cGy on the day prior to surgery with postoperative radiation therapy reserved for patients with either involved margins of resection, advanced stage or high grade. A fourth group of 20 patients was either not offered or refused preoperative radiation. Nine patients received only postoperative radiation therapy. The 5-year actuarial disease-free survival for pathologic Stages B2, C, and D lesions (T3-4, N0-2), was 63% for those who had received high-dose radiation versus 21% for those that had low-dose or no radiation. Patients with advanced pathologic stage disease who had received greater than 2000 cGy had a reduced rate of local failure (11% versus 27% for those who had received less treatment). Patients with abnormal upper tracts as shown on the intravenous pyelograms (IVP) had a reduced 5-year determinate survival of 23% versus 65% for patients with normal upper tracts. This condition did not independently affect survival, but rather reflected advanced stage. Patients with abnormal creatinine levels had a decreased survival that was independent of stage. Computed tomography was found to have low sensitivity for determining extravesical extension (39%) and metastatic lymphadenopathy (12%). Patients with clinical Stage B2 and C disease (T3) that were downstaged had a 63% 5-year survival versus 18% of those that were not downstaged. The incidence of both ureteroenteral strictures and stomal complications was found to be higher in the 2000 cGy group than in those patients treated with the other regimens. The overall incidence of complications in that group was also significantly greater. We conclude that there is a continuing role for adjuvant radiotherapy in invasive bladder carcinoma to improve both pelvic control and survival. The 500 cGy radiotherapy "sandwich" regimen was equal in terms of pelvic control and survival to the other regimens and showed less overall morbidity. The 2000 cGy regimen was associated with the greatest incidence of morbidity and did not substantially improve pelvic control.

The role of radiotherapy in urinary bladder cancer: current status

“…At the beginning, many retrospective studies confirmed a real benefit in the use of preoperative RT compared to cystectomy alone (13)(14)(15). A review published by the University of Florida (16) in the 80's with stage T3 patients concluded that preoperative RT would give a 5-year survival benefit of 5% (15% versus 20%) when compared to surgery alone.…”

Radiation therapy in urinary cancer: state of the art and perspective

“…Postoperative RT is administered to patients with extravesical disease, positive resection margins or involved pelvic lymph nodes with doses of 40-50 Gy. Some studies reported reduction of the risk of pelvic recurrence from 30% to 50% to 10% to 20% [39][40][41], but some patients also received preoperative RT. Only one randomised study of radical cystectomy alone vs cystectomy and postoperative RT [41] reported a 5-year pelvic recurrence of 5% (50% in the cystectomy arm) and an improvement in DFS in patients with schistosomiasis.…”

“…Only one randomised study of radical cystectomy alone vs cystectomy and postoperative RT [41] reported a 5-year pelvic recurrence of 5% (50% in the cystectomy arm) and an improvement in DFS in patients with schistosomiasis. The main disadvantage of postoperative RT is the high rate (20%-40%) of serious late gastrointestinal complications [39,40,[42][43][44] because of the larger volume of small bowel occupying the pelvis after cystectomy. Patients at high risk of recurrence are probably better treated with CT, which may prevent local and distant relapse and is usually well tolerated.…”

“…La RT post-operatoria è somministrata nei pazienti con malattia extra-vescicale, margini di resezione positivi o interessamento linfonodale, con dosi di 40-50 Gy. Alcuni studi hanno riportato una riduzione del rischio di recidive pelviche dal 30% al 50% al 10% al 20% [39][40][41], ma alcuni pazienti hanno anche ricevuto RT pre-operatoria. Solo uno studio randomizzato sulla cistectomia radicale da sola verso cistectomia e RT postoperatoria [41], ha riportato recidive pelviche a 5 anni del 5% (50% nel braccio della cistectomia) ed un incremento della SLM nei pazienti con schistosomiasi.…”

“…Solo uno studio randomizzato sulla cistectomia radicale da sola verso cistectomia e RT postoperatoria [41], ha riportato recidive pelviche a 5 anni del 5% (50% nel braccio della cistectomia) ed un incremento della SLM nei pazienti con schistosomiasi. Il principale svantaggio della RT post-operatoria è l'alta percentuale (20%-40%) di gravi complicanze gastrointestinali tardive [39,40,[42][43][44], poiché una gran parte di volume dell'intestino tenue occupa la pelvi dopo cistectomia. I pazienti ad alto rischio di recidiva sono probabilmente trattati in modo migliore con la CT, che può prevenire recidive locali e a distanza ed è di solito ben tollerata.…”