Clinical Investigation
Bladder Function Preservation With Brachytherapy, External Beam Radiation Therapy, and Limited Surger in Bladder Cancer Patients: Long-Term Results

Presented as an oral presentation at the 55th Annual Meeting of the American Society for Radiation Oncology (ASTRO), Atlanta, GA, September 22-25, 2013.
https://doi.org/10.1016/j.ijrobp.2013.11.227Get rights and content

Purpose

To report long-term results of a bladder preservation strategy for muscle-invasive bladder cancer (MIBC) using external beam radiation therapy and brachytherapy/interstitial radiation therapy (IRT).

Methods and Materials

Between May 1989 and October 2011, 192 selected patients with MIBC were treated with a combined regimen of preoperative external beam radiation therapy and subsequent surgical exploration with or without partial cystectomy and insertion of source carrier tubes for afterloading IRT using low dose rate and pulsed dose rate. Data for oncologic and functional outcomes were prospectively collected. The primary endpoints were local recurrence-free survival (LRFS), bladder function preservation survival, and salvage cystectomy-free survival. The endpoints were constructed according to the Kaplan-Meier method.

Results

The mean follow-up period was 105.5 months. The LRFS rate was 80% and 73% at 5 and 10 years, respectively. Salvage cystectomy-free survival at 5 and 10 years was 93% and 85%. The 5- and 10-year overall survival rates were 65% and 46%, whereas cancer-specific survival at 5 and 10 years was 75% and 67%. The distant metastases-free survival rate was 76% and 69% at 5 and 10 years. Multivariate analysis revealed no independent predictors of LRFS. Radiation Therapy Oncology Group grade ≥3 late bladder and rectum toxicity were recorded in 11 patients (5.7%) and 2 patients (1%), respectively.

Conclusions

A multimodality bladder-sparing regimen using IRT offers excellent long-term oncologic outcome in selected patients with MIBC. The late toxicity rate is low, and the majority of patients preserve their functional bladder.

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.

References (25)

Cited by (23)

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    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.

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Conflict of interest: none.

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