International Journal of Radiation Oncology*Biology*Physics
Clinical InvestigationBladder Function Preservation With Brachytherapy, External Beam Radiation Therapy, and Limited Surger in Bladder Cancer Patients: Long-Term Results
Introduction
Bladder cancer (BC) is the fifth most common cancer in Western countries 1, 2. Bladder cancer is muscle-invasive in 30% of cases, whereas 70%-75% is non-muscle-invasive. Approximately 10%-20% of non-muscle-invasive tumors will progress to muscle-invasive BC (MIBC) (3).
The outcome of MIBC is poor: only 50%-60% of patients survive in the long term, regardless of treatment. Radical surgery is the frontline treatment for MIBC; however, the surgical mortality and morbidity rates and surgery's negative impact on quality of life are considerable (4).
The role of radiation treatment is increasing in selected patients with MIBC, in an effort to offer bladder function preservation with oncologic results comparable to those with surgery.
Recently it was shown that concurrent chemoradiation therapy is an alternative curative treatment modality for MIBC patients who are potential candidates for cystectomy or for patients who are unfit for or refuse radical surgery 3, 5, 6.
Brachytherapy/interstitial radiation therapy (IRT) is the most common bladder preservation technique used and is mostly combined with external beam radiation therapy (EBRT) and partial cystectomy 7, 8.
In 1951, IRT was introduced as a treatment option for BC patients (9). In 1989, remote-controlled continuous afterloading low-dose-rate (cLDR) IRT was introduced using 192Ir wires, which was then followed by pulsed-dose-rate (PDR) stepping source IRT in 1992. Patients treated accordingly have been followed prospectively since 1989 8, 10. Here we report the long-term oncologic and functional outcome of the largest single-center series on 192 patients with MIBC who were treated with IRT (LDR or PDR).
Section snippets
Patients
Patients with a solitary, histologically proven MIBC (urothelial carcinoma) without clinical evidence of nodal or distant metastases (using computed tomography of the abdomen and computed tomography or x-ray of the thorax; bone scintegraphy or magnetic resonance imaging was only used in selected cases) were considered eligible for IRT.
Exclusion criteria were carcinoma in situ, tumor at the bladder neck or trigone, diameter of the (tumor) area to be treated >5 cm, and multifocal tumors.
The final
Results
Between May 1989 and October 2011, 192 selected MIBC patients were treated with IRT. Table 1 shows patients characteristics. Twenty-one patients (10.4%) were referred for treatment of a recurrent tumor that occurred after intravesical instillations with Bacillus Calmette-Guérin.
Discussion
In this large, single-institution series of 192 selected patients with MIBC, we showed that a bladder-sparing regimen of EBRT followed by IRT with or without partial cystectomy resulted in excellent recurrence-free and metastases-free survival. With a median follow-up of more than 6 years, late rectal and bladder toxicity as assessed prospectively according to the RTOG/EORTC criteria (12) were low, and <10% of the patients underwent salvage cystectomy for local tumor recurrence.
Conclusions
A multimodality bladder-preserving treatment including EBRT, limited surgery, and IRT resulted in good long-term survival with a high percentage of bladder function preservation in selected patients with MIBC. The long-term local control and CSS are excellent, with an acceptable percentage of late toxicity. This regimen raises the opportunity for selected MIBC patients to preserve their bladder without compromising survival.
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Disease-Free Survival of Patients With Muscle-Invasive Bladder Cancer Treated With Radical Cystectomy Versus Bladder-Preserving Therapy: A Nationwide Study
2024, International Journal of Radiation Oncology Biology PhysicsAuthors’ response to Letter to the Editor “Don't forget Arnhem”
2020, Radiotherapy and OncologyIncreased risk for second primary rectal cancer after pelvic radiation therapy
2020, European Journal of CancerCitation Excerpt :For example, late grade ≥2 toxicity (following the Radiation Therapy Oncology Group [RTOG] and the European Organization for Research and Treatment of Cancer [EORTC]. radiation morbidity scoring schema) occurs in approximately 3–7% of patients with bladder cancer, 5–20% in patients with prostate cancer, 10–20% in patients with cervical cancer and up to 22% in patients with endometrial cancer [28–33]. In combination with the findings in the present study, it could be hypothesised that this may be an explanation for the increased risk of rectal cancer in patients with prostate and endometrial cancer.
Long-term survival and complications following bladder-preserving brachytherapy in patients with cT1-T2 bladder cancer
2019, Radiotherapy and OncologyCitation Excerpt :In a multicentre cohort comprising 1040 brachytherapy patients, 5 and 10-year OS was 62% and 44% respectively [7]. Some smaller single centre studies reported 5-year OS rates between 63% and 67% after brachytherapy [13–15]. These findings are in line with our results (5 and 10-year OS after brachytherapy of 66% and 49%, respectively).
Robot-assisted Laparoscopic Implantation of Brachytherapy Catheters in Bladder Cancer
2018, European UrologyCitation Excerpt :Cases requiring more extensive tumour (scar) resection and patients with extensive prior transperitoneal surgery were not included. In the study by Aluwini et al [15], 6% of the patients had T3 disease and were treated via the open technique, whereas we did not include T3 disease. RAL implantation is technically more challenging and the technique is still developing.
GEC-ESTRO/ACROP recommendations for performing bladder-sparing treatment with brachytherapy for muscle-invasive bladder carcinoma
2017, Radiotherapy and OncologyCitation Excerpt :Tumor not located in the bladder neck or the prostatic urethra in male patients. In the literature cases have been reported of patients with a limited T3 disease, which were treated by brachytherapy after a partial cystectomy [12,13,16,21]. Treatment of a T3 tumor should be reserved for experienced urologists and radiation oncologists with specialization in brachytherapy.
Conflict of interest: none.