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Fonteyne V, Dirix P, Van Praet C, Berghen C, Albersen M, Junius S, Liefhooghe N, Noé L, De Meerleer G, Ost P, Villeirs G, Verbeke S, De Maeseneer D, Rammant E, Verghote F, Elhaseen E, De Man K, Decaestecker K. Adjuvant Radiotherapy After Radical Cystectomy for Patients with High-risk Muscle-invasive Bladder Cancer: Results of a Multicentric Phase II Trial. Eur Urol Focus 2022; 8:1238-1245. [PMID: 34893458 DOI: 10.1016/j.euf.2021.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/27/2021] [Accepted: 11/18/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND High-risk muscle-invasive bladder cancer (MIBC) has a poor prognosis. Old trials showed that external beam radiotherapy (EBRT) after radical cystectomy (RC) decreases the incidence of local recurrences but induces severe toxicity. OBJECTIVE To evaluate the toxicity and local control rate after adjuvant EBRT after RC delivered with volumetric arc radiotherapy. DESIGN, SETTING, AND PARTICIPANTS This is a multicentric phase 2 trial. From August 2014 till October 2020, we treated 72 high-risk MIBC patients with adjuvant EBRT after RC. High-risk MIBC is defined as ≥pT3-MIBC ± lymphovascular invasion, fewer than ten lymph nodes removed, pathological positive lymph nodes, or positive surgical margins. INTERVENTION Patients received 50 Gy in 25 fractions with intensity-modulated radiotherapy to the pelvic lymph nodes ± cystectomy bed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome is acute toxicity. We report on local relapse-free rate (LRFR), clinical relapse-free survival (CRFS), overall survival (OS), and bladder cancer-specific survival (BCSS). RESULTS AND LIMITATIONS The median follow-up is 18 mo. Forty-two patients (61%) developed acute grade 2 gastrointestinal (GI) toxicity. Four patients (6%) had acute grade 3 GI toxicity. One patient had grade 5 diarrhea and vomiting due to obstruction at 1 mo. Two-year probabilities of developing grade ≥3 and ≥2 GI toxicity were 17% and 76%, respectively. Urinary toxicity, assessed in 17 patients with a neobladder, was acceptable with acute grade 2 and 3 urinary toxicity reported in 53% (N = 9) and 18% (N = 3) of the patients, respectively. The 2-yr LRFR is 83% ± 5% and the 2-yr CRFS rate is 43% with a median CRFS time of 12 mo (95% confidence interval: 3-21 mo). Two-year OS and BCSS are 52% ± 7% and 62% ± 7%, respectively. Shortcomings are the nonrandomized study design and limited follow-up. CONCLUSIONS Adjuvant EBRT after RC can be administered without excessive severe toxicity. PATIENT SUMMARY In this report, we looked at the incidence of toxicity and local control after adjuvant external beam radiotherapy (EBRT) following radical cystectomy (RC) in high-risk muscle-invasive bladder cancer patients. We found that adjuvant EBRT was feasible and resulted in good local control. We conclude that these data support further enrollment of patients in ongoing trials to evaluate the place of adjuvant EBRT after RC.
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Affiliation(s)
- Valérie Fonteyne
- Department of Radiotherapy-Oncology, Ghent University Hospital, Ghent, Belgium.
| | - P Dirix
- Department of Radiation-Oncology, Iridium Network, Antwerp, Belgium
| | - C Van Praet
- Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - C Berghen
- Department of Radiotherapy-Oncology, University Hospitals Leuven, Leuven, Belgium
| | - M Albersen
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - S Junius
- Department of Radiotherapy-Oncology, CH-M/AMPR, Mouscron, Belgium
| | - N Liefhooghe
- Department of Radiotherapy-Oncology, AZ Groeninge, Kortrijk, Belgium
| | - L Noé
- Department of Radiotherapy-Oncology, Limburg Oncology Center, Jessa Hospital, Hasselt, Belgium
| | - G De Meerleer
- Department of Radiotherapy-Oncology, University Hospitals Leuven, Leuven, Belgium
| | - P Ost
- Department of Human structure and Repair, Ghent University, Ghent, Belgium
| | - G Villeirs
- Department of Medical Imaging, Ghent University Hospital, Ghent, Belgium
| | - S Verbeke
- Department of Pathology, Ghent University Hospital, Ghent, Belgium
| | - D De Maeseneer
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - E Rammant
- Department of Radiotherapy-Oncology, Ghent University Hospital, Ghent, Belgium
| | - F Verghote
- Department of Radiotherapy-Oncology, Ghent University Hospital, Ghent, Belgium
| | - E Elhaseen
- Department of Radiotherapy-Oncology, Ghent University Hospital, Ghent, Belgium
| | - K De Man
- Department of Medical Imaging, Ghent University Hospital, Ghent, Belgium
| | - K Decaestecker
- Department of Urology, Ghent University Hospital, Ghent, Belgium
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Verghote F, Poppe L, Verbeke S, Dirix P, Albersen M, De Meerleer G, Berghen C, Ost P, Villeirs G, De Visschere P, De Man K, De Maeseneer D, Rottey S, Van Praet C, Decaestecker K, Fonteyne V. Evaluating the impact of 18F-FDG-PET-CT on risk stratification and treatment adaptation for patients with muscle-invasive bladder cancer (EFFORT-MIBC): a phase II prospective trial. BMC Cancer 2021; 21:1113. [PMID: 34663254 PMCID: PMC8522089 DOI: 10.1186/s12885-021-08861-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 10/11/2021] [Indexed: 12/09/2022] Open
Abstract
Background The outcome of patients with muscle-invasive bladder cancer (MIBC) remains poor, despite aggressive treatments. Inadequate primary staging, classically performed by computed tomography (CT)-imaging, could lead to inappropriate treatment and might contribute to these poor results. Although not (yet) adapted by international guidelines, several reports have indicated the superiority of 18F-fluorodeoxyglucose-positron emission tomography-CT (18F-FDG-PET-CT) compared to CT in the detection of lymph node and distant metastases. Thereby the presence of extra-vesical disease on 18F-FDG-PET-CT has been correlated with a worse overall survival. This supports the hypothesis that 18F-FDG-PET-CT is useful in stratifying MIBC patients and that adapting the treatment plan accordingly might result in improved outcome. Methods EFFORT-MIBC is a multicentric prospective phase II trial aiming to include 156 patients. Eligible patients are patients with histopathology-proven MIBC or ≥ T3 on conventional imaging treated with MIBC radical treatment, without extra-pelvic metastases on conventional imaging (thoracic CT and abdominopelvic CT/ magnetic resonance imaging (MRI)). All patients will undergo radical local therapy and if eligible neo-adjuvant chemotherapy. An 18F-FDG-PET-CT will be performed in addition to and at the timing of the conventional imaging. In case of presence of extra-pelvic metastasis on 18F-FDG-PET-CT, appropriate intensification of treatment with metastasis-directed therapy (MDT) (in case of ≤3 metastases) or systemic immunotherapy (> 3 metastases) will be provided. The primary outcome is the 2-year overall survival rate. Secondary endpoints are progression-free survival, distant metastasis-free survival, disease-specific survival and quality of life. Furthermore, the added diagnostic value of 18F-FDG-PET-CT compared to conventional imaging will be evaluated and biomarkers in tumor specimen, urine and blood will be correlated with primary and secondary endpoints. Discussion This is a prospective phase II trial evaluating the impact of 18F-FDG-PET-CT in stratifying patients with primary MIBC and tailoring the treatment accordingly. We hypothesize that the information on the pelvic nodes can be used to guide local treatment and that the presence of extra-pelvic metastases enables MDT or necessitates the early initiation of immunotherapy leading to an improved outcome. Trial registration The Ethics Committee of the Ghent University Hospital (BC-07456) approved this study on 11/5/2020. The trial was registered on ClinicalTrials.gov (NCT04724928) on 21/1/2021. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-08861-x.
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Affiliation(s)
- Flor Verghote
- Department of Radiotherapy-Oncology, Ghent University Hospital, Ghent, Belgium. .,Department of Human structure and Repair, Ghent University, Ghent, Belgium.
| | - Lindsay Poppe
- Department of Radiotherapy-Oncology, Ghent University Hospital, Ghent, Belgium.,Department of Human structure and Repair, Ghent University, Ghent, Belgium
| | - Sofie Verbeke
- Department of Pathology, Ghent University Hospital, Ghent, Belgium
| | - Piet Dirix
- Department of Radiation-Oncology, Iridium Network, Antwerp, Belgium
| | - Maarten Albersen
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Gert De Meerleer
- Department of Radiotherapy-Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Charlien Berghen
- Department of Radiotherapy-Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Piet Ost
- Department of Human structure and Repair, Ghent University, Ghent, Belgium
| | - Geert Villeirs
- Department of Radiology, Ghent University Hospital, Ghent, Belgium
| | | | - Kathia De Man
- Department of Nuclear Medicine, Ghent University Hospital, Ghent, Belgium
| | - Daan De Maeseneer
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Sylvie Rottey
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Charles Van Praet
- Department of Human structure and Repair, Ghent University, Ghent, Belgium.,Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - Karel Decaestecker
- Department of Human structure and Repair, Ghent University, Ghent, Belgium.,Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - Valérie Fonteyne
- Department of Radiotherapy-Oncology, Ghent University Hospital, Ghent, Belgium.,Department of Human structure and Repair, Ghent University, Ghent, Belgium
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