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Sargos P, Supiot S, Créhange G, Fromont-Hankard G, Barret E, Beauval JB, Brureau L, Dariane C, Fiard G, Gauthé M, Mathieu R, Roubaud G, Ruffion A, Renard-Penna R, Neuzillet Y, Rouprêt M, Ploussard G. Oncologic Impact and Safety of Pre-Operative Radiotherapy in Localized Prostate and Bladder Cancer: A Comprehensive Review from the Cancerology Committee of the Association Française d'Urologie. Cancers (Basel) 2021; 13:6070. [PMID: 34885179 PMCID: PMC8656987 DOI: 10.3390/cancers13236070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/26/2021] [Accepted: 11/28/2021] [Indexed: 11/23/2022] Open
Abstract
Preoperative radiotherapy (RT) is commonly used for the treatment of various malignancies, including sarcomas, rectal, and gynaecological cancers, but it is preferentially used as a competitive treatment to radical surgery in uro-oncology or as a salvage procedure in cases of local recurrence. Nevertheless, preoperative RT represents an attractive strategy to prevent from intraoperative tumor seeding in the operative field, to sterilize microscopic extension outside the organ, and to enhance the pathological and/or imaging tumor response rate. Several clinical works support this research field in uro-oncology. In this review article, we summarized the oncologic impact and safety of preoperative RT in localized prostate and muscle-invasive bladder cancer. Preliminary studies suggest that both modalities can be complementary as initial primary tumor treatments and that a pre-operative radiotherapy strategy could be beneficial in a well-defined population of patients who are at a very high-risk of local relapse. Future prospective trials are warranted to evaluate the oncologic benefit of such a combination of local treatments in addition to new life-prolonging systemic therapies, such as immunotherapy, and new generation hormone therapies. Moreover, the safety and the feasibility of salvage surgical procedures due to non-response or local recurrence after pelvic RT remain poorly evaluated in that context.
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Affiliation(s)
- Paul Sargos
- Department of Radiotherapy, Institut Bergonié, 33000 Bordeaux, France;
| | - Stéphane Supiot
- Department of Radiotherapy, Insitut de Cancérologie de l’Ouest, 44800 St-Herblain, France;
| | - Gilles Créhange
- Department of Radiotherapy, Institut Curie, 75005 Paris, France;
| | | | - Eric Barret
- Department of Urology, Institut Mutualiste Montsouris, 75014 Paris, France;
| | | | - Laurent Brureau
- Department of Urology, CHU de Pointe-à-Pitre, University of Antilles, University of Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)—UMR_S 1085, 97110 Pointe-à-Pitre, France;
| | - Charles Dariane
- Department of Urology, Hôpital Européen Georges-Pompidou, APHP, Paris—Paris University—U1151 Inserm-INEM, Necker, 75015 Paris, France;
| | - Gaëlle Fiard
- Department of Urology, Grenoble Alpes University Hospital, Université Grenoble Alpes, CNRS, Grenoble INP, TIMC-IMAG, 38000 Grenoble, France;
| | - Mathieu Gauthé
- Unité de Recherche Clinique en Économie de la Santé, CRESS METHODS INSERM UMR 1153, 75000 Paris, France;
| | - Romain Mathieu
- Department of Urology, CHU Rennes, 35033 Rennes, France;
| | - Guilhem Roubaud
- Department of Medical Oncology, Institut Bergonié, 33000 Bordeaux, France;
| | - Alain Ruffion
- Service d’Urologie Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 69002 Lyon, France;
- Equipe 2, Centre d’Innovation en Cancérologie de Lyon (EA 3738 CICLY), Faculté de Médecine Lyon Sud, Université Lyon 1, 69002 Lyon, France
| | - Raphaële Renard-Penna
- Department of Radiology, Sorbonne University, AP-HP, Pitie-Salpetriere Hospital, 75013 Paris, France;
| | - Yann Neuzillet
- Department of Urology, Hôpital Foch, 92151 Suresnes, France;
| | - Morgan Rouprêt
- Department of Urology, Sorbonne University, GRC 5 Predictive Onco-Uro, AP-HP, Pitie-Salpetriere Hospital, 75013 Paris, France;
| | - Guillaume Ploussard
- Department of Urology, La Croix du Sud Hôpital, 31130 Quint Fonsegrives, France;
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2
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Baumann BC, Zaghloul MS, Sargos P, Murthy V. Adjuvant and Neoadjuvant Radiation Therapy for Locally Advanced Bladder Cancer. Clin Oncol (R Coll Radiol) 2021; 33:391-399. [PMID: 33972025 DOI: 10.1016/j.clon.2021.03.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/09/2021] [Accepted: 03/26/2021] [Indexed: 01/06/2023]
Abstract
Local-regional failure for patients with ≥pT3 urothelial carcinoma after radical cystectomy is a significant clinical challenge. Prospective randomised trials have failed to show that chemotherapy reduces the risk of local-regional recurrences. Salvage treatment for local failures is difficult and often unsuccessful. There is promising evidence, particularly from a recent Egyptian National Cancer Institute trial, that radiation therapy plus chemotherapy can significantly reduce local recurrences compared with chemotherapy alone, and that this improvement in local-regional control may translate to meaningful improvements in disease-free and overall survival with acceptable toxicity. In light of the high rates of local failure following cystectomy for locally advanced disease and the progress that has been made in identifying patients at high risk of failure and the patterns of failure in the pelvis, the National Comprehensive Cancer Network guidelines were revised to include postoperative radiotherapy as an option to consider for patients with ≥pT3 disease. Here we review the problem of local-regional failure after cystectomy, identify patients who would probably benefit from adjuvant radiotherapy, review the patterns of pelvic failure after cystectomy, discuss technical details of radiation treatment and review the modern literature on this topic. Adjuvant radiotherapy should be considered as a treatment option for patients with locally advanced disease, especially those with positive margins or squamous cell carcinoma.
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Affiliation(s)
- B C Baumann
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO, USA; Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - M S Zaghloul
- National Cancer Institute, Cairo, Egypt; Children's Cancer Hospital, Cairo, Egypt
| | - P Sargos
- Department of Radiotherapy, Institut Bergonié, Bordeaux, France
| | - V Murthy
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India.
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3
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Bowa K, Mulele C, Kachimba J, Manda E, Mapulanga V, Mukosai S. A review of bladder cancer in Sub-Saharan Africa: A different disease, with a distinct presentation, assessment, and treatment. Ann Afr Med 2019; 17:99-105. [PMID: 30185677 PMCID: PMC6126046 DOI: 10.4103/aam.aam_48_17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Cancer of the bladder is the ninth leading cause of cancer in developed countries. It is the second most common urological malignancy. Transitional cell carcinoma (TCC) is the most common histological subtype in developed countries. In most of Africa, the most common type is squamous cell carcinoma (SCC). Cancer of bladder guidelines produced by the European Urological Association and the American Urological Association, including the tumor, node, and metastasis staging is focused on TCC of the bladder. Objectives The purpose of the study is to review the pathogenesis, pathology, presentation, and management of cancer of the bladder in Africa and to use this information to propose a practical staging system for SCC. Methods The study used the meta-analysis guideline provided by PRISMA using bladder cancer in Africa as the key search word. The study collected articles available on PubMed as of July 2017, Africa Online and Africa Index Medicus. PRISMA guidelines were used to screen for full-length hospital-based articles on cancer of the bladder in Africa. These articles were analyzed under four subcategories which were pathogenesis, pathology, clinical presentation, and management. The information extracted was pooled and used to propose a practical staging system for use in African settings. Results The result of evaluation of 821 articles yielded 23 full-length papers on hospital-based studies of cancer of the bladder in Africa. Cancer of the bladder in most of Africa is still predominantly SCC (53%-69%). There has been a notable increase in TCC in Africa (9%-41%). The pathogenesis is mostly schistosoma-related SCC presents late with painful hematuria and necroturia (20%). SCC responds poorly to chemotherapy or radiotherapy. The main management of SCC is open surgery. This review allowed for a practical organ-based stage of SCC of the bladder that can be used in Africa. Conclusion Bladder cancer in Africa presents differently from that in developed countries. Guidelines on cancer of the bladder may need to take account of this to improve bladder cancer management in Africa.
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Affiliation(s)
- K Bowa
- Department of Surgery, Copperbelt University School of Medicine, Ndola, Zambia
| | - C Mulele
- Department of Pathology, Copperbelt University School of Medicine, Ndola, Zambia
| | - J Kachimba
- Department of Surgery, Livingstone Central Hospital, Livingstone, Zambia
| | - E Manda
- Department of Surgery, Ndola Teaching Hospital, Ndola, Zambia
| | - V Mapulanga
- Department of Surgery, University Teaching Hospital, Lusaka, Zambia
| | - S Mukosai
- Department of Surgery, Ndola Teaching Hospital, Ndola, Zambia
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McAlpine K, Fergusson DA, Breau RH, Reynolds LF, Shorr R, Morgan SC, Eapen L, Cagiannos I, Morash C, Lavallée LT. Radiotherapy with radical cystectomy for bladder cancer: A systematic review and meta-analysis. Can Urol Assoc J 2018; 12:351-360. [PMID: 29989916 PMCID: PMC6192740 DOI: 10.5489/cuaj.5244] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Muscle-invasive bladder cancer (MIBC) is associated with high recurrence and mortality rates. The role of radiotherapy as an adjunct to radical cystectomy is not well-defined. We sought to evaluate the efficacy and safety of radiotherapy preoperatively or postoperatively for patients with MIBC receiving cystectomy compared to cystectomy alone. The primary outcome was overall survival. The secondary outcome was adverse effects. METHODS MEDLINE, EMBASE, and CENTRAL were searched on August 30, 2016 for randomized controlled trials (RCTs) of patients undergoing cystectomy for bladder cancer. A control group receiving cystectomy alone and an intervention group with radiotherapy and cystectomy were required. The Jadad score was used to assess for bias. Fifteen studies representing 10 RCTs met eligibility criteria. RESULTS A total of 996 patients were randomized in seven trials included in a meta-analysis of neoadjuvant radiotherapy. Insufficient data were available to complete a pooled analysis for adjuvant radiotherapy. There was a non-statistically significant improvement in overall survival for patients who received neo-adjuvant radiotherapy and cystectomy. At three years and five years, the odds ratios were 1.23 (95% confidence interval [CI] 0.72-2.09) and 1.26 (95% CI 0.76-2.09), respectively, in favour of neoadjuvant radiotherapy. Subgroup analyses including higher doses of radiotherapy showed greater effect on survival. CONCLUSIONS These data suggest that radiotherapy prior to cystectomy may improve overall survival. This review was limited by old studies, heterogeneous patient populations, and radiotherapy treatment techniques that may not meet current standards. There is a need for current RCTs to further evaluate this effect.
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Affiliation(s)
| | - Dean A. Fergusson
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Rodney H. Breau
- Division of Urology, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | | | - Risa Shorr
- Library Services, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Scott C. Morgan
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
- Division of Radiation Oncology, University of Ottawa, Ottawa, ON, Canada
| | - Libni Eapen
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
- Division of Radiation Oncology, University of Ottawa, Ottawa, ON, Canada
| | - Ilias Cagiannos
- Division of Urology, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Chris Morash
- Division of Urology, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Luke T. Lavallée
- Division of Urology, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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Leonetti A, D'Abbiero N, Baldari G, Andreani S, Ruffini L, Viansone AA, Buti S. Radiotherapy for the treatment of distant nodes metastases from oligometastatic urothelial cancer: A retrospective case series. Int J Urol 2018; 25:879-886. [DOI: 10.1111/iju.13773] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 07/09/2018] [Indexed: 01/08/2023]
Affiliation(s)
| | | | - Giorgio Baldari
- Nuclear Medicine Unit; University Hospital of Parma; Parma Italy
| | | | - Livia Ruffini
- Nuclear Medicine Unit; University Hospital of Parma; Parma Italy
| | | | - Sebastiano Buti
- Medical Oncology Unit; University Hospital of Parma; Parma Italy
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Sargos P, Larré S, Chapet O, Latorzeff I, Fléchon A, Roubaud G, Orré M, Belhomme S, Richaud P. [Adjuvant radiotherapy for bladder cancer in patients with risk of locoregional recurrence: Who, what and how?]. Cancer Radiother 2017; 21:67-72. [PMID: 28187997 DOI: 10.1016/j.canrad.2016.08.131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 07/26/2016] [Accepted: 08/03/2016] [Indexed: 01/22/2023]
Abstract
Radical cystectomy with extended pelvic lymph node dissection remains the standard of care for non-metastatic muscle-invasive bladder cancer. Locoregional control is a key factor in the outcome of patients since it is related to overall survival, metastasis-free survival and specific survival. Locoregional recurrence rate is directly correlated to pathological results and the quality of lymphadenectomy. In addition, while pre- or postoperative chemotherapy improved overall survival, it showed no impact on locoregional recurrence-free survival. Several recent publications have led to the development of a nomogram that predicts the risk of locoregional recurrence, in order to identify patients for which adjuvant radiotherapy could be beneficial. International cooperative groups have then come together to provide the rational for adjuvant radiotherapy, reinforced by recent technical developments limiting toxicity, and to develop prospective studies to reduce the risk of relapse. The aim of this critical literature review is to provide an overview of the elements in favor of adjuvant radiation for patients treated for muscle-invasive bladder cancer.
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Affiliation(s)
- P Sargos
- Département de radiothérapie, institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France.
| | - S Larré
- Service d'urologie, CHU de Reims, 45, rue Cognacq-Jay, 51100 Reims, France
| | - O Chapet
- Département de radiothérapie, CHU Lyon Sud, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France
| | - I Latorzeff
- Département de radiothérapie, groupe Oncorad Garonne, clinique Pasteur, bâtiment Atrium, 1, rue de la Petite-Vitesse, 31300 Toulouse, France
| | - A Fléchon
- Département d'oncologie médicale, centre Léon-Bérard, 28, promenade Léa-et-Napoléon-Bullukian, 69008 Lyon, France
| | - G Roubaud
- Département d'oncologie médicale, institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France
| | - M Orré
- Département de radiothérapie, institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France
| | - S Belhomme
- Département de physique médicale, institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France
| | - P Richaud
- Département de radiothérapie, institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France
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Sargos P, Baumann BC, Eapen LJ, Bahl A, Murthy V, Roubaud G, Orré M, Efstathiou JA, Shariat S, Larré S, Richaud P, Christodouleas JP. Adjuvant radiotherapy for pathological high-risk muscle invasive bladder cancer: time to reconsider? Transl Androl Urol 2016; 5:702-710. [PMID: 27785427 PMCID: PMC5071208 DOI: 10.21037/tau.2016.08.18] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Radical cystectomy with extended pelvic lymph-node dissection, associated with neo-adjuvant chemotherapy, remains the standard of care for advanced, non-metastatic muscle-invasive bladder cancer (MIBC). Loco-regional control is a key factor in the outcome of patients since it is related to overall survival (OS), disease-free survival (DFS) and cause-specific survival. The risk of loco-regional recurrence (LRR) is correlated to pathological factors as well as the extent of the lymphadenectomy. In addition, neither pre- nor post-operative chemotherapy have shown a clear impact on LRR-free survival. Several recent publications have led to the development of a nomogram predicting the risk of LRR, in order to identify patients most likely to benefit from adjuvant radiotherapy. Given the high risk of LRR for selected patients and improvements in radiation techniques that can reduce toxicity, there is a growing interest in adjuvant radiotherapy; international cooperative groups have come together to provide the rationale in favor of adjuvant radiotherapy. Clinical trials in order to reduce the risk of pelvic relapse are opened based on this optimizing patient selection. The aim of this critical literature review is to provide an overview of the rationale supporting the studies of adjuvant radiation for patients with pathologic high-risk MIBC.
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Affiliation(s)
- Paul Sargos
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
| | - Brian C Baumann
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Libni J Eapen
- Department of Radiation Oncology, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Amit Bahl
- Department of Radiation Oncology, University Hospitals Bristol, Bristol, UK
| | - Vedang Murthy
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | - Guilhem Roubaud
- Department of Medical Oncology, Institut Bergonié, Bordeaux, France
| | - Mathieu Orré
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Shahrokh Shariat
- Department of Urology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Stephane Larré
- Department of Urology, Reims University Hospital, Reims, France
| | - Pierre Richaud
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
| | - John P Christodouleas
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
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Orré M, Latorzeff I, Fléchon A, Xylinas E, Roubaud G, Chapet O, Richaud P, Sargos P. Radiothérapie périopératoire dans la prise en charge des tumeurs urothéliales infiltrantes de la vessie (TVIM) : une indication à reconsidérer ? ONCOLOGIE 2015. [DOI: 10.1007/s10269-015-2504-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Zaghloul MS. The need to revisit adjuvant and neoadjuvant radiotherapy in bladder cancer. Expert Rev Anticancer Ther 2014; 10:1527-8. [DOI: 10.1586/era.10.138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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10
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Zaghloul MS, Gouda I. Schistosomiasis and bladder cancer: similarities and differences from urothelial cancer. Expert Rev Anticancer Ther 2014; 12:753-63. [DOI: 10.1586/era.12.49] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Zaghloul MS. Bladder cancer and schistosomiasis. J Egypt Natl Canc Inst 2012; 24:151-9. [PMID: 23159285 DOI: 10.1016/j.jnci.2012.08.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Revised: 08/11/2012] [Accepted: 08/25/2012] [Indexed: 10/27/2022] Open
Abstract
Schistosoma-associated bladder cancer was believed, for several decades, to be a completely unique entity of disease, different from urothelial cancer. This was probably due to its distinct clinicopathologic and demographic features that varied from those of urothelial entity. The carcinogenesis is an extremely complex process resulting from the accumulation of many genetic and epigenetic changes leading to alterations in the cell proliferation regulation process. In bladder cancer, many of these carcinogenic cascades were not fully documented or somewhat conflicting. Inspite of the efforts performed, much is still needed to explore the presence or absence of the carcinogenic difference with a different etiology. The control of schistosomiasis in certain countries and the subsequent decrease in the intensity of infestation showed changing of features approaching that of urothelial tumors. However the schistosoma-associated bladder cancer presented in more advanced stages than schistosoma-non associated urothelial cancer. More recently, data are gathered that, upon applying the same treatment protocol and management care, stage by stage comparison of the treatment end-results were found to be similar in bladder cancer patients with a different etiology. All treatment options; including radical cystectomy with or without adjuvant or neoadjuvant chemo- or radiotherapy or trimodality bladder preserving treatment seem to lead to similar end-results regardless of etiologic factor(s) implicated in bladder cancer development.
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Affiliation(s)
- Mohamed S Zaghloul
- Radiation Oncology Department, Children's Cancer Hospital and National Cancer Institute, Cairo University, Cairo, Egypt.
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12
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Abstract
Background: There is a significant variation in the treatment strategies adopted for the treatment of locally advanced T3b, T4a, N1-3 and metastatic bladder cancer. There is increasing evidence that we would be able to offer them some benefit in terms of disease-free survival and improving the quality of life. This article is aimed at reviewing the current literature on the treatment strategies in locally advanced and metastatic bladder cancer. Materials and Methods: Extensive literature search was done on Medline/Pubmed from 1980-2007 using the key words - treatment of locally advanced, metastatic bladder cancer. Standard textbooks on urology, urologic oncology and monograms were reviewed. Guidelines such as National Comprehensive Cancer Network guidelines, European Urology Association guidelines and American Urology Association guidelines were also studied. Results and Conclusions: There is a place for radical cystectomy in locally advanced T3b-T4 and N1-3 bladder cancer. Radical cystectomy alone rarely cures this subgroup of patients. There is increasing evidence that meticulous surgical clearance and extended lymphadenectomy has significant impact on disease-free survival. Adjuvant chemotherapy has been found to be effective in terms of recurrence-free survival and better than cystectomy alone. Neoadjuvant chemotherapy followed by radical cystectomy also has beneficial effects in terms of downstaging the disease and improving recurrence-free survival. This perioperative chemotherapy (adjuvant/neoadjuvant) has 5-7% survival benefit and 10% reduction in the death due to cancer disease. Excellent five-year survival rates have been achieved in patients achieving pT0 stage at surgery following chemotherapy (around 80%) and overall 40% five-year survival in node positive patients, which is promising. Though practiced widely, perioperative chemotherapy is not considered as a standard of care as yet. Current ongoing trials are likely to help us in reaching a consensus over this. There is no role of preoperative or postoperative radiotherapy in locally advanced/metastatic bladder cancer except in non TCC bilharzial/squamous cell carcinoma of bladder. Use of nomograms and prognostic factor evaluation may help us in the future in predicting the disease relapse and may help us in tailoring the treatment accordingly. Newer and more effective chemotherapeutic drugs and ongoing trials will have a significant impact on the treatment strategies and outcome of these patients in the future.
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Affiliation(s)
- Makarand V Khochikar
- Department of Uro-Oncology, Siddhi Vinayak Ganapati Cancer Hospital, Miraj, India
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13
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El-Monim HA, El-Baradie MM, Younis A, Ragab Y, Labib A, El-Attar I. A prospective randomized trial for postoperative vs. preoperative adjuvant radiotherapy for muscle-invasive bladder cancer. Urol Oncol 2011; 31:359-65. [PMID: 21353794 DOI: 10.1016/j.urolonc.2011.01.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2010] [Revised: 01/07/2011] [Accepted: 01/09/2011] [Indexed: 11/29/2022]
Abstract
PURPOSE Although radical cystectomy is considered to be the primary treatment for muscle-invasive bladder cancer, it is associated with unfavorable outcome. Local recurrence is still a major problem. Survival rates as well as quality of live are far from being satisfactory. Postoperative radiotherapy is considered the standard adjuvant treatment in the NCI-Egypt. This is a prospective randomized study conducted to compare preoperative with postoperative radiotherapy as regard the survival and complication rates. PATIENTS AND METHODS In the period from May, 2004 to June 2007, 100 eligible patients were included into the study, 50 patients in each treatment arm. Pelvic irradiation was identical in both groups aiming at 50 Gy/25 Fs/5 wk. Radical cystectomy was the standard surgery. Locoregional control, survival rates, and complications rates were compared in both arms. RESULTS Patients had a median follow-up period of 32 months (range 0-69 months). Patients had an average age of 54.8 ± 9.5 years with a male/female ratio 3:1. In the present study, transitional cell carcinoma constitutes (51%), while squamous cell carcinoma was reported in 46% of cases. Grades II and III pathology were 81% and 17%, respectively. Pathological stage P2b was encountered in 39.5% of the patients followed by P3b (33.3%) and P3a (14.6%). For the preoperative group, the 3-year overall survival, disease-free survival, locoregional control, and metastases-free survival rates were 53.4%, 47.4%, 89.3%, and 61.5%, respectively. The corresponding figures for the postoperative group were 51.8%, 34.1%, 80.6%, and 55.7% for the postoperative group. None of the patients had serious radiation reactions. CONCLUSION In our study, preoperative radiotherapy was almost equivalent to postoperative radiation therapy as regard OS, DFS, as well as complication rates. Given the recent physical developments in radiation therapy techniques and the biological rationale for treating the pelvis after cystectomy, adjuvant radiotherapy should be re-evaluated world wide. Preoperative radiotherapy may re-emerge as a useful tool for adjuvant treatment.
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Affiliation(s)
- Hassan Abd El-Monim
- Department of Radiation, National Cancer Institute, Cairo University, Cairo, Egypt
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14
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Zaghloul MS. Adjuvant and neoadjuvant radiotherapy for bladder cancer: revisited. Future Oncol 2010; 6:1177-91. [DOI: 10.2217/fon.10.82] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
To date, radical cystectomy has continued to be the treatment of choice for muscle-invasive bladder cancer. It is associated with a 5-year disease-free survival rate ranging from 27–55%. This outcome is significantly worse when reporting upon locally advanced cases. The independent prognostic factors include: tumor stage, grade, pelvic nodal involvement and some other additional factors. Beside the higher reported incidence of distant metastasis, local recurrence either alone or combined with systemic relapse has been shown to be experienced by 23–50% of locally advanced patients – a rate that was much more frequent than previously believed. Nonrandomized trials of preoperative radiotherapy have suggested improved survival rates. However, only one out of the six randomized preoperative trials in the literature published in English has proved to be significant. On the other hand, the only randomized trial and most retrospective studies dealing with postoperative radiotherapy revealed a significant increase in disease-free survival. Late complications of post operative radiotherapy, contrary to former belief, were acceptable and generally depended upon the volume of the irradiated normal tissues and the radiotherapy techniques used. Most of these adjuvant or neoadjuvant reports were performed in the 1970s and 1980s using conventional radiation techniques. Modern radiotherapy, delivering higher doses to the tumor while saving a significant amount of the surrounding normal structure, has not been rigorously tested. However, these techniques have already succeeded in improving treatment end results in other pelvic tumors.
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Affiliation(s)
- Mohamed Saad Zaghloul
- Radiation Oncology Department, Children’s Cancer Hospital (57357), Egypt & National Cancer Institute, Cairo University, 1 Sekket El Emam, Sayeda Zainab, Cairo, Egypt
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Abol-Enein H, Kava BR, Carmack AJK. Nonurothelial cancer of the bladder. Urology 2007; 69:93-104. [PMID: 17280911 DOI: 10.1016/j.urology.2006.08.1107] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2006] [Accepted: 08/22/2006] [Indexed: 10/23/2022]
Abstract
In this article, we review available evidence on the treatment of patients with nonurothelial cancer of the bladder. More than 150 published works were reviewed in preparation for this summary. Squamous cell carcinoma and adenocarcinoma are ideally treated with radical cystectomy. High-risk groups for these diseases are defined. Small cell carcinoma should be treated with multimodality therapy, including chemotherapy. Other rarer tumors of the bladder are also discussed.
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Affiliation(s)
- Hassan Abol-Enein
- Department of Urology, University of Mansoura, Urology and Nephrology Center, Egypt.
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Abstract
BACKGROUND Distant metastasis is rarely described among bilharzial bladder cancer patients. However, with improved 5-year survival rates following adjuvant local therapy, distant metastasis is now reported with increasing frequency. METHODS Three-hundred-fifty-seven bilharzial bladder cancer patients were treated at the National Cancer Institute in Cairo, Egypt, during the period 1981-1990. They were treated with either cystectomy alone, cystectomy preceded by a short course of preoperative radiotherapy (2000 cGy/5 fractions/1 week), or cystectomy followed by postoperative irradiation (5000 cGy/25 fractions/5 weeks or 3750 cGy/30 fractions/2 weeks). These patients were retrospectively analyzed. RESULTS The overall 5-year actuarial rate of distant metastasis was 23% (95% confidence interval, 21-25%), which was essentially the same in the 3 therapeutic groups. Both univariate and multivariate analyses revealed that the independent risk factors for distant metastasis were pelvic lymph node involvement (P = 0.005), pathologic stage (P = 0.004), and histopathologic grade (P = 0.05). Histologic type and local pelvic recurrence appeared in the univariate analysis as working risk factors; however, they were proven by multivariate analysis to be dependent on other risk factors. Patients who had none of the independent risk factors had a lower rate of distant metastasis (II%) and a high local control rate (88%). Those who had more than one risk factor had high distant metastasis rate (51%) and low local control rate (41%), regardless of the therapeutic modality used. The identified independent risk factors determined both the distant metastasis and the local control rates. CONCLUSIONS Unlike previous reports, this rigorous study of distant metastasis in bilharzial bladder cancer revealed an occurrence rate of 23%. This high rate was associated with pelvic lymph node involvement, pathologic stage, and histopathologic grade. Histologic type, local pelvic recurrence, or the addition of pre- or post-operative radiotherapy proved not to be independent risk factors.
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Affiliation(s)
- M S Zaghloul
- Radiotherapy Department, National Cancer Institute, Cairo, Egypt
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Duchesne GM. Radical treatment for primary bladder cancer: where are we and where do we go from here? A review. Clin Oncol (R Coll Radiol) 1994; 6:121-6. [PMID: 8018570 DOI: 10.1016/s0936-6555(05)80115-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The management of the primary tumour in muscle-invasive bladder cancer is determined more by geographical location than by firm evidence of the superiority of either surgery or radiotherapy over the other. Recent technological advances in both specialties may change their acceptability and efficacy, but as yet none has been fully evaluated. The effect of chemotherapy on primary tumour control may also influence management choices. There is a need to reexamine the merits of surgery and radiotherapy in the modern era.
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Affiliation(s)
- G M Duchesne
- Meyerstein Institute of Oncology, Middlesex Hospital, London, UK
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Parsons JT, Million RR. Role of planned preoperative irradiation in the management of clinical stage B2-C (T3) bladder carcinoma in the 1980s. SEMINARS IN SURGICAL ONCOLOGY 1989; 5:255-65. [PMID: 2672231 DOI: 10.1002/ssu.2980050408] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
In recent years the role of planned preoperative irradiation in the management of clinical stage B2-C (T3) bladder cancer has been questioned by a number of investigators. Much of the confusion regarding the efficacy of combined therapy results from studies that compare the results of treatment of pathological stage B2-C patients treated by cystectomy alone versus clinical stage B2-C patients treated by preoperative irradiation plus cystectomy. Such comparisons are biased because of 1) the exclusion of a large number of pathological stage D patients from cystectomy-alone series and their inclusion in preoperative irradiation plus cystectomy series and 2) the inclusion in the cystectomy-alone series of patients whose clinical stages were less than or equal to T2. The purpose of this paper is to compare the results of treatment in patients with clinical stage B2-C bladder carcinoma following radical cystectomy alone versus preoperative irradiation plus cystectomy. This article reviews the rationale for administering preoperative irradiation, the effect of preoperative irradiation on the pathological specimen (including down-staging, the effect on regional lymph nodes, and radioresponsiveness according to tumor configuration, i.e., papillary vs. solid), the impact of preoperative irradiation on pelvic recurrence and 5-year survival, and the effect of preoperative irradiation on operative and postoperative complications. This paper cites all known literature on the subject in the English language. Data comparing 5-year survival results of radical cystectomy alone versus preoperative irradiation plus cystectomy are analyzed in three different ways: a) retrospective comparisons of historical results, b) comparison of contemporaneous "modern-day" (1960-1980) series comprising 1185 patients who received either radical cystectomy alone or preoperative irradiation plus cystectomy, and c) review of the results of six randomized trials. Preoperative results are also analyzed according to dose level (2,000 cGy versus 4,000 cGy vs. 4,500-5,000 cGy). The data presented indicate that the addition of preoperative irradiation to cystectomy for clinical stage B2-C (T3) bladder cancer adds approximately 15-20 percentage points to the 5-year survival, leading to a survival figure that is approximately half again that achieved by cystectomy alone.
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Affiliation(s)
- J T Parsons
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville
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21
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Parsons JT, Million RR. Planned preoperative irradiation in the management of clinical stage B2-C (T3) bladder carcinoma. Int J Radiat Oncol Biol Phys 1988; 14:797-810. [PMID: 3280534 DOI: 10.1016/0360-3016(88)90102-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
In recent years the role of planned preoperative irradiation in the management of clinical Stage B2-C (T3) bladder cancer has been questioned by a number of investigators. Much of the confusion regarding the efficacy of combined therapy results from studies that compare the results of treatment of pathological Stage B2-C patients treated by cystectomy alone versus clinical Stage B2-C patients treated by preoperative irradiation plus cystectomy. Such comparisons are biased because of (1) the exclusion of a large number of Stage D patients from cystectomy-alone series and their inclusion in preoperative irradiation plus cystectomy series and (2) the inclusion in the cystectomy-alone series of patients whose clinical stages were less than or equal to T2. The purpose of this paper is to compare the results of treatment in patients with clinical Stage B2-C bladder carcinoma following radical cystectomy alone versus preoperative irradiation plus cystectomy. This article reviews the rationale for administering preoperative irradiation, the effect of preoperative irradiation on the pathological specimen (including down-staging, the effect on regional lymph nodes, and radioresponsiveness according to tumor configuration, i.e., papillary vs. solid), the impact of preoperative irradiation on pelvic recurrence and 5-year survival, and the effect of preoperative irradiation on operative and postoperative complications. This paper cites all known literature on the subject in the English language. Data comparing 5-year survival results between radical cystectomy alone versus preoperative irradiation plus cystectomy are analyzed in three different ways: (a) retrospective comparisons of historical results, (b) review of the results of 6 randomized trials, and (c) comparison of concomitantly treated "modern-day" (1960-1980) series treated by either radical cystectomy alone versus preoperative irradiation plus cystectomy in 1185 patients. Preoperative results are also analyzed according to dose level (2000 rad versus 4000 rad versus 4500-5000 rad). The data presented indicate that the addition of preoperative irradiation to cystectomy for clinical Stage B2-C (T3) bladder cancer adds approximately 15 to 20 percentage points to the 5-year survival, leading to a survival figure that is approximately half-again that achieved by cystectomy alone.
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Affiliation(s)
- J T Parsons
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville
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Zaghloul MS, Awwad HK, Soliman O, Omar S, el Badawy S, Barsoum M, Mocktar N, Amer F. Postoperative radiotherapy of carcinoma in bilharzial bladder using a three-fractions per day regimen. Radiother Oncol 1986; 6:257-65. [PMID: 3534966 DOI: 10.1016/s0167-8140(86)80192-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Patients with T3 bladder cancer who survived surgery and proved to have P3a, P3b or P4a tumors were randomized to either no further treatment (61 patients) or postoperative total pelvic irradiation (55 patients). A three-fraction per day regime was adopted with a dose per fraction of 125 cGy and an interval of 3 h between fractions. The total dose amounted to 3750 cGy divided into 30 fractions over 12 days. Patients of the postoperative radiotherapy group were re-randomized to radiotherapy alone or radiotherapy plus misonidazole (MISO) in a daily dose of 1 g/m2 given orally 2 h before the first daily fraction. The 2-year disease-free survival rate in the cystectomy alone group was 33 +/- 6% compared to 65 +/- 6% in the postoperative radiotherapy group. The therapeutic benefit applied to the two cell types, all histological grades and stages and to patients with or without nodal metastases. The benefit of postoperative irradiation was also verified by the Cox's multivariant analysis which adjusts for the relative representation of the important prognostic factors particularly pathological stage and nodal involvement. MISO did not seem to add to the therapeutic gain. No late complications were encountered in the wall of the rectum, small bowel or uretero-intestinal anastomotic sites. This is suggested to be due to the small dose per fraction used. However, early small bowel reactions were dose-limiting.
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Awwad H, Ezzat S, Hegazy M, Dahaba N, el Bolkaini N, Abd el Baki H, Abd el Moneim H, Mansour M, Ela MA, Abd el Meguid H. Cell proliferation in carcinoma in bilharzial bladder: influence of pre-operative irradiation and clinical implications. Int J Radiat Oncol Biol Phys 1984; 10:2265-72. [PMID: 6511523 DOI: 10.1016/0360-3016(84)90232-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Cell proliferation in carcinoma in the bilharzial bladder was studied in 92 patients in terms of the in vitro labeling index (LI), cell density (CD) and labeled cell density (LCD) using the in vitro 3H-Tdr technique. Cell proliferation was much greater in high than in low grade tumors and in deep than in superficial parts of the tumor, but was much less dependent on cell type; transitional cell cancer had the highest activity followed by squamous cell and adenocarcinoma. The probability of local recurrence after cystectomy decreased markedly when the LI exceeded 5.0%. The influence of the following three pre-operative radiotherapy regimens was studied: split-course (SC): the initial course consisted of 20 Gy in 10 treatments with a similar course was given after one week, hyper-fractionation using 17 treatments 0.6 Gy each on two successive days, this 2-day course of 20 Gy was repeated after one week, and concentrated irradiation consisting of two treatments, 6.0 Gy each with a gap of one week. Cystectomy was performed 14-20 days after treatment in all groups. Preoperative irradiation was generally associated with an increased probability of local control. The unfavorable influence of a high pretreatment LI was not noted after pre-operative irradiation. The CD was also reduced in proportion to the pretreatment LI. It is proposed that the response to irradiation was proportional to the initial proliferation activity and hence the prognostic significance of tumor grade and pretreatment LI was masked. Postirradiation tumor volume reduction was a strong predictor of treatment outcome. Concentrated irradiation was the least efficient pre-operative irradiation regimen and was associated with the least tumor volume reduction.
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Awwad HK, Akhoush H, El-Merzabani M, El Badawy S, Barsoum M, el Baki HA. Experience in the radical radiotherapy of cancer in the bilharzial bladder: the use of misonidazole. Radiother Oncol 1984; 2:1-8. [PMID: 6095372 DOI: 10.1016/s0167-8140(84)80031-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The results of application of a protracted split-course radiotherapy regimen in T3 carcinoma in the bilharzial bladder are presented. A total dose of 70 Gy spread over 61 days was divided into four courses separated by gaps of 1, 2 and 1 week, respectively. Each of the first three sessions comprised eight fractions, 2.5 Gy each, while four such fractions were given during the fourth course. Patients were randomized between radiotherapy alone (32 patients) and radiotherapy plus misonidazole (MIS) (30 patients). The drug was given in a daily oral dose of 0.5 g/m2, 3.5 h prior to each radiation treatment. The treatment was well tolerated and MIS did not augment the radiation reaction. Mild or moderate peripheral neuropathy was experienced by 63% of patients of the group. Age and degree of upper obstructive uropathy were the most important determinants of the risk of neuropathy. The 2-year disease-free actuarial survival rates amounted to 58% and 44% in the MIS and radiotherapy alone groups respectively; the difference is not significant. The results were significantly better in case of transitional cell (67%) than squamous cell cancer (29%) but were independent of the histological grade. A strong correlation was found between the magnitude of tumour volume reduction after 40 Gy and the long-term end results.
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Caldwell WL. Preoperative irradiation of patients with T3 carcinoma in bilharzial bladder. Int J Radiat Oncol Biol Phys 1979; 5:1007-8. [PMID: 511614 DOI: 10.1016/0360-3016(79)90608-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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