Treatment of T3a bladder cancer with iridium implantation

Perpetual role of brachytherapy in organ-sparing treatment for bladder cancer: a historical review

Brachytherapy-based radiotherapy has been applied for decades in the curative treatment for solitary, ≤ 5 cm bladder tumors. This review provides a historical perspective of this organ sparing approach.

A systematic search of the published literature between 1900 and 2019 was performed on the subject of bladder brachytherapy using PubMed, with digitally retrievable articles being supplemented with articles from the personal collection of the authors.

The articles were divided into consecutive time periods, each reflecting the impact of authors on the development of brachytherapy treatment: the time of pioneers, early innovators, modifiers, and recent innovators. Three case-controlled studies comparing brachytherapy-based organ-sparing treatment with cystectomy, demonstrated similarity between the two approaches in terms of disease-free and overall survival, whereas brachytherapy-based approach offered the advantage of at least 80% chance of bladder preservation. The overview was organized in a chronological order, starting from the evolution of brachytherapy from radium, followed by remote afterloading and dose-rate adjustments, and closing with modern era of high-dose-rate and image-guided brachytherapy. Importantly, we demonstrated how essential and beneficial for the patients is a close collaboration between radiation oncologists and urologists, and how adopting a modern surgical development, i.e. the laparoscopic implantation technique, which later became robot-assisted, contributed to the success of this multidisciplinary brachytherapy treatment.

We concluded that this highly effective brachytherapy method with very limited toxicity deserves more worldwide popularity.

Radiotherapy for carcinoma of the bladder: a review

Carcinoma of the bladder (CaB) is a common and important tumor in North America and Western Europe. There has been a steady increase in the incidence of CaB during the past 25 years in both of these regions with a simultaneous decrease in the mortality rates. The decrease in mortality is primarily due to an earlier diagnosis and the availability of more effective therapeutic interventions resulting from major advances in surgery and a wide use of multimodality bladder preservation therapy.The use of radiotherapy in the management of muscle-invasive CaB has undergone a major evolution. External beam radiotherapy alone is used infrequently in carefully selected patients. The same applies to the use of preoperative irradiation. Brachytherapy alone or combined with external beam radiotherapy has been used successfully in Europe but is used infrequently in North America. External beam radiotherapy is an essential component of a multimodality therapy consisting of cytoreductive surgery via transurethral resection of a bladder tumor followed by a planned combination of radiotherapy and chemotherapy. The outcomes of this bladder preservation therapy are similar to those reported in a like patient population treated with radical cystectomy. The main benefit of conservatively treated patients is functioning bladder in about 50% of those receiving conservative therapy. Radiotherapy alone or in a combination with chemotherapy remains an important and effective palliative therapy for patients with recurrent and/or metastatic CaB. Current research efforts are directed toward a better identification of important pretreatment risk factors predicting failure thus helping in a more optimal selection of patients who would benefit most from radical cystectomy or from the application of bladder preservation therapy.

Muscle invasive bladder cancer treated by transurethral resection, followed by external beam radiation and interstitial iridium-192

PURPOSE

To evaluate the results of transurethral resection (TUR), external beam radiotherapy (EBRT), and interstitial radiation (IRT) with iridium-192, using the afterloading technique in patients with muscle invasive bladder cancer.

METHODS AND MATERIALS

From May 1989 until September 1995, 66 patients with primary, solitary muscle invasive bladder cancer were treated with TUR, EBRT, and IRT, aiming at bladder preservation. According to the protocol, in three patients low-dose EBRT was applied, whereas 63 patients received high-dose EBRT. Immediately prior to IRT, 42 patients underwent a lymphnode dissection, and in 16 cases a partial cystectomy was performed. For IRT, two to five catheters were used and IRT was started within 24 h after surgery. The majority of patients received 30 Gy of IRT, with a mean dose rate of .58 Gy/h. In three patients, additional EBRT was applied following IRT. Follow-up consisted of regular cystoscopies, mostly done during joint clinics of urologist and radiation oncologist, with urine cytology routinely performed. The median follow-up period was 26 months. The Kaplan-Meier method was used for the determination of survival rates.

RESULTS

In seven patients, a bladder relapse developed. The probability of remaining bladder relapse free at 5 years was 88%. The bladder was preserved in 98% of the surviving patients. Metastases developed in 16 patients, and the probability of remaining metastasis free at 5 years was 66%. The cumulative 5-year overall and bladder and distant relapse free survival were 48% and 69%, respectively. Acute toxicity was not serious in the majority of cases; surgical correction of a persisting vesicocutaneous fistula was necessary in two patients, whereas a wound toilet had to be performed in another patient. Serious late toxicity (bladder, RTOG Grade 3) was experienced by only one patient.

CONCLUSIONS

Interstitial radiation preceded by TUR and EBRT, in a selected group of patients with muscle invasive bladder cancer, yields an excellent bladder tumor control rate with a high probability of bladder preservation. Survival was mainly dependent on the development of distant metastases. Serious acute and late toxicity was rare.