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8 - Pianificazione E Somministrazione Del Trattamento Radioterapico. TUMORI JOURNAL 2018; 104:S31-S35. [PMID: 29893177 DOI: 10.1177/0300891618766111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Bamias A, Tsantoulis P, Zilli T, Papatsoris A, Caparrotti F, Kyratsas C, Tzannis K, Stravodimos K, Chrisofos M, Wirth GJ, Skolarikos A, Mitropoulos D, Constantinides CA, Deliveliotis C, Iselin CE, Miralbell R, Dietrich P, Dimopoulos MA. Outcome of patients with nonmetastatic muscle-invasive bladder cancer not undergoing cystectomy after treatment with noncisplatin-based chemotherapy and/or radiotherapy: a retrospective analysis. Cancer Med 2016; 5:1098-107. [PMID: 27004619 PMCID: PMC4924368 DOI: 10.1002/cam4.685] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 02/03/2016] [Accepted: 02/04/2016] [Indexed: 11/13/2022] Open
Abstract
Transurethral resection of bladder tumor (TURBT), radiotherapy, chemotherapy, or combinations can be used in patients with muscle-invasive bladder cancer (MIBC) not undergoing cystectomy. Nevertheless, unfitness for cystectomy is frequently associated with unfitness for other therapeutic modalities. We report the outcome of patients with MIBC who did not undergo cystectomy and did not receive cisplatin-based chemotherapy. Selection criteria for the study were nonmetastatic MIBC, no cystectomy, no cisplatin-based chemotherapy. Chemotherapy and/or radiotherapy should have been used aside from TURBT. Forty-nine patients (median age 79), managed between April 2001 and January 2012, were included in this analysis. Median Charlson Comorbidity Index was 5, while 76% were unfit for cisplatin. Treatment included radiotherapy (n = 7), carboplatin-based chemotherapy (n = 25), carboplatin-based chemotherapy followed by radiotherapy (n = 10), and radiochemotherapy (n = 7). Five-year event-free rate was 26% (standard error [SE] = 7) for overall survival, 23% (SE = 7) for progression-free survival, and 30 (SE = 8) for cancer-specific survival (CSS). Patients who were treated with combination of radiotherapy and chemotherapy had significantly longer CSS compared to those treated with radiotherapy or chemotherapy only (5-year CSS rate: 16% [SE 8] vs. 63% [SE 15], P = 0.053). Unfit-for-cystectomy patients frequently receive suboptimal nonsurgical treatment. Their outcome was poor. Combining chemotherapy with radiotherapy produced better outcomes and should be prospectively evaluated.
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Affiliation(s)
- Aristotle Bamias
- Hellenic Genito‐Urinary Cancer GroupAthensGreece
- Department of Clinical TherapeuticsMedical SchoolAthens UniversityAthensGreece
| | - Petros Tsantoulis
- Department of Oncology and Centre de Recherche Clinique Dubois FerrariGeneva University HospitalGenevaSwitzerland
| | - Thomas Zilli
- Department of Radiation OncologyGeneva University HospitalGenevaSwitzerland
| | - Athanasios Papatsoris
- Hellenic Genito‐Urinary Cancer GroupAthensGreece
- 2 Department of UrologyUniversity of AthensAthensGreece
| | | | - Christos Kyratsas
- Hellenic Genito‐Urinary Cancer GroupAthensGreece
- 2 Department of UrologyUniversity of AthensAthensGreece
| | - Kimon Tzannis
- Department of Clinical TherapeuticsMedical SchoolAthens UniversityAthensGreece
| | - Kostas Stravodimos
- Hellenic Genito‐Urinary Cancer GroupAthensGreece
- 1 Department of UrologyUniversity of AthensAthensGreece
| | - Michael Chrisofos
- Hellenic Genito‐Urinary Cancer GroupAthensGreece
- 2 Department of UrologyUniversity of AthensAthensGreece
| | - Gregory J. Wirth
- Department of Urology DepartmentGeneva University HospitalGenevaSwitzerland
| | - Andreas Skolarikos
- Hellenic Genito‐Urinary Cancer GroupAthensGreece
- 2 Department of UrologyUniversity of AthensAthensGreece
| | - Dionysios Mitropoulos
- Hellenic Genito‐Urinary Cancer GroupAthensGreece
- 1 Department of UrologyUniversity of AthensAthensGreece
| | | | - Charalambos Deliveliotis
- Hellenic Genito‐Urinary Cancer GroupAthensGreece
- 2 Department of UrologyUniversity of AthensAthensGreece
| | | | - Raymond Miralbell
- Department of Radiation OncologyGeneva University HospitalGenevaSwitzerland
| | - Pierre‐Yves Dietrich
- Department of Oncology and Centre de Recherche Clinique Dubois FerrariGeneva University HospitalGenevaSwitzerland
| | - Meletios A. Dimopoulos
- Hellenic Genito‐Urinary Cancer GroupAthensGreece
- Department of Clinical TherapeuticsMedical SchoolAthens UniversityAthensGreece
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Feng YH, Shen KH, Huang KH, Tzeng WS, Li CF, Lin KL. An Effective and Well Tolerated Strategy of Bladder Preservation Therapy in Cisplatin-Ineligible Patients With Muscle-Invasive Bladder Cancer. Clin Genitourin Cancer 2015; 14:e67-74. [PMID: 26428609 DOI: 10.1016/j.clgc.2015.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 08/03/2015] [Accepted: 08/24/2015] [Indexed: 10/23/2022]
Abstract
UNLABELLED To investigate bladder preservation therapy with a well tolerated strategy, 30 patients with bladder cancer underwent concomitant chemoradiotherapy with weekly carboplatin. The 2-year overall survival was 75% for all patients, 43% and 95% for patients without adjuvant chemotherapy or with adjuvant chemotherapy separately. This strategy was well tolerated with 7% of Grade 3/4 late bladder toxicity. BACKGROUND The purpose of this study was to determine the feasibility and clinical effectiveness of concurrent weekly carboplatin chemotherapy in conjunction with definite radiation with or without adjuvant chemotherapy in the treatment of muscle-invasive bladder cancer. PATIENTS AND METHODS Between April 2010 and December 2013, 30 patients with muscle-invasive bladder cancer were evaluated retrospectively in this study. Concurrent chemoradiotherapy (CCRT) with weekly carboplatin was initiated. CCRT was followed by 2 courses of carboplatin and gemcitabine limited to patients with Eastern Cooperative Oncology Group performance status < 3 and age < 80 years. RESULTS Thirty patients were treated and all completed the CCRT protocol. Seven of 8 patients (88%) achieved a pathological complete response (pCR) with CCRT alone, and 18 of 22 patients (82%) treated with CCRT followed by adjuvant chemotherapy had a pCR. The median follow-up was 23.2 (range, 8.3-40.7) months. The median progression-free survival was 15.9 months for the CCRT group, and not sufficient to evaluate CCRT followed by adjuvant chemotherapy. The median overall survival with CCRT was 18.8 months, and had not yet been reached for CCRT with adjuvant chemotherapy. The protocol was well tolerated for adverse events. CONCLUSION Our study has shown that concomitant chemotherapy using weekly carboplatin in the management of muscle-invasive bladder cancer is feasible and well tolerated, even in older patients. Additional adjuvant chemotherapy with 2 cycles of carboplatin and gemcitabine should be encouraged in physically fit patients. These results provide a basis for randomized studies to compare this approach with conventional therapy for patients who wish to preserve the bladder.
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Affiliation(s)
- Yin-Hsun Feng
- Division of Hematology and Oncology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan, Taiwan; Department of Nursing, College of Medicine and Life Science, Chung Hwa University of Medical Technology, Tainan, Taiwan.
| | - Kun-Hung Shen
- Division of Urology, Department of Surgery, Chi-Mei Medical Center, Tainan, Taiwan; Department of Optometry, College of Medicine and Life Science, Chung Hwa University of Medical Technology, Tainan, Taiwan; Department of Urology, Taipei Medical University, Taipei, Taiwan
| | - Kuan-Hua Huang
- Division of Urology, Department of Surgery, Chi-Mei Medical Center, Tainan, Taiwan
| | - Wen-Sheng Tzeng
- Department of Medical Imaging, Chi-Mei Medical Center, Tainan, Taiwan; Department of Medical Imaging and Radiological Science, College of Health Sciences, Central Taiwan University of Science and Technology, Taichung, Taiwan
| | - Chien-Feng Li
- Department of Pathology, Chi-Mei Medical Center, Tainan, Taiwan
| | - Kuei-Li Lin
- Department of Radiation Oncology, Chi-Mei Medical Center, Tainan, Taiwan.
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Régnier É, Nguyen T, Beckendorf V, Lagrange JL. Marges en radiothérapie du cancer de la vessie. Cancer Radiother 2013; 17:470-6. [DOI: 10.1016/j.canrad.2013.06.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Revised: 06/14/2013] [Accepted: 06/21/2013] [Indexed: 10/26/2022]
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Transurethral resection, neoadjuvant chemotherapy and accelerated hyperfractionated radiotherapy (concomitant boost), with or without concurrent cisplatin, for patients with invasive bladder cancer - clinical outcome. Contemp Oncol (Pozn) 2013; 17:302-6. [PMID: 24596519 PMCID: PMC3934068 DOI: 10.5114/wo.2013.35276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Revised: 11/25/2012] [Accepted: 01/10/2013] [Indexed: 11/17/2022] Open
Abstract
AIM OF THE STUDY To evaluate the toxicity, clinical effectiveness and survival rate of transurethral resection, neoadjuvant chemotherapy and accelerated hyperfractionated radiotherapy (concomitant boost), with or without concurrent cisplatin in patients with muscle invasive bladder cancer. MATERIAL AND METHODS Between March 2004 and December 2009, 35 patients with histologically proven invasive carcinoma of the bladder (T2-4a, N0-1, M0), who were fit for combined radiochemotherapy and refused radical surgery or were medically or surgically inoperable, were selected for the bladder-sparing protocol. RESULTS In this study, twenty-five patients (25/35; 72%) received two cycles of neoadjuvant chemotherapy, and ten of them (10/35; 28%) only one, because of treatment-related toxicity. In twenty-one patients (21/35; 60%) chemotherapy consisting of gemcitabine with cisplatin and in fourteen patients (14/35; 40%) gemcitabine with carboplatin were applied. Only 13 patients (13/35; 37%) received combined irradiation with cisplatin. All patients completed their planned course of radiation therapy. Complete response (CR) occurred in 26/35 (74%) patients, partial response (PR) in 2/35(6%), and stable disease (SD) in 7/35 (20%). The overall actuarial survival rates at 3 and 5 years were 75% and 66%, respectively. Disease-specific actuarial survival rates at 3 and 5 years were 81% and 71%, respectively. CONCLUSIONS Conservative treatment of patients with muscle-invasive bladder cancer by transurethral resection, neoadjuvant chemotherapy, and accelerated hyperfractionated radiotherapy with concomitant boost, with or without concurrent cisplatin, provides a high probability of local and distal response with acceptable toxicity in properly selected patients.
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Conservative treatment in patients with muscle-invasive bladder cancer by transurethral resection, neoadjuvant chemotherapy with gemcitabine and cisplatin, and accelerated radiotherapy with concomitant boost plus concurrent cisplatin – assessment of response and toxicity. Rep Pract Oncol Radiother 2008. [DOI: 10.1016/s1507-1367(10)60016-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Koukourakis MI, Tsolos C, Touloupidis S. Radical hypofractionated accelerated radiotherapy with cytoprotection for invasive bladder cancer. Urology 2007; 69:245-50. [PMID: 17320657 DOI: 10.1016/j.urology.2006.09.064] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2006] [Revised: 08/17/2006] [Accepted: 09/29/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To report a series of patients with bladder cancer treated with hypofractionated accelerated radiotherapy with amifostine cytoprotection, with or without concurrent liposomal doxorubicin. Radiochemotherapy has been shown to be an effective alternative to cystectomy. METHODS A total of 38 patients with invasive bladder cancer were treated with 15 consecutive fractions of 3.4 Gy (2.7 Gy to the pelvis and a 0.7-Gy concomitant boost to the bladder; total biologic dose 66 to 72 Gy in 19 days). An individualized amifostine dose of up to 1000 mg was given subcutaneously before each radiotherapy fraction. Nineteen patients received concomitant liposomal doxorubicin (25 mg/m2 every 2 weeks for six cycles). RESULTS Of the 38 patients, 33 tolerated a daily amifostine dose of 750 to 1000 mg well. For these patients, the acute radiation toxicity in the bladder and rectum was minimal. Liposomal doxorubicin did not increase radiation sequela and had no systemic side effects. At a median follow-up of 22 months, severe late sequelae were infrequent (5.5% dysuria grade 2, 7.8% frequency grade 1, and 2.8% incontinence grade 2). Cystoscopy confirmed significant bladder shrinkage in 8% of patients. Intermittent rectal urgency was noted in only 5.5% of patients. A complete response was obtained in 32 (84.2%) of 38 patients. Despite the 10% greater complete response rate noted in patients receiving chemotherapy, the difference did not reach statistical significance. The 2-year local relapse-free survival rate was 80%. CONCLUSIONS Hypofractionated accelerated radiotherapy with amifostine cytoprotection with or without concomitant liposomal doxorubicin provided high control rates of bladder cancer with low toxicity, and also had the advantage of reducing by 4 weeks the overall treatment time compared with standard radiotherapy.
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Affiliation(s)
- Michael I Koukourakis
- Department of Radiotherapy and Oncology, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece.
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Muren LP, Redpath AT, McLaren D, Rørvik J, Halvorsen OJ, Høstmark J, Bakke A, Thwaites D, Dahl O. A concomitant tumour boost in bladder irradiation: Patient suitability and the potential of intensity-modulated radiotherapy. Radiother Oncol 2006; 80:98-105. [PMID: 16876274 DOI: 10.1016/j.radonc.2006.06.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2005] [Revised: 06/13/2006] [Accepted: 06/26/2006] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND PURPOSE In radiotherapy (RT) of bladder cancer, dose escalation without increased adverse effects could be achieved with a concomitant bladder tumour boost. In this study we quantified (1) the fraction of patients suitable for this approach, and (2) the potential of intensity-modulated RT (IMRT) to achieve this boost while also sparing normal tissues. MATERIALS AND METHODS The fraction of patients suitable for this boost approach was quantified using both a series of 30 radical therapy candidates, and a series of 15 consecutive RT patients. IMRT plans with 3, 5, 7 and 9 equi-spaced beams were set up for the patients in the RT series found suitable for a boost. Two sets of targets were defined, with (i) wide and (ii) narrow margins around both the tumour (prescribed 120% dose) and the non-involved bladder (prescribed 100% dose). The inverse planning optimisation minimised the dose deviation across the targets whilst fulfilling dose-volume histogram (DVH) constraints--based on what could be achieved with conformal RT (CRT)--for both the normal tissues and the targets. RESULTS Fourteen of the 30 radical therapy candidates (47%) and 10 of the 15 RT patients (67%) were suitable for a boost. The 20% boost could be obtained while maintaining target coverage with at least one IMRT plan in 9 of 10 cases with wide margins and for all 10 cases with narrow margins. Using wide margins, all 3-field plans were unacceptable, the 5-field plans were acceptable for 5 of 10, and the 7- and 9-field plans for 9 of the 10 patients. The normal tissue volumes receiving doses >100% were on average reduced by a factor of 3-4 compared with CRT. The normal tissue volumes receiving intermediate doses (73-88%) decreased slightly, whereas volumes receiving the lowest doses (30-48%) increased with the number of beams. The use of narrow margins resulted in markedly lower normal tissue irradiation. CONCLUSION This study has shown bladder tumour boosting to be both clinically relevant and technically feasible using IMRT. This approach is ready for clinical implementation, although further improvement could be expected if integrated with target localisation techniques.
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Affiliation(s)
- Ludvig Paul Muren
- Section of Oncology, Institute of Medicine, Medical Faculty, University of Bergen, Norway.
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Hata M, Miyanaga N, Tokuuye K, Saida Y, Ohara K, Sugahara S, Kagei K, Igaki H, Hashimoto T, Hattori K, Shimazui T, Akaza H, Akine Y. Proton beam therapy for invasive bladder cancer: A prospective study of bladder-preserving therapy with combined radiotherapy and intra-arterial chemotherapy. Int J Radiat Oncol Biol Phys 2006; 64:1371-9. [PMID: 16580495 DOI: 10.1016/j.ijrobp.2005.10.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2005] [Revised: 08/29/2005] [Accepted: 10/05/2005] [Indexed: 10/24/2022]
Abstract
PURPOSE To present outcomes of bladder-preserving therapy with proton beam irradiation in patients with invasive bladder cancer. METHODS AND MATERIALS Twenty-five patients with transitional cell carcinoma of the urinary bladder, cT2-3N0M0, underwent transurethral resection of bladder tumor(s), followed by pelvic X-ray irradiation combined with intra-arterial chemotherapy with methotrexate and cisplatin. Upon completion of these treatments, patients were evaluated by transurethral resection biopsy. Patients with no residual tumor received proton irradiation boost to the primary sites, whereas patients demonstrating residual tumors underwent radical cystectomy. RESULTS Of 25 patients, 23 (92%) were free of residual tumor at the time of re-evaluation; consequently, proton beam therapy was applied. The remaining 2 patients presenting with residual tumors underwent radical cystectomy. Of the 23 patients treated with proton beam therapy, 9 experienced recurrence at the median follow-up time of 4.8 years: local recurrences and distant metastases in 6 and 2 patients, respectively, and both situations in 1. The 5-year overall, disease-free, and cause-specific survival rates were 60%, 50%, and 80%, respectively. The 5-year local control and bladder-preservation rates were 73% and 96%, respectively, in the patients treated with proton beam therapy. Therapy-related toxicities of Grade 3-4 were observed in 9 patients: hematologic toxicities in 6, pulmonary thrombosis in 1, and hemorrhagic cystitis in 2. CONCLUSIONS The present bladder-preserving regimen for invasive bladder cancer was feasible and effective. Proton beam therapy might improve local control and facilitate bladder preservation.
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Affiliation(s)
- Masaharu Hata
- Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan.
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Prout GR, Wesley MN, Yancik R, Ries LAG, Havlik RJ, Edwards BK. Age and comorbidity impact surgical therapy in older bladder carcinoma patients. Cancer 2005; 104:1638-47. [PMID: 16130136 DOI: 10.1002/cncr.21354] [Citation(s) in RCA: 163] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Bladder carcinoma often occurs in older patients who also may have other comorbid conditions that could influence the administration of surgical therapy. The current study was conducted to describe the distribution of comorbid conditions in patients with bladder carcinoma and ascertain whether these conditions, as grouped by the American Society of Anesthesiologists physical status classification, affected the choice of surgical therapy. METHODS The authors examined six population-based cancer registries from the National Cancer Institute's Surveillance, Epidemiology, and End Results Program in 1992. A total of 820 individuals age 55 years and older was found. A random sample of newly diagnosed bladder carcinoma patients were stratified according to registry, age group (ages 55-64 yrs, ages 65-74 yrs, and age 75 yrs and older), and gender. Data regarding comorbid conditions were abstracted from the medical records and merged with routinely collected cancer registry data. The main outcome measures were the prevalence and distribution of comorbid conditions, American Society of Anesthesiologists physical status classification, and the receipt of cystectomy in patients with muscle invasion. RESULTS Hypertension, chronic pulmonary disease, arthritis, and heart disease were found to affect at least 15% of the study population. Approximately 38% of patients were current or former smokers. Greater than 90% of patients with superficial disease were treated with transurethral resection alone. Among those patients with muscle invasion, only 55% of those ages 55-59 years underwent cystectomy; this percentage dropped to 4% in patients age 85 years and older. Among patients with an American Society of Anesthesiologists physical status classification of 0-2, the cystectomy rate ranged from 53% in those ages 55-59 years to 9% in those age 85 years and older. CONCLUSIONS There were no significant treatment differences noted with regard to age among patients with superficial disease. Among those patients with muscle invasion, those age 75 years and older were less likely to undergo radical cystectomy (14%) compared with patients ages 55-64 years (48%) and those ages 65-74 years (43%). Patient age may contribute to treatment decisions in patients with muscle-invasive disease, even when comorbidity is taken into account.
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Affiliation(s)
- George R Prout
- Urological Services, Massachusetts General Hospital, Boston, MA, USA
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Muren LP, Smaaland R, Dahl O. Conformal radiotherapy of urinary bladder cancer. Radiother Oncol 2004; 73:387-98. [PMID: 15588887 DOI: 10.1016/j.radonc.2004.08.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2003] [Revised: 07/07/2004] [Accepted: 08/10/2004] [Indexed: 11/16/2022]
Abstract
Recent advances in radiotherapy (RT) are founded on the enhanced tumour visualisation capabilities of new imaging modalities and the precise deposition of individualised radiation dose distributions made possible with the new systems for RT planning and delivery. These techniques have a large potential to also improve the results of RT of urinary bladder cancer. Major challenges to take full advantage of these advances in the management of bladder cancer are to control, and, as far as possible, reduce bladder motion, and to reliably account for the related intestine and rectum motion. If these obstacles are overcome, it should be possible in the near future to offer selected patients with muscle invading bladder cancer an organ-sparing, yet effective combined-modality treatment as an alternative to radical surgery.
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Affiliation(s)
- Ludvig Paul Muren
- Department of Oncology and Medical Physics, Haukeland University Hospital, N-5021 Bergen, Norway
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Horwich A, Dearnaley D, Huddart R, Graham J, Bessell E, Mason M, Bliss J. A randomised trial of accelerated radiotherapy for localised invasive bladder cancer. Radiother Oncol 2004; 75:34-43. [PMID: 15878099 DOI: 10.1016/j.radonc.2004.11.003] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2003] [Revised: 10/14/2004] [Accepted: 11/01/2004] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND PURPOSE To evaluate the efficacy and toxicity of an accelerated fractionation regimen to treat localised muscle invasive bladder cancer. PATIENTS AND METHODS A prospective randomised trial was undertaken in 229 patients randomised between 1988 and 1998 comparing accelerated fractionation (AF) to a dose of 60.8 Gy in 32 fractions over 26 days with conventional fractionation (CF) treating to 64 Gy in 32 fractions over 45 days. Accelerated fractionation was delivered using two fractions per day with a 6h gap between fractions and with the first daily fraction size being 1.8 Gy and the second daily fraction size being 2.0 Gy. There was a 1 week treatment gap after the first 12 fractions. Conventional fractionation was one fraction per day, 5 days per week. Eligible patients had clinical stage T2 or T3, N0 or N1, M0 transitional cell carcinoma. The primary endpoint of the trial was local control and the trial was powered to detect a 20% difference (alpha 0.05, power 90%). Secondary endpoints were toxicity and survival. RESULTS In the initial phase of the trial, randomisation was unequal such that in total 129 patients were randomised to accelerated fractionation and 100 to conventional fractionation. Acute toxicity was evaluable in 121 patients treated with AF and 96 patients treated with CF. RTOG grade 2 or 3 bowel toxicity was noted in 44% of AF patients compared to 26% of CF patients (P trend =0.001). Acute grade 2 or 3 bladder toxicity was seen in 35% of AF patients compared to 36% of CF patients (P=0.99). Late radiation toxicity was evaluated in patients surviving free from local recurrence at 2 years post treatment. Late radiation toxicity equivalent to RTOG grade 2 or more had occurred in 44% (95% CI 34-55%) of AF patients and in 38% (95% CI 26-49%) of CF patients (logrank over 5 years follow-up P=0.23). There was no significant difference in analysis of time to loss of local tumour control comparing the two treatment arms; local recurrence was recorded in 29 of the 100 patients treated with CF and in 41 of 129 patients treated with AF (logrank P=0.86). There was also no significant difference between the treatment arms comparing disease-free survival and overall survival. The overall survival figures at 3 years were for AF 54% (95% CI 45-63%) and for CF 47% (95% CI 36-57%). By 5 years the overall survival was 37% for AF and 40% for CF. There were two treatment related deaths, both on the AF arm of the trial. CONCLUSIONS This accelerated fractionation schedule did not improve on the efficacy of conventional fractionation for patients with T2 and T3 bladder cancer and accelerated fractionation was associated with increased acute bowel reactions.
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Affiliation(s)
- Alan Horwich
- Academic Unit of Radiotherapy and Oncology, The Royal Marsden NHS Trust, The Institute of Cancer Research, Sutton SM2 5PT, UK.
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Muren LP, Smaaland R, Dahl O. Organ motion, set-up variation and treatment margins in radical radiotherapy of urinary bladder cancer. Radiother Oncol 2003; 69:291-304. [PMID: 14644489 DOI: 10.1016/s0167-8140(03)00246-9] [Citation(s) in RCA: 144] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE A major challenge in conformal radiotherapy of bladder cancer is to determine adequate treatment margins. For this purpose, we therefore quantified the internal motion of the urinary bladder as well as the external patient set-up variation during a course of fractionated radiotherapy. In the light of the recently introduced ICRU-62 concept, the planning organ at risk volume, we also studied the internal motion of nearby organs at risk, the rectum and intestine. MATERIAL AND METHODS Weekly CT scans and electronic portal images (EPIs) were sampled from 20 patients during radical, conformal bladder irradiation (60-64 Gy/2 Gy in five fractions weekly). The planning scans were acquired with 70 ml of bladder contrast instilled, and patients were instructed to void before the treatment/repeat scanning sessions. Internal motion of the bladder, rectum and intestine was measured by 3-D image matching of the repeat scans to the patients' planning scans. Internal margins (CTV-to-ITV) were determined using both a direct empirical approach and an analytically derived margin recipe. The external patient set-up variability was determined by 2-D matching of front and lateral EPIs to corresponding digitally reconstructed radiographs. RESULTS A total of 149 CT scans (20 for planning, 129 during the treatment course) and 133 sets of EPIs were analysed. Bladder volumes were smaller during treatment than in the planning situation in 85% of the repeat scans. Nevertheless, we found the repeat scan bladder volumes to extend outside the planning scan bladder contours in 89% of the scans, on average with 9% of the volume (range: 0-47%). Eight patients (40%) had at least one repeat scan (25 scans in total) where displacements >15 mm were observed at one or more sides of the bladder. CTV-to-ITV margins of 10 mm inferior, 20 mm superior, 11 mm left, 8 mm right, 20 mm anterior and 14 mm posterior were required to simultaneously encompass all bladder deflections except for the largest outward deflection in all directions in 84% of the patients. Including patient set-up variation (CTV-to-PTV), we found that an additional safety margin of 2-6 mm had to be added in the various directions. The rectum expanded outside the planning contours in all repeat scans, on average with 24% of the volume (range: 2-69%). The volume of intestine found close to the bladder were significantly and negatively correlated to the bladder volume in almost half of the patients. CONCLUSION This study documented both a large internal motion of the bladder and a substantial patient set-up variation. Our current treatment margins have been adjusted according to the findings of this study. Considerable variation in position and volume of the rectum and intestine was also documented.
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Affiliation(s)
- Ludvig Paul Muren
- Department of Oncology and Medical Physics, Haukeland University Hospital, N-5021 Bergen, Norway
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Yavuz AA, Yavuz MN, Ozgur GK, Colak F, Ozyavuz R, Cimsitoglu E, Ilis E. Accelerated superfractionated radiotherapy with concomitant boost for invasive bladder cancer. Int J Radiat Oncol Biol Phys 2003; 56:734-45. [PMID: 12788179 DOI: 10.1016/s0360-3016(03)00111-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE To determine the toxicity and clinical effectiveness of accelerated superfractionated radiotherapy with delayed concomitant boost (ASCBRT) in locally invasive carcinoma of the bladder. METHODS AND MATERIALS Between July 1997 and December 2001, 87 patients (unsuitable or refusing cystectomy) with invasive bladder cancer underwent ASCBRT. The mean patient age was 66 years (range 40-90). The stage distribution was as follows: 2 T1, 51 T2, 13 T3, and 21 T4. Initially, the whole pelvis was treated by 1.8-Gy conventional daily fractions up to a total dose of 45 Gy. A small field boost covering gross disease was added as a second daily fraction (1.5 Gy) during the last 3 weeks of the 5-week schedule up to a total dose of 67.5 Gy. The interfraction interval was a minimum of 6 h. The patients were evaluated in follow-up for toxicity, local control, and survival. RESULTS All but 2 patients completed the study protocol. Grade 3 acute urinary toxicity was observed in 2 patients. Grade 2 and 3 late bladder toxicity was observed in 12 patients and 1 patient, respectively. Grade 2 and 3 late bowel toxicity was observed in 5 and 3 patients, respectively. The 3-year actuarial local control, distant disease control, cause-specific survival, and overall survival rate was 64%, 78%, 58%, and 46%, respectively. Multivariate analysis revealed T stage as independent predictor of complete response. For Stage T2 and T3, the 3-year local control rate was 77% and 48%, respectively. At the last follow-up, 53 patients (61%) were still alive with a survival time between 6 and 62 months. CONCLUSION ASCBRT is feasible with acceptable tolerance even in relatively old patients with Stage T3 or greater tumor. The encouraging locoregional control and survival results of this institutional experience, favorable compared with conventional radical and other accelerated fractionated (with or without a concomitant boost) RT series, make ASCBRT worthy of further study in a Phase III trial.
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Affiliation(s)
- A Aydin Yavuz
- Department of Radiation Oncology, Karadeniz Technical University School of Medicine, Trabzon, Turkey.
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Chen WC, Liaw CC, Chuang CK, Chen MF, Chen CS, Lin PY, Chang PL, Chu SH, Wu CT, Hong JH. Concurrent cisplatin, 5-fluorouracil, leucovorin, and radiotherapy for invasive bladder cancer. Int J Radiat Oncol Biol Phys 2003; 56:726-33. [PMID: 12788178 DOI: 10.1016/s0360-3016(03)00124-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE To investigate the tolerance and efficacy of a modified concurrent chemoradiation (CCRT) protocol for patients with invasive bladder cancer "unfit" for radical cystectomy. METHODS AND MATERIALS Twenty-three muscle-invasive bladder cancer patients who were unfit for or unwilling to receive radical cystectomy were enrolled in this study. All patients had transitional cell carcinoma of bladder, and distribution of stage was 14 (61%), 1 (4%), and 8 (35%) for T3a, T3b, and T4, respectively. This study included a relatively old-age population, with the median age being 75 and 70% of patients over 70 years old. Patients were treated with maximal transurethral resection of the bladder tumor followed by curative CCRT. The chemotherapy (C/T) regimen was comprised of cisplatin, 50 mg/m(2) intravenously (i.v.) on Day 1; 5-fluorouracil (5-FU), 500 mg/m(2)/day by continuous i.v. infusion on Days 1-3; and leucovorin, 50 mg/day by continuous i.v. infusion on Days 1-3. Chemotherapy course was repeated at 21-day intervals. The radiation dose was 44-45 Gy to whole pelvis and 60-61.2 Gy to bladder, with a daily fraction of 1.8-2 Gy. The completeness of the CCRT protocol was defined as patients receiving at least 55 Gy of radiotherapy to the whole bladder and at least three courses C/T. RESULTS Seventy-four percent of patients (17/23) completed the CCRT protocol. Radiation Therapy Oncology Group (RTOG) Grade 3 acute toxicities were observed in 4 patients, which included leucopenia, vomiting, genitourinary (GU) tract infection, and diarrhea. No treatment-related deaths occurred during the CCRT period. RTOG Grade 3 or more late complications were observed in 3 patients; one of them died of radiation cystitis superimposed with GU infection. Of the 18 patients whose response to CCRT was evaluated, a complete tumor response was documented in 16 patients (89%). With a median follow-up of 3 years, the 3-year overall survival (OS) and disease-free survival (DFS) for all patients was 69% and 65% respectively. Meanwhile, the 3-year overall and DFS rates for patients who completed CCRT vs. those who did not complete CCRT were 82% vs. 33% and 75% vs. 33%, respectively (p = 0.18 for OS and p = 0.04 for DFS). CONCLUSIONS Concurrent cisplatin, 5-FU, leucovorin, and radiotherapy for treatment of invasive bladder cancer is a feasible and promising treatment even for relatively old patients. Our results are comparable to those in recent studies by using combined modality treatment or neoadjuvant chemotherapy plus radical cystectomy. Consequently, this novel protocol warrants a prospective clinical trial and may be a safe, effective alternative to radical cystectomy.
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Affiliation(s)
- Wen-Cheng Chen
- Department of Radiation Oncology, Chang Gung Memorial Hospital, Chiayi, Taiwan
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