Role of planned preoperative irradiation in the management of clinical stage B2‐C (T3) bladder carcinoma in the 1980s

Abstract

In recent years the role of planned preoperative irradiation in the management of clinical stage B2-C (T3) bladder cancer has been questioned by a number of investigators. Much of the confusion regarding the efficacy of combined therapy results from studies that compare the results of treatment of pathological stage B2-C patients treated by cystectomy alone versus clinical stage B2-C patients treated by preoperative irradiation plus cystectomy. Such comparisons are biased because of 1) the exclusion of a large number of pathological stage D patients from cystectomy-alone series and their inclusion in preoperative irradiation plus cystectomy series and 2) the inclusion in the cystectomy-alone series of patients whose clinical stages were less than or equal to T2. The purpose of this paper is to compare the results of treatment in patients with clinical stage B2-C bladder carcinoma following radical cystectomy alone versus preoperative irradiation plus cystectomy. This article reviews the rationale for administering preoperative irradiation, the effect of preoperative irradiation on the pathological specimen (including down-staging, the effect on regional lymph nodes, and radioresponsiveness according to tumor configuration, i.e., papillary vs. solid), the impact of preoperative irradiation on pelvic recurrence and 5-year survival, and the effect of preoperative irradiation on operative and postoperative complications. This paper cites all known literature on the subject in the English language. Data comparing 5-year survival results of radical cystectomy alone versus preoperative irradiation plus cystectomy are analyzed in three different ways: a) retrospective comparisons of historical results, b) comparison of contemporaneous "modern-day" (1960-1980) series comprising 1185 patients who received either radical cystectomy alone or preoperative irradiation plus cystectomy, and c) review of the results of six randomized trials. Preoperative results are also analyzed according to dose level (2,000 cGy versus 4,000 cGy vs. 4,500-5,000 cGy). The data presented indicate that the addition of preoperative irradiation to cystectomy for clinical stage B2-C (T3) bladder cancer adds approximately 15-20 percentage points to the 5-year survival, leading to a survival figure that is approximately half again that achieved by cystectomy alone.