Bladder cancer.Superiority of preoperative irradiation and cystectomy in clinical stages B2 and C

Abstract

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.

Bladder cancer and schistosomiasis

“…Although the difference was statistically significant on univariate analysis it was not statistically significant when multivariate analysis was applied [41]. Similarly, the incidence of distant metastasis in urothelial cancer ranged from 12% to 35% [42,43]. Loco-regional recurrence with or without distant metastasis was found in 5-31% of the patients treated with RC, depending on their pathological and clinical features [44].…”

The role of radiotherapy in urinary bladder cancer: current status

“…And, most of the times, a small number of patients were included which limited the statistical power of these analyses. Except for the MD Anderson experience (Miller) (21) that showed statistically significant benefit favoring bimodal therapy, the other studies did not find any difference in terms of patient's survival in the evaluated groups. However, the study of Miller also must be interpreted with caution considering the small number of patients analyzed and the fact that only patients with large T3 tumors were considered.…”

“…Conflicting results were found in studies that compared preoperative RT followed by immediate radical surgery versus radical treatment with RT and salvage surgery at recurrence (17)(18)(19)(20)(21). It is important to note that the RT scheme used was different in each of these studies.…”

Chemotherapy for muscle-invasive bladder cancer treated with definitive radiotherapy: persisting uncertainties

“…The results of three studies in which patients were randomly assigned to receive planned preoperative radiotherapy and cystectomy or radical radiotherapy followed with salvage cystectomy upon recurrence are summarized in Table 2. [28][29][30] The smallest and earliest study 28 showed a survival difference in favor of preoperative radiation and cystectomy (46% versus 16%; P <0.01), but no survival differences were observed in the other two studies. A recent meta-analysis that combined the results of these studies also indicated improved survival with immediate cystectomy.…”