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Ghali F, Holt SK, Koehne EL, Chen JJ, Weg ES, Liao JJ, Zeng J, Grivas P, Hawley JE, Hsieh AC, Montgomery RB, Wright JL. Patterns of chemotherapy use with primary radiotherapy for localized bladder cancer in patients 65 or older. Front Oncol 2024; 14:1341655. [PMID: 38812783 PMCID: PMC11133586 DOI: 10.3389/fonc.2024.1341655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 04/08/2024] [Indexed: 05/31/2024] Open
Abstract
Introduction Bladder preservation with concurrent chemoradiotherapy after maximum transurethral resection of bladder tumor is an alternative to radical cystectomy in select patients with muscle invasive bladder cancer (MIBC). Concurrent administration of radio-sensitizing chemotherapy and radiation therapy (RT) has been shown to have superior disease control compared with RT alone and can often be administered with modest added toxicity. We sought to describe national patterns of chemotherapy use. Methods The linked surveillance, epidemiology, and end results (SEER)-Medicare database was used to identify patients with cT2-4, N0/X, M0/X BC who received radiation between 2004 and 2018. Data on demographics, clinicopathologic factors, therapy and outcomes were extracted. Concurrent utilization of chemotherapy with RT was also identified (CRT). Multivariate logistic regression (MVA) models were used to explore factors associated with receipt of chemotherapy and overall survival (OS). Results 2190 patients met inclusion criteria. Of these, 850 (38.8%) received no chemotherapy. Among those receiving chemotherapy, the most frequent regimens were single agent carboplatin, cisplatin, or gemcitabine. Factors that were independently associated with decreased likelihood of chemotherapy use were increasing age (OR 0.93, CI 0.92 - 0.95), Hispanic race (compared with White, OR 0.62, CI 0.39 - 0.99), cT3 or T4 (compared with cT2, OR 0.70, CI 0.55 - 0.90), and lower National Cancer Institute comorbidity index (OR 0.60, CI 0.51 - 0.70) (p < 0.05). Variables independently associated with increased likelihood of receipt of chemotherapy were married status (OR 1.28, CI 1.06 - 1.54), higher socioeconomic status (OR 1.31, CI 1.06 - 1.64), and later year of diagnosis (OR 1.09, CI 1.06 - 1.12). Receipt of concurrent chemotherapy with RT was associated with superior OS compared with RT alone. Conclusion Over a third of patients >/65 years old receiving curative-intent RT for MIBC do not receive concurrent chemotherapy. Considering the improvement in oncologic outcomes with CRT over RT alone and more options, such as low dose gemcitabine which can be administered with modest toxicity, efforts are needed to identify barriers to utilization and increase the use of radio-sensitizing chemotherapy.
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Affiliation(s)
- Fady Ghali
- Department of Urology, Yale School of Medicine, New Haven, CT, United States
| | - Sarah K. Holt
- Department of Urology, University of Washington School of Medicine, Seattle, WA, United States
| | - Elizabeth L. Koehne
- Department of Urology, University of Washington School of Medicine, Seattle, WA, United States
| | - Jonathan J. Chen
- Division of Radiation Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, United States
| | - Emily S. Weg
- Division of Radiation Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, United States
| | - Jay J. Liao
- Division of Radiation Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, United States
| | - Jing Zeng
- Division of Radiation Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, United States
| | - Petros Grivas
- Division of Hematology Oncology, Department of Medicine, University of Washington School of medicine, Seattle, WA, United States
- Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - Jessica E. Hawley
- Division of Hematology Oncology, Department of Medicine, University of Washington School of medicine, Seattle, WA, United States
- Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - Andrew C. Hsieh
- Division of Hematology Oncology, Department of Medicine, University of Washington School of medicine, Seattle, WA, United States
- Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - Robert Bruce Montgomery
- Division of Hematology Oncology, Department of Medicine, University of Washington School of medicine, Seattle, WA, United States
- Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - Jonathan L. Wright
- Department of Urology, University of Washington School of Medicine, Seattle, WA, United States
- Fred Hutchinson Cancer Center, Seattle, WA, United States
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Abedi Z, MotieGhader H, Hosseini SS, Sheikh Beig Goharrizi MA, Masoudi-Nejad A. mRNA-miRNA bipartite networks reconstruction in different tissues of bladder cancer based on gene co-expression network analysis. Sci Rep 2022; 12:5885. [PMID: 35393513 PMCID: PMC8991185 DOI: 10.1038/s41598-022-09920-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 03/24/2022] [Indexed: 12/14/2022] Open
Abstract
Bladder cancer (BC) is one of the most important cancers worldwide, and if it is diagnosed early, its progression in humans can be prevented and long-term survival will be achieved accordingly. This study aimed to identify novel micro-RNA (miRNA) and gene-based biomarkers for diagnosing BC. The microarray dataset of BC tissues (GSE13507) listed in the GEO database was analyzed for this purpose. The gene expression data from three BC tissues including 165 primary bladder cancer (PBC), 58 normal looking-bladder mucosae surrounding cancer (NBMSC), and 23 recurrent non-muscle invasive tumor tissues (RNIT) were used to reconstruct gene co-expression networks. After preprocessing and normalization, deferentially expressed genes (DEGs) were obtained and used to construct the weighted gene co-expression network (WGCNA). Gene co-expression modules and low-preserved modules were extracted among BC tissues using network clustering. Next, the experimentally validated mRNA-miRNA interaction information were used to reconstruct three mRNA-miRNA bipartite networks. Reactome pathway database and Gene ontology (GO) was subsequently performed for the extracted genes of three bipartite networks and miRNAs, respectively. To further analyze the data, ten hub miRNAs (miRNAs with the highest degree) were selected in each bipartite network to reconstruct three bipartite subnetworks. Finally, the obtained biomarkers were comprehensively investigated and discussed in authentic studies. The obtained results from our study indicated a group of genes including PPARD, CST4, CSNK1E, PTPN14, ETV6, and ADRM1 as well as novel miRNAs (e.g., miR-16-5p, miR-335-5p, miR-124-3p, and let-7b-5p) which might be potentially associated with BC and could be a potential biomarker. Afterward, three drug-gene interaction networks were reconstructed to explore candidate drugs for the treatment of BC. The hub miRNAs in the mRNA-miRNA bipartite network played a fundamental role in BC progression; however, these findings need further investigation.
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Affiliation(s)
- Zahra Abedi
- Laboratory of Systems Biology and Bioinformatics (LBB), Institute of Biochemistry and Biophysics, University of Tehran, Tehran, Iran
| | - Habib MotieGhader
- Department of Biology, Tabriz Branch, Islamic Azad University, Tabriz, Iran.
| | - Sahar Sadat Hosseini
- Laboratory of Systems Biology and Bioinformatics (LBB), Institute of Biochemistry and Biophysics, University of Tehran, Tehran, Iran
| | | | - Ali Masoudi-Nejad
- Laboratory of Systems Biology and Bioinformatics (LBB), Institute of Biochemistry and Biophysics, University of Tehran, Tehran, Iran.
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3
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Bladder-Sparing Approaches to Treatment of Muscle-Invasive Bladder Cancer. Urol Oncol 2022. [DOI: 10.1007/978-3-030-89891-5_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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4
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Arnold CR, Lindner AK, Schachtner G, Tulchiner G, Tulchiner N, Mangesius J, Maffei M, Horninger W, Kouvaiou O, Lukas P, Ganswindt U, Pichler R, Skvortsov S. Vinorelbine in bladder-preserving multimodality treatment for muscle-invasive bladder cancer-a valid option for cisplatin-unfit patients? Strahlenther Onkol 2021; 198:25-32. [PMID: 34414475 PMCID: PMC8760228 DOI: 10.1007/s00066-021-01837-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 06/13/2021] [Indexed: 11/17/2022]
Abstract
Purpose Treatment of muscle-invasive bladder cancer (MIBC) remains challenging, especially for elderly and/or comorbid patients. Patients who are unfit for or refuse surgery should receive bladder-preserving multimodality treatment (BPMT), consisting of transurethral resection of the bladder tumor (TURB) followed by combined chemoradiotherapy (CRT). We aimed to investigate the effectiveness of vinorelbine, a chemotherapeutic agent not routinely used for MIBC, in patients referred to CRT who are unfit for standard chemotherapy and would thus rely solely on radiotherapy (RT). Methods We retrospectively analyzed 52 consecutive patients with MIBC who received standard CRT with cisplatin (n = 14), CRT with vinorelbine (n = 26), or RT alone (n = 12). Primary endpoints were median overall survival (OS) and median cancer-specific survival (CSS). Secondary endpoints were median local control (LC), median distant control (DC), and OS, CSS, LC, and DC after 1, 2, and 3 years, respectively. Results Median OS and CSS were significantly higher for patients who received vinorelbine as compared to RT alone (OS 8 vs. 22 months, p = 0.003; CSS 11 months vs. not reached, p = 0.001). Median LC and DC did not differ significantly between groups. Vinorelbine was well tolerated with no reported side effects >grade II. Conclusion Our results suggest that CRT with vinorelbine is well tolerated and superior to RT alone in terms of OS and CSS. Therefore, this treatment regime might constitute a new treatment option for patients with MIBC who are unfit for or refuse surgery or standard chemotherapy. This study encourages a randomized controlled trial to compare this new regime to current standard therapies.
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Affiliation(s)
- C R Arnold
- Department of Therapeutic Radiology and Oncology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - A K Lindner
- Department of Urology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - G Schachtner
- Department of Urology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - G Tulchiner
- Department of Urology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - N Tulchiner
- Department of Urology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - J Mangesius
- Department of Therapeutic Radiology and Oncology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - M Maffei
- Department of Radiation Oncology, General Hospital Bolzano, Lorenz Böhler Straße 5, 39100, Bolzano, Italy
| | - W Horninger
- Department of Urology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - O Kouvaiou
- Department of Therapeutic Radiology and Oncology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - P Lukas
- Department of Therapeutic Radiology and Oncology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - U Ganswindt
- Department of Therapeutic Radiology and Oncology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - R Pichler
- Department of Urology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
| | - S Skvortsov
- Department of Therapeutic Radiology and Oncology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
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5
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Kabha A, Bukchin-Tihomirov A, Shlomi I, Ammar AA, Bidder M, Amiel G, Zussman E. Biodegradable Controlled-Release Device for Localized Chemotherapeutic Treatment of Bladder Cancer. ACS Biomater Sci Eng 2021; 7:2548-2557. [PMID: 33957037 DOI: 10.1021/acsbiomaterials.1c00339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Intravesical therapy for the treatment of superficial urinary bladder tumors is promising. However, it is also challenging, due to bladder contraction and relaxation and drug elimination via urination or dilution by urine production. We developed a biodegradable drug-eluting device positioned in the renal pelvis as an alternative strategy for bladder instillation. The urine drains from the renal pelvis into the ureter, collects the eluted drug, and transports it into the bladder. The combination of the renal pelvis and the bladder creates a two-compartment system. The drug is administered into the depot compartment, the renal pelvis, and is instantly and homogeneously distributed into the central compartment, the bladder. This results in an increase in its residence time and in gradual adsorption into the urothelium. The device is inserted through the ureter, followed by upset bulging after reaching the renal pelvis in order to guarantee fixation, while preventing urinary obstruction. The device is made of electrospun poly(lactic-co-glycolic acid) (PLGA) fibers that encapsulate a chemotherapeutic drug, cisplatin (1.17-2.34% w/w). Experimental studies of the stresses developed during the bulging and simulations of the urine flow interaction with the device demonstrated structural longevity and operational safety of the device. Sustained release of 94% of the device content was demonstrated after 1 week in vitro with a flow rate of 30 mL/h. We believe that the drug-eluted device may offer a significant advantage over existing therapies for treatment of nonmuscle invasive bladder cancer.
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Affiliation(s)
- Ahmad Kabha
- NanoEngineering Group, Department of Mechanical Engineering, Technion - Israel Institute of Technology, 3200003 Haifa, Israel
| | - Alexandra Bukchin-Tihomirov
- NanoEngineering Group, Department of Mechanical Engineering, Technion - Israel Institute of Technology, 3200003 Haifa, Israel
| | - Idan Shlomi
- NanoEngineering Group, Department of Mechanical Engineering, Technion - Israel Institute of Technology, 3200003 Haifa, Israel
| | - Aiman Abu Ammar
- NanoEngineering Group, Department of Mechanical Engineering, Technion - Israel Institute of Technology, 3200003 Haifa, Israel
| | - Miri Bidder
- Department of Urology, Rambam Health Care Campus, HaAliya HaShniya St. 8, 3109601 Haifa, Israel
| | - Gilad Amiel
- Department of Urology, Rambam Health Care Campus, HaAliya HaShniya St. 8, 3109601 Haifa, Israel
| | - Eyal Zussman
- NanoEngineering Group, Department of Mechanical Engineering, Technion - Israel Institute of Technology, 3200003 Haifa, Israel
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6
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Merten R, Ott O, Haderlein M, Bertz S, Hartmann A, Wullich B, Keck B, Kühn R, Rödel CM, Weiss C, Gall C, Uter W, Fietkau R. Long-Term Experience of Chemoradiotherapy Combined with Deep Regional Hyperthermia for Organ Preservation in High-Risk Bladder Cancer (Ta, Tis, T1, T2). Oncologist 2019; 24:e1341-e1350. [PMID: 31292267 PMCID: PMC6975936 DOI: 10.1634/theoncologist.2018-0280] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 02/11/2019] [Indexed: 01/19/2023] Open
Abstract
This article reports on the different treatments for bladder cancer and related effects on frequency of bladder preservation, disease‐free survival, and overall survival, with a focus on the efficacy and safety of chemoradiotherapy combined with regional deep hyperthermia of high‐risk bladder cancer after transurethral resection of bladder tumor. Background. The aim of this study was to evaluate the efficacy and safety of chemoradiotherapy (RCT) combined with regional deep hyperthermia (RHT) of high‐risk bladder cancer after transurethral resection of bladder tumor (TUR‐BT). Materials and methods. Between 1982 and 2016, 369 patients with pTa, pTis, pT1, and pT2 cN0–1 cM0 bladder cancer were treated with a multimodal treatment after TUR‐BT. All patients received radiotherapy (RT) of the bladder and regional lymph nodes. RCT was administered to 215 patients, RCT + RHT was administered to 79 patients, and RT was used in 75 patients. Treatment response was evaluated 4–6 weeks after treatment with TUR‐BT. Results. Complete response (CR) overall was 83% (290/351), and in treatment groups was RT 68% (45/66), RCT 86% (178/208), and RCT + RHT 87% (67/77). CR was significantly improved by concurrent RCT compared with RT (odds ratio [OR], 2.32; 95% confidence interval [CI], 1.05–5.12; p = .037), less influenced by hyperthermia (OR, 2.56; 95% CI, 0.88–8.00; p = .092). Overall survival (OS) after RCT was superior to RT (hazard ratio [HR], 0.7; 95% CI, 0.50–0.99; p = .045). Five‐year OS from unadjusted Kaplan‐Meier estimates was RCT 64% versus RT 45%. Additional RHT increased 5‐year OS to 87% (HR, 0.32; 95% CI, 0.18–0.58; p = .0001). RCT + RHT compared with RCT showed a significantly better bladder‐preservation rate (HR, 0.13; 95% CI, 0.03–0.56; p = .006). Median follow‐up was 71 months. The median number of RHT sessions was five. Conclusion. The multimodal treatment consisted of a maximal TUR‐BT followed by RT; concomitant platinum‐based chemotherapy combined with RHT in patients with high‐grade bladder cancer improves local control, bladder‐preservation rate, and OS. It offers a promising alternative to surgical therapies like radical cystectomy. Implications for Practice. Radical cystectomy with appropriate lymph node dissection has long represented the standard of care for muscle‐invasive bladder cancer in medically fit patients, despite many centers reporting excellent long‐term results for bladder preserving strategies. This retrospective analysis compares different therapeutic modalities in bladder‐preservation therapy. The results of this study show that multimodal treatment consisting of maximal transurethral resection of bladder tumor followed by radiotherapy, concomitant platinum‐based chemotherapy combined with regional deep hyperthermia in patients with Ta, Tis, T1–2 bladder carcinomas improves local control, bladder‐preservation rate, and survival. More importantly, these findings offer a promising alternative to surgical therapies like radical cystectomy. The authors hope that, in the future, closer collaboration between urologists and radiotherapists will further improve treatments and therapies for the benefit of patients.
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Affiliation(s)
- Ricarda Merten
- Department of Radiation Oncology, Universitätsklinikum Erlangen Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Oliver Ott
- Department of Radiation Oncology, Universitätsklinikum Erlangen Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Marlen Haderlein
- Department of Radiation Oncology, Universitätsklinikum Erlangen Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Simone Bertz
- Institute of Pathology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Arndt Hartmann
- Institute of Pathology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Bernd Wullich
- Department of Urology and Pediatric Urology, Universitätsklinikum Erlangen Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Bastian Keck
- Department of Urology and Pediatric Urology, Universitätsklinikum Erlangen Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Reinhard Kühn
- Department of Urology, Martha Maria Medical Center, Nuremberg, Germany
| | - Claus Michael Rödel
- Department of Radiotherapy and Oncology, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Christian Weiss
- Department of Radiation Oncology, Klinikum Darmstadt GmbH, Darmstadt, Germany
| | - Christine Gall
- Department of Medical Informatics, Biometry and Epidemiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Wolfgang Uter
- Department of Medical Informatics, Biometry and Epidemiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
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Bajaj A, Martin B, Bhasin R, Hentz C, Block AM, Harkenrider MM, Solanki AA. The Impact of Academic Facility Type and Case Volume on Survival in Patients Undergoing Curative Radiation Therapy for Muscle-Invasive Bladder Cancer. Int J Radiat Oncol Biol Phys 2017; 100:851-857. [PMID: 29485062 DOI: 10.1016/j.ijrobp.2017.11.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 11/21/2017] [Accepted: 11/27/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE Bladder-preserving curative radiation therapy (RT) has been established as an excellent treatment option for select patients with muscle-invasive bladder cancer (MIBC). However, some clinicians have concerns that good outcomes are only achievable at high-volume facilities (HVFs) and academic centers (ACs), questioning successful reproducibility of curative RT at smaller centers. This study sought to determine whether treatment at ACs or HVFs was associated with better overall survival (OS) than treatment at nonacademic centers or lower-volume facilities. METHODS AND MATERIALS We performed a retrospective cohort study of National Cancer Database patients (n=2763) with cT2 to cT4 N0 M0 transitional cell MIBC who received curative RT (60-70 Gy) with or without concurrent chemotherapy. Cox proportional hazards models were used to estimate the instantaneous hazard of death as a function of univariate and multivariate patient characteristics and clinical measures. RESULTS Univariate analysis showed that academic facility type was significantly associated with improved OS (hazard ratio [HR], 0.88; 95% confidence interval [CI] 0.79-0.98; P=.02) whereas higher case volume was not associated with improved survival (HR, 0.97; 95% CI 0.92-1.01; P=.15). Multivariate analysis showed no differences in OS for treatment at ACs versus nonacademic centers (HR, 0.94; 95% CI 0.84-1.06; P=.31) or HVFs versus lower-volume facilities (HR, 0.99; 95% CI 0.94-1.04; P=.60). The 2-year OS rate was 54.5% (95% CI 52.5%-56.4%), and the 5-year OS rate was 28.9% (95% CI 27.0%-30.8%). CONCLUSIONS Although some providers are cautious about offering curative RT at all centers, this large hospital-based study suggests that facility type and volume are not significantly associated with OS for patients undergoing curative RT after we account for other clinically relevant risk factors. The results of this study demonstrate that curative RT in the treatment of MIBC may be considered for patients regardless of facility type or volume.
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Affiliation(s)
- Amishi Bajaj
- Department of Radiation Oncology, Stritch School of Medicine, Health Sciences Division, Loyola University Chicago, Maywood, Illinois
| | - Brendan Martin
- Clinical Research Office, Health Sciences Division, Loyola University Chicago, Maywood, Illinois
| | - Richa Bhasin
- Department of Radiation Oncology, Stritch School of Medicine, Health Sciences Division, Loyola University Chicago, Maywood, Illinois
| | - Courtney Hentz
- Department of Radiation Oncology, Stritch School of Medicine, Health Sciences Division, Loyola University Chicago, Maywood, Illinois
| | - Alec M Block
- Department of Radiation Oncology, Stritch School of Medicine, Health Sciences Division, Loyola University Chicago, Maywood, Illinois
| | - Matthew M Harkenrider
- Department of Radiation Oncology, Stritch School of Medicine, Health Sciences Division, Loyola University Chicago, Maywood, Illinois
| | - Abhishek A Solanki
- Department of Radiation Oncology, Stritch School of Medicine, Health Sciences Division, Loyola University Chicago, Maywood, Illinois.
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Lobo N, Mount C, Omar K, Nair R, Thurairaja R, Khan MS. Landmarks in the treatment of muscle-invasive bladder cancer. Nat Rev Urol 2017; 14:565-574. [DOI: 10.1038/nrurol.2017.82] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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9
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Bachir BG, Souhami L, Mansure JJ, Cury F, Vanhuyse M, Brimo F, Aprikian AG, Tanguay S, Sturgeon J, Kassouf W. Phase I Clinical Trial of Everolimus Combined with Trimodality Therapy in Patients with Muscle-Invasive Bladder Cancer. Bladder Cancer 2017; 3:105-112. [PMID: 28516155 PMCID: PMC5409045 DOI: 10.3233/blc-160090] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background: Local control following trimodality therapy (TMT) for muscle-invasive bladder cancer (MIBC) requires further optimization. Objective: Evaluating the biologic endpoint, feasibility, and toxicity of integrating everolimus to TMT in patients with MIBC. Methods: This was a phase I trial in patients with MIBC who were not surgical candidates or who refused cystectomy. Following maximal transurethral tumor resection, patients were treated by radiotherapy (50 Gy/20 fractions), gemcitabine (100 mg/m2/weekly) and escalating doses of everolimus (2.5–5.0 mg/day). Everolimus was given daily for one month prior to radiation, during treatment, and one month post-radiation. Toxicity assessment followed the Radiation Therapy Oncology Group Acute Radiation Morbidity Scoring Criteria. Biologic endpoint with downregulation of phospho-S6 (pS6) was assessed using immunohistochemistry. Local response was evaluated with imaging and bladder biopsy post-therapy. Results: 10 patients were recruited; 8 males, 2 females. Median age was 78 years (range: 63–85). Four patients entered everolimus 2.5 mg cohort. Six other patients entered everolimus 5.0 mg cohort. Toxicities were encountered in 2 patients (Grade I), 6 patients (Grade II), 9 patients (Grade III) and 1 patient (Grade IV), with some experiencing more than one toxicity. Most Grade III and IV toxicities were encountered from everolimus alone prior to combination testing. Trial was terminated early due to toxicity. Interestingly, 6/10 patients (60%) achieved a complete response with negative post-treatment biopsies. Significant decrease of pS6 was demonstrated post-therapy (p = 0.03). Conclusions: Although combining everolimus with TMT achieved a biological endpoint and complete response in a significant number of patients with MIBC and negative prognostic factors, it was associated with unacceptable increased toxicity.
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Affiliation(s)
- Bassel G Bachir
- Department of Urology, McGill University Health Center, Montreal, QC, Canada
| | - Luis Souhami
- Division of Oncology, Division of Radiation Oncology, McGill University Health Center, Montreal, QC, Canada
| | - Jose João Mansure
- Department of Urology, McGill University Health Center, Montreal, QC, Canada
| | - Fabio Cury
- Division of Oncology, Division of Radiation Oncology, McGill University Health Center, Montreal, QC, Canada
| | - Marie Vanhuyse
- Department of Medical Oncology, McGill University Health Center, Montreal, QC, Canada
| | - Fadi Brimo
- Department of Pathology, McGill University Health Center, Montreal, QC, Canada
| | - Armen G Aprikian
- Department of Urology, McGill University Health Center, Montreal, QC, Canada
| | - Simon Tanguay
- Department of Urology, McGill University Health Center, Montreal, QC, Canada
| | - Jeremy Sturgeon
- Department of Medical Oncology, McGill University Health Center, Montreal, QC, Canada
| | - Wassim Kassouf
- Department of Urology, McGill University Health Center, Montreal, QC, Canada
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Abstract
Systemic chemotherapy is essential for the management of muscle-invasive bladder cancer (MIBC) and metastatic bladder cancer (BCa). Neoadjuvant chemotherapy is key to the management of MIBC with many cisplatin-based regimens. Adjuvant chemotherapy may be considered for selected patients who did not receive neoadjuvant therapy. Systemic chemotherapy with radiotherapy is a critical component of a trimodal bladder-preserving approach and is superior to radiotherapy alone. Cisplatin-based chemotherapy has been the mainstay for metastatic BCa. Immunotherapy in the form of checkpoint inhibitors is a promising new drug for the treatment of BCa. Molecular characterization of each individual BCa is likely to lead to a target-directed therapeutic revolution.
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Affiliation(s)
- Ian G. Pinto
- Department of Hematology and Medical Oncology, Sir H. N. Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra, India
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11
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Thompson C, Joseph N, Sanderson B, Logue J, Wylie J, Elliott T, Lyons J, Anandadas C, Choudhury A. Tolerability of Concurrent Chemoradiation Therapy With Gemcitabine (GemX), With and Without Prior Neoadjuvant Chemotherapy, in Muscle Invasive Bladder Cancer. Int J Radiat Oncol Biol Phys 2016; 97:732-739. [PMID: 28244408 DOI: 10.1016/j.ijrobp.2016.11.040] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 11/14/2016] [Accepted: 11/21/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE The aim of this study is to assess the tolerability of concurrent chemoradiation therapy with gemcitabine (GemX) in muscle invasive bladder cancer following neoadjuvant chemotherapy (neoGemX) by use of patient- and provider-reported outcomes. METHODS AND MATERIALS Seventy-eight patients were treated with GemX. Thirty-eight received prior neoadjuvant chemotherapy (NAC). Patients were prospectively assessed during treatment and at 6 weeks and 12 months after treatment completion. Radiation therapy was given to a total dose of 52.5 Gy in 20 fractions with weekly concurrent gemcitabine chemotherapy, 100 mg/m2. Toxicity was assessed by the care provider and by a patient-reported outcome questionnaire collecting scores on the late effects in normal tissues-subjective, objective, management, and analytic scales and was statistically compared at baseline and 12 months, as well as between the neoGemX and GemX groups. RESULTS The median duration of follow-up was 15.9 months. The radiation therapy completion rate was 95%, and 96% of patients completed at least 3 cycles of gemcitabine. Bowel toxicity of grade 3 or greater was reported in 7 of 38 patients (18%) in the neoGemX group and 5 of 25 (20%) in the GemX group. Three GemX and two neoGemX patients had grade 3 or greater urinary toxicity. Forty-nine patients completed questionnaires and were included in the analysis. Scores on the late effects in normal tissues-subjective, objective, management, and analytic scales showed an expected peak by week 4 of treatment. There was no statistically significant difference between mean scores at baseline and 12 months after treatment completion or between the neoGemX and GemX groups. CONCLUSIONS This study demonstrates that GemX, alone or following NAC, has manageable toxicity and acceptable treatment completion rates. Allowing for small patient numbers and the nonrandomized nature of this study, these results do not suggest any additional toxicity from the use of NAC prior to GemX.
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Affiliation(s)
- Catherine Thompson
- University Hospitals of Morecambe Bay, Lancaster, UK; Rosemere Cancer Centre, Preston, UK.
| | - Nuradh Joseph
- General Hospital Polonnaruwa, Ministry of Health, Polonnaruwa, Sri Lanka
| | - Benjamin Sanderson
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - John Logue
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - James Wylie
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Tony Elliott
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Jeanette Lyons
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Carmel Anandadas
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Ananya Choudhury
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK; Division of Molecular and Clinical Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Rose TL, Deal AM, Ladoire S, Créhange G, Galsky MD, Rosenberg JE, Bellmunt J, Wimalasingham A, Wong YN, Harshman LC, Chowdhury S, Niegisch G, Liontos M, Yu EY, Pal SK, Chen RC, Wang AZ, Nielsen ME, Smith AB, Milowsky MI. Patterns of Bladder Preservation Therapy Utilization for Muscle-Invasive Bladder Cancer. Bladder Cancer 2016; 2:405-413. [PMID: 28035321 PMCID: PMC5181658 DOI: 10.3233/blc-160072] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background: Trimodality bladder preservation therapy (BPT) in muscle invasive bladder cancer (MIBC) includes a maximal transurethral resection followed by concurrent chemoradiotherapy as an alternative to radical cystectomy (RC) in appropriately selected patients, or as a treatment option in non-cystectomy candidates. Several chemotherapy regimens can be used in BPT, but little is known about current practice patterns. Objective: To describe utilization patterns of BPT and associated survival outcomes in MIBC. Methods: Data were collected from the Retrospective International Study of Cancers of the Urothelial Tract (RISC), a database of 3,024 consecutive patients from 29 international academic centers from 2005 to 2013. Patients with clinical T2-T4aN0M0 urothelial cancer of the bladder were included. Results: 265 patients received BPT. Compared with the 1,447 patients who received RC, BPT patients were older, had poorer performance status, and had more comorbidities (p < 0.01 for all). Median overall survival (OS) was similar for patients treated with curative radiation doses in BPT and patients treated with RC (41 vs 46 months, p = 0.33, respectively). 45% of BPT patients received concurrent chemotherapy with radiation. The most common regimens included cisplatin alone (23%), carboplatin alone (22%), gemcitabine alone (10%), paclitaxel alone (9%), and 5-FU+mitomycin (5%). There were no significant differences in survival among chemotherapy regimens. Only 10 patients (4% of BPT patients) underwent salvage cystectomy. Conclusions: In clinical practice, BPT patients have similar survival to RC patients when treated with curative radiotherapy doses. Choice of concurrent chemotherapy regimen varied widely with no clear standard. Salvage cystectomy is rarely performed. Continued research is needed on the comparative effectiveness among BPT and RC, and among chemotherapy regimens in BPT.
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Affiliation(s)
- Tracy L. Rose
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Allison M. Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sylvain Ladoire
- Georges François Leclerc Center, University of Burgundy, Dijon, France
| | - Gilles Créhange
- Georges François Leclerc Center, University of Burgundy, Dijon, France
| | | | | | - Joaquim Bellmunt
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Akhila Wimalasingham
- Barts Cancer Institute ECMC, Barts Health and the Royal Free NHS Trust, Queen Mary University of London, London, UK
| | - Yu-Ning Wong
- Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, USA
| | - Lauren C. Harshman
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | | | - Guenter Niegisch
- Department of Urology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | | | - Evan Y. Yu
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Sumanta K. Pal
- City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Ronald C. Chen
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Andrew Z. Wang
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Matthew E. Nielsen
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Angela B. Smith
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Matthew I. Milowsky
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - the Retrospective International Study of Cancers of the Urothelial Tract (RISC) Investigators
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Georges François Leclerc Center, University of Burgundy, Dijon, France
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
- Barts Cancer Institute ECMC, Barts Health and the Royal Free NHS Trust, Queen Mary University of London, London, UK
- Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, USA
- Guy’s and St. Thomas’ Hospital, London, UK
- Department of Urology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
- University of Athens, Athens, Greece
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- City of Hope Comprehensive Cancer Center, Duarte, CA, USA
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13
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Abstract
The standard treatment for muscle invasive bladder cancer (MIBC) has been considered to be radical cystectomy (RC) with pelvic lymphadenectomy. However morbidity and impact on quality of life is significant. Radiotherapy has been used in MIBC patients who choose bladder preservation or who are unfit for RC with comparable outcomes. Evidence from some prospective and large retrospective series supports the use of radiotherapy as an attractive alternative option. In this paper we review the evidence and practice of bladder preservation strategies with radiotherapy for muscle invasive bladder cancer.
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Affiliation(s)
- Arafat Mirza
- The Christie NHS Foundation Trust , Manchester, UK
| | - Ananya Choudhury
- The Christie NHS Foundation Trust, Manchester, UK; The Institute of Cancer Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
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15
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Turgeon GA, Souhami L, Cury FL, Faria SL, Duclos M, Sturgeon J, Kassouf W. Hypofractionated intensity modulated radiation therapy in combined modality treatment for bladder preservation in elderly patients with invasive bladder cancer. Int J Radiat Oncol Biol Phys 2014; 88:326-31. [PMID: 24411604 DOI: 10.1016/j.ijrobp.2013.11.005] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 11/01/2013] [Accepted: 11/04/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE/OBJECTIVE(S) To review our experience with bladder-preserving trimodality treatment (TMT) using hypofractionated intensity modulated radiation therapy (IMRT) for the treatment of elderly patients with muscle-invasive bladder cancer. METHODS AND MATERIALS Retrospective study of elderly patients treated with TMT using hypofractionated IMRT (50 Gy in 20 fractions) with concomitant weekly radiosensitizing chemotherapy. Eligibility criteria were as follows: age ≥70 years, a proven diagnosis of muscle-invasive transitional cell bladder carcinoma, stage T2-T3N0M0 disease, and receipt of TMT with curative intent. Response rate was assessed by cystoscopic evaluation and bladder biopsy. RESULTS 24 patients with a median age of 79 years were eligible. A complete response was confirmed in 83% of the patients. Of the remaining patients, 1 of them underwent salvage cystectomy, and no disease was found in the bladder on histopathologic assessment. After a median follow-up time of 28 months, of the patients with a complete response, 2 patients had muscle-invasive recurrence, 1 experienced locoregional failure, and 3 experienced distant metastasis. The overall and cancer-specific survival rates at 3 years were 61% and 71%, respectively. Of the surviving patients, 75% have a disease-free and functioning bladder. All patients completed hypofractionated IMRT, and 19 patients tolerated all 4 cycles of chemotherapy. Acute grade 3 gastrointestinal or genitourinary toxicities occurred in only 4% of the patients, and acute grade 3 or 4 hematologic toxicities, liver toxicities, or both were experienced by 17% of the cohort. No patient experienced grade 4 gastrointestinal or genitourinary toxicity. CONCLUSIONS Hypofractionated IMRT with concurrent radiosensitizing chemotherapy appears to be an effective and well-tolerated curative treatment strategy in the elderly population and should be considered for patients who are not candidates for cystectomy or who wish to avoid cystectomy.
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Affiliation(s)
- Guy-Anne Turgeon
- Department of Oncology, Division of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Luis Souhami
- Department of Oncology, Division of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada.
| | - Fabio L Cury
- Department of Oncology, Division of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sergio L Faria
- Department of Oncology, Division of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Marie Duclos
- Department of Oncology, Division of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jeremy Sturgeon
- Department of Medical Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Wassim Kassouf
- Department of Urology, McGill University Health Centre, Montreal, Quebec, Canada
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Hindson BR, Turner SL, Millar JL, Foroudi F, Gogna NK, Skala M, Kneebone A, Christie DRH, Lehman M, Wiltshire KL, Tai KH. Australian & New Zealand Faculty of Radiation Oncology Genito-Urinary Group: 2011 consensus guidelines for curative radiotherapy for urothelial carcinoma of the bladder. J Med Imaging Radiat Oncol 2012; 56:18-30. [PMID: 22339742 DOI: 10.1111/j.1754-9485.2011.02336.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Curative radiotherapy, with or without concurrent chemotherapy, is recognized as a standard treatment option for muscle-invasive bladder cancer. It is commonly used for two distinct groups of patients: either for those medically unfit for surgery, or as part of a 'bladder preserving' management plan incorporating the possibility of salvage cystectomy. However, in both situations, the approach to radiotherapy varies widely around the world. The Australian and New Zealand Faculty of Radiation Oncology Genito-Urinary Group recognised a need to develop consistent, evidence-based guidelines for patient selection and radiotherapy technique in the delivery of curative radiotherapy. Following a workshop convened in May 2009, a working party collated opinions and conducted a wide literature appraisal linking each recommendation with the best available evidence. This process was subject to ongoing re-presentation to the Faculty of Radiation Oncology Genito-Urinary Group members prior to final endorsement. These Guidelines include patient selection, radiation target delineation, dose and fractionation schedules, normal tissue constraints and investigational techniques. Particular emphasis is given to the rationale for the target volumes described. These Guidelines provide a consensus-based framework for the delivery of curative radiotherapy for muscle-invasive bladder cancer. Widespread input from radiation oncologists treating bladder cancer ensures that these techniques are feasible in practice. We recommend these Guidelines be adopted widely in order to encourage a uniformly high standard of radiotherapy in this setting, and to allow for better comparison of outcomes.
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Affiliation(s)
- Benjamin R Hindson
- William Buckland Radiation Oncology, Alfred Health, Melbourne, Victoria, Australia.
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Azuma H, Inamoto T, Takahara K, Ibuki N, Nomi H, Yamamoto K, Narumi Y, Ubai T. Neoadjuvant and adjuvant chemotherapy for locally advanced bladder carcinoma: development of novel bladder preservation approach, Osaka Medical College regimen. Int J Urol 2011; 19:26-38. [PMID: 22077821 DOI: 10.1111/j.1442-2042.2011.02856.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Cisplatin-based chemotherapy has been widely used in a neoadjuvant as well as adjuvant setting. Furthermore, trimodal approaches including complete transurethral resection of the bladder tumor followed by combined chemotherapy and radiation have generally been performed as bladder preservation therapy. However, none of the protocols have achieved a 5-year survival rate of more than 70%. Additionally, the toxicity of chemotherapy and/or a decreased quality of life due to urinary diversion cannot be ignored, as most patients with bladder cancer are elderly. We therefore newly developed the novel trimodal approach of "combined therapy using balloon-occluded arterial infusion of anticancer agent and hemodialysis with concurrent radiation, which delivers an extremely high concentration of anticancer agent to the site of a tumor without systemic adverse effects ("Osaka Medical College regimen" referred to as the OMC regimen). We initially applied the OMC regimen as neoadjuvant chemotherapy for locally advanced bladder cancer. However, since more than 85% of patients with histologically-proven urothelial cancer achieved complete response with no evidence of recurrence after a mean follow-up of 170 (range 21-814) weeks, we have been applying the OMC-regimen as a new approach for bladder sparing therapy. We summarize the advantage and/or disadvantage of chemotherapy in neoadjuvant as well as adjuvant settings, and show the details of our newly developed bladder sparing approach OMC regimen in this review.
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Affiliation(s)
- Haruhito Azuma
- Departments of Urology, Osaka Medical College, Takatsuki, Osaka, Japan.
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18
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Whole-pelvis or bladder-only chemoradiation for lymph node-negative invasive bladder cancer: single-institution experience. Int J Radiat Oncol Biol Phys 2011; 82:e457-62. [PMID: 21945107 DOI: 10.1016/j.ijrobp.2011.05.051] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Revised: 05/21/2011] [Accepted: 05/31/2011] [Indexed: 01/08/2023]
Abstract
PURPOSE Whole-pelvis (WP) concurrent chemoradiation (CCRT) is the standard bladder preserving option for patients with invasive bladder cancer. The standard practice is to treat elective pelvic lymph nodes, so our aim was to evaluate whether bladder-only (BO) CCRT leads to results similar to those obtained by standard WP-CCRT. METHODS AND MATERIALS Patient eligibility included histopathologically proven muscle-invasive bladder cancer, lymph nodes negative (T2-T4, N-) by radiology, and maximal transurethral resection of bladder tumor with normal hematologic, renal, and liver functions. Between March 2005 and May 2006, 230 patients were accrued. Patients were randomly assigned to WP-CCRT (120 patients) and BO-CCRT (110 patients). Data regarding the toxicity profile, compliance, initial complete response rates at 3 months, and occurrence of locoregional or distant failure were recorded. RESULTS With a median follow-up time of 5 years (range, 3-6), WP-CCRT was associated with a 5-year disease-free survival of 47.1% compared with 46.9% in patients treated with BO-CCRT (p = 0.5). The bladder preservation rates were 58.9% and 57.1% in WP-CCRT and BO-CCRT, respectively (p = 0.8), and the 5-year overall survival rates were 52.9% for WP-CCRT and 51% for BO-CCRT (p = 0.8). CONCLUSION BO-CCRT showed similar rates of bladder preservation, disease-free survival, and overall survival rates as those of WP-CCRT. Smaller field sizes including bladder with 2-cm margins can be used as bladder preservation protocol for patients with muscle-invasive lymph node-negative bladder cancer to minimize the side effects of CCRT.
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Zaghloul MS, Mousa AG. Trimodality treatment for bladder cancer: does modern radiotherapy improve the end results? Expert Rev Anticancer Ther 2011; 10:1933-44. [PMID: 21110759 DOI: 10.1586/era.10.156] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
With the advancement in endoscopic surgery, radiation treatment planning and execution, as well as the use of new chemotherapeutic regimens, bladder conservation has evolved into a competing alternative to radical cystectomy. Trimodality treatment has the great advantage of preserving a normally functioning urinary bladder. Despite the absence of direct randomized trials comparing both modalities, trimodality treatment comprising maximal transuretheral resection of bladder tumors followed by different regimens of combined radiochemotherapy achieved comparable results to radical cystectomy in many trials. Those who did not achieve complete remission after induction radiochemotherapy were salvaged by radical cystectomy. Improving the radiotherapeutic window is a challenging issue. In radiotherapy for bladder cancer, uncertainties include set-up errors, patient movement, internal organ movement and volume changes due to bladder filling (both inter- and intrafraction). The advancement in treatment verification procedures in modern radiotherapy and the use of fiducial markers reduces set-up errors, while adaptive radiotherapy could decrease the unnecessary irradiation of normal tissues by tracking bladder volume changes. In addition, new radiotherapeutic techniques, such as intensity-modulated radiotherapy and volume-modulated radiotherapy, permit dose escalation to the target without increasing the dose to the surrounding normal tissues.
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Affiliation(s)
- Mohamed S Zaghloul
- Radiation Oncology Department, Children's Cancer Hospital, Sayeda Zainab, Egypt.
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Choudhury A, Swindell R, Logue JP, Elliott PA, Livsey JE, Wise M, Symonds P, Wylie JP, Ramani V, Sangar V, Lyons J, Bottomley I, McCaul D, Clarke NW, Kiltie AE, Cowan RA. Phase II study of conformal hypofractionated radiotherapy with concurrent gemcitabine in muscle-invasive bladder cancer. J Clin Oncol 2011; 29:733-8. [PMID: 21205754 DOI: 10.1200/jco.2010.31.5721] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE The aim of this prospective, phase II trial was to determine the response of muscle-invasive bladder cancer (MIBC) to concurrent chemoradiotherapy of weekly gemcitabine with 4 weeks of radiotherapy (RT; GemX). PATIENTS AND METHODS Fifty patients with transitional cell carcinoma, stage T2-3, N0, M0 after transurethral resection and magnetic resonance imaging, were recruited. Gemcitabine was given intravenously at 100 mg/m(2) on days 1, 8, 15, and 22 of a 28-day RT schedule that delivered 52.5 Gy in 20 fractions. Chemotherapy was stopped for Radiation Therapy Oncology Group (RTOG) grade 3 bladder or bowel toxicity. The primary end points were tumor response, toxicity, and survival. RESULTS All patients completed RT; 46 tolerated all four cycles of gemcitabine. Two patients stopped after two cycles, and two stopped after three cycles, because of bowel toxicity. Forty-seven patients had a post-treatment cystoscopy; 44 (88%) achieved a complete endoscopic response. At a median follow-up of 36 months (range, 15 to 62 months), 36 patients were alive, and 32 of these had a functional and intact bladder. Fourteen patients died; seven died as a result of metastatic MIBC, five died as a result of intercurrent disease, and two died as a result of treatment-associated deaths. Four patients underwent cystectomy; three because of recurrent disease and one because of toxicity. One patient required a bowel resection for late toxicity. By using Kaplan-Meier analyses, 3-year cancer-specific survival was 82%, and overall survival was 75%. CONCLUSION Concurrent gemcitabine-based chemoradiotherapy (ie, GemX) produces a high response rate in MIBC and has durable local control and acceptable toxicity, which allows patients to preserve their own bladder. This treatment modality warrants additional investigation in a phase III setting.
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Affiliation(s)
- Ananya Choudhury
- The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX United Kingdom
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22
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Chimioradiothérapie concomitante des carcinomes de la vessie. Bull Cancer 2010; 97 Suppl Cancer de la vessie:19-25. [DOI: 10.1684/bdc.2010.1099] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Treatment Results of Radiation Therapy for Muscle-Invasive Bladder Cancer. Strahlenther Onkol 2010; 186:203-9. [DOI: 10.1007/s00066-010-2053-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2009] [Accepted: 11/26/2009] [Indexed: 10/19/2022]
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Joung JY, Han KS, Kim TS, Seo HK, Chung J, Lee KH. Single institutional experience of bladder-preserving trimodality treatment for muscle-invasive bladder cancer. J Korean Med Sci 2008; 23:598-603. [PMID: 18756044 PMCID: PMC2526414 DOI: 10.3346/jkms.2008.23.4.598] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The authors designed this study to determine the clinical effectiveness of trimodality treatment, i.e., transurethral resection of a bladder tumor (TURBT) and concurrent chemoradiotherapy (CRT). Twenty patients with a muscle-invasive bladder cancer were treated by TURBT followed by concurrent cisplatin (75 mg/m(2) day), administered on weeks 1 and 4 of radiotherapy. According to residual tumor status after TURBT, patients were classified into patients with a complete TURBT group and incomplete TURBT group. Response to treatment was evaluated by restaging TURBT at 4 weeks after completing CRT (post-CRT). Fifteen patients (75%) achieved complete remission (CR) at restaging; 10 patients (50%) remained continuously free of tumor recurrence. Disease-specific and overall survivals were 51.1% and 38.6% at 5 yr post-CRT, respectively. Of 16 patients in the complete TURBT group, 14 patients (87.5%) achieved CR, which was significantly different from that observed in the incomplete TURBT group, in which only 1 (25%) of 4 patients achieved CR (p=0.032). Five- year disease-specific and overall survivals were 71.6% and 53.5%, respectively. Ten patients (90.9%) maintained their own bladder among the 11 surviving patients. Trimodality treatment was found to be an effective treatment in patients who underwent complete TURBT for a muscle-invasive bladder cancer.
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Affiliation(s)
- Jae Young Joung
- Urologic Oncology Clinic, Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Kyung Seok Han
- Urologic Oncology Clinic, Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Taek Sang Kim
- Urologic Oncology Clinic, Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Ho Kyung Seo
- Urologic Oncology Clinic, Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jinsoo Chung
- Urologic Oncology Clinic, Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Kang Hyun Lee
- Urologic Oncology Clinic, Institute and Hospital, National Cancer Center, Goyang, Korea
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Koga F, Yoshida S, Kawakami S, Kageyama Y, Yokoyama M, Saito K, Fujii Y, Kobayashi T, Kihara K. Low-dose chemoradiotherapy followed by partial or radical cystectomy against muscle-invasive bladder cancer: an intent-to-treat survival analysis. Urology 2008; 72:384-8. [PMID: 18455771 DOI: 10.1016/j.urology.2008.03.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2007] [Revised: 03/07/2008] [Accepted: 03/13/2008] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To evaluate the clinical outcomes of patients with muscle-invasive bladder cancer treated with a prospective institutional protocol composed of induction low-dose chemoradiotherapy (LCRT) plus partial or radical cystectomy. METHODS From March 1997 to March 2006, 102 patients with Stage T2-T4aN0M0 bladder urothelial carcinoma consecutively underwent transurethral resection of the bladder tumor followed by LCRT consisting of radiotherapy to the bladder (radiation dose 40 Gy) concurrent with two cycles of intravenous (20 mg/d for 5 days) or intra-arterial (100 mg) cisplatin. Depending to their post-LCRT tumor status, patients were recommended to undergo partial or radical cystectomy with curative intent. RESULTS LCRT-related toxicity of grade 3 or greater was rare (3%). Of 97 eligible patients, 41 (42%) had a complete response, 29 (30%) a partial response, 24 (25%) had stable disease, and 3 (4%) progressive disease. Of the 97 patients, 19, underwent partial cystectomy, and 58 underwent radical cystectomy, 2 underwent transurethral resection of the bladder tumor, and 18 did not undergo surgery. The 5-year overall survival and cancer-specific survival (CSS) rate was 66% and 74%, respectively. The median follow-up was 43 months (range 3-126). On multivariate analysis, the response to LCRT had the strongest effect on CSS, and CSS was clearly stratified by the response to LCRT (P < .0001), with a 5-year CSS rate of 100% for the 41 patients with a complete response. CONCLUSIONS The results of our study have shown that LCRT is an effective and less-toxic induction therapy against muscle-invasive bladder cancer. Our therapeutic protocol with LCRT plus partial or radical cystectomy yielded favorable survival outcomes. The response to LCRT was the strongest prognostic factor for CSS.
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Affiliation(s)
- Fumitaka Koga
- Department of Urology, Tokyo Medical and Dental University, Graduate School, Tokyo, Japan.
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Abstract
PURPOSE To determine the maximum tolerated dose of 3D conformal radiotherapy in combination with Cisplatin for patients with recurrent malignant gliomas. METHODS From 1999-2003, nine patients with recurrent malignant glioma received fractionated radiotherapy and Cisplatin (20 mg/m2/d IV on days 1-5) in a Phase I radiation dose escalation trial. Three sequential dose levels were evaluated: 25 Gy, 30 Gy, and 35 Gy, using 5 Gy fractions. All patients received prior external beam radiation (median dose 59.4 (20-60) Gy) and five patients received prior chemotherapy. RESULTS Six male and three female patients were enrolled with a median age of 52 years, and a median Karnofsky performance status score of 70. The median re-irradiated tumor volume was 18.9 (0.1-78.5) cm3 and the median follow-up was 8.8 (3.2-31.2) months. One patient (30 Gy/ 6 fractions) experienced medically reversible acute grade 3 toxicity. A second patient (35 Gy/ 7 fractions) experienced acute grade 2 toxicity and histology showed tumor and radiation effect. A third patient (25 Gy/ 5 fractions) experienced late grade 3 toxicity from radiation necrosis. The radiological responses consisted of complete response (1 patient), partial response (1 patient), and stable disease (2 patients). The median overall survival was 8.8 months (95% CI 8.0-9.9), and the median disease free interval was 2.0 months (95% CI 1.4-4.4). Seven patients received chemotherapy following re-irradiation and Cisplatin. CONCLUSION The maximum tolerated dose of 3D conformal fractionated radiotherapy was 30 Gy in 6 fractions with low dose Cisplatin, which was well tolerated in terms of acute toxicity for our patient population. This regimen demonstrated only modest efficacy in the treatment of recurrent malignant glioma. Combinations of conformal re-irradiation and other systemic agents may merit investigation. Currently our recommended dose is 30 Gy in 6 fractions for selected patients.
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Rödel C, Weiss C, Sauer R. Trimodality Treatment and Selective Organ Preservation for Bladder Cancer. J Clin Oncol 2006; 24:5536-44. [PMID: 17158539 DOI: 10.1200/jco.2006.07.6729] [Citation(s) in RCA: 135] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Standard treatment for muscle-invasive bladder cancer is cystectomy. Trimodality treatment, including transurethral resection of the bladder tumor (TURBT), radiation therapy and chemotherapy, has been shown to produce survival rates comparable to those of cystectomy. With these programs, cystectomy has been reserved for patients with incomplete response or local relapse. During the past 15 years, organ preservation by trimodality treatment has been investigated in prospective series from single centers and cooperative groups, with more than 1,000 patients included. Five-year overall survival rates in the range of 50% to 60% have been reported, and approximately three quarters of the surviving patients maintained their bladder. Clinical criteria helpful in determining ideal patients for bladder preservation include early tumor stage (including high-risk T1 disease), a visibly complete TURBT, and absence of ureteral obstruction. Close coordination among all disciplines is required to achieve optimal results. Future investigations will focus on (1) optimizing radiation techniques and incorporating more effective systemic chemotherapy, and (2) the proper selection of patients based on molecular makers.
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Affiliation(s)
- Claus Rödel
- Department of Radiation Therapy, University of Erlangen, Erlangen, Germany.
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Sawada Y, Takeuchi Y, Iwasawa T, Kuroda K, Matsushima M, Nagamoto M, Wakayama M. Comparison of two-port and four-port irradiation in the bladder preservation therapy for locally invasive bladder cancer. Int J Urol 2006; 13:1470-4. [PMID: 17118019 DOI: 10.1111/j.1442-2042.2006.01680.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM To ascertain therapeutic effectiveness and adverse reactions with radiochemotherapy for locally invasive bladder cancer, comparison was made between two-port and four-port irradiation with intravenous cisplatin administration. METHODS In 86 patients who were diagnosed with locally invasive bladder cancer on the basis of imaging and biopsy findings, transurethral tumor resection was carried out initially to minimize tumor volume, and then radiochemotherapy was done. From 1985 to 1997, bilateral two-port irradiation was carried out, and after 1998, four-port irradiation was done. In regards to chemotherapy, cisplatin was administered intravenously. Therapeutic effects were assessed 1 month after the end of therapy. RESULTS Fifty-five patients underwent two-port irradiation; complete response (CR) was achieved in 26 and partial response (PR) in 29 patients. Thirty-one patients underwent four-port irradiation; CR was achieved in 20 patients and PR in 11 patients. The cause-specific 5-year survival rate did not differ significantly between two-port and four-port irradiation (74%vs 79%), but there was a significant difference of survival between CR and PR patients. In the two-port irradiation group, 5-year bladder preservation rate was 89% in CR patients and 52% in PR patients. In the four-port irradiation group, 5-year bladder preservation rate was 90% in CR patients and 46% in PR patients. Of the various adverse reactions, no significant differences in leukopenia, thrombocytopenia or bladder symptoms were observed between two-port and four-port irradiation, but the incidence and severity of loss of appetite, nausea and/or vomiting, diarrhea and dermatitis were significantly greater for two-port irradiation. CONCLUSION Radiochemotherapy are considered to be modest effective in the bladder preservation therapy for locally invasive bladder cancer. The four-port irradiation shows less adverse reactions than two-port irradiation.
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Affiliation(s)
- Yoshitomo Sawada
- Departmant of Urology, Toho University Medical Center Ohashi Hospital, Tokyo, Japan.
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29
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Gogna NK, Matthews JHL, Turner SL, Mameghan H, Mameghan H, Duchesne GM, Spry N, Berry MP, Keller J, Tripcony L. Efficacy and tolerability of concurrent weekly low dose cisplatin during radiation treatment of localised muscle invasive bladder transitional cell carcinoma: a report of two sequential Phase II studies from the Trans Tasman Radiation Oncology Group. Radiother Oncol 2006; 81:9-17. [PMID: 17011058 DOI: 10.1016/j.radonc.2006.09.001] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2006] [Revised: 08/20/2006] [Accepted: 09/04/2006] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE To determine the feasibility, toxicity, and clinical effectiveness of concurrent weekly cisplatin chemotherapy in conjunction with definitive radiation in the treatment of localised muscle invasive bladder cancer. PATIENTS AND METHODS In January 1997 the Trans Tasman Radiation Oncology Group embarked on a Phase II study (TROG 97.01) of weekly cisplatin (35 mg/m(2) x 7 doses) plus radiation to a dose of 63 Gy over 7 weeks. Following an interim toxicity analysis, the dose intensity of cisplatin was reduced to 6 cycles and the radiation schedule changed to 64 Gy over 6.5 weeks leading to the second study (TROG 99.06). A total of 113 patients were enrolled. RESULTS Acute grade 3 urinary toxicity occurred in 23% of the patients. Acute grade 4 pelvic toxicity was not seen. Thirty-eight patients (33%) experienced grade 3 or 4 cisplatin related toxicities with 15 patients (12%) requiring significant dose modification. The reduced dose intensity in Study 99.06 improved tolerability. Incidence of significant late morbidity was low (6%). Seventy-nine patients (70%) achieved complete remission at the 6 month cystoscopic assessment. Local invasive recurrence was seen in 11 of the 79 patients (14%). In 18 patients (16%) isolated superficial TCC/CIS were detected (6 months and beyond). The local control rate was 45% with a functional bladder being retained in 69 of the 113 patients (61%). RFS and DSS at 5 years were 33% and 50%, respectively. CONCLUSION Our two sequential Phase II studies have shown that concurrent chemoradiation using weekly cisplatin in the management of localised invasive bladder TCC is feasible and reasonably well tolerated. This approach is currently being investigated further in a randomised study.
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Affiliation(s)
- Nirdosh Kumar Gogna
- Mater Radiation Oncology Centre, Princess Alexandra Hospital, Brisbane, Qld, Australia.
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Rödel C, Sauer R. What is the role of radiotherapy in bladder-preserving cancer therapy? ACTA ACUST UNITED AC 2005; 2:4-5. [PMID: 16264831 DOI: 10.1038/ncponc0052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2004] [Accepted: 11/16/2004] [Indexed: 11/09/2022]
Affiliation(s)
- Claus Rödel
- Department of Radiation Therapy, University of Erlangen, Germany.
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31
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Ennis RD. Combined chemotherapy and external beam radiotherapy for transitional cell carcinoma of the bladder. Curr Oncol Rep 2004; 6:230-6. [PMID: 15066235 DOI: 10.1007/s11912-004-0054-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
A growing body of evidence supports the treatment of invasive transitional cell carcinoma of the bladder with transurethral resection, chemotherapy, and external beam radiotherapy. Randomized trials have demonstrated the superiority of chemotherapy plus radiotherapy to radiotherapy alone. Several series with 10 years of follow-up demonstrate that the success of this approach can be maintained. Preservation of the urothelium, however, results in continued risk of de novo bladder cancer development in addition to the possibility of recurrence. Thus, continued close surveillance and treatment of subsequent superficial or invasive bladder cancer is an essential component of this bladder preservation approach. Concomitant cisplatin chemotherapy and radiotherapy or initial (neoadjuvant) combination cisplatin-based chemotherapy followed by radiotherapy are the two options best supported by the literature. How these regimens compare with each other and with cystectomy-based treatment remains to be defined.
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Affiliation(s)
- Ronald D Ennis
- Department of Radiation Oncology, College of Physicians and Surgeons of Columbia University, 622 West 168th Street, BHN-Room B11, New York, NY 10032, USA.
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Abstract
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.
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Affiliation(s)
- Z Petrovich
- Department of Radiation Oncology and Urology, University of Southern California School of Medicine, Los Angeles 90033, USA
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33
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Dunst J, Rödel C, Zietman A, Schrott KM, Sauer R, Shipley WU. Bladder preservation in muscle-invasive bladder cancer by conservative surgery and radiochemotherapy. SEMINARS IN SURGICAL ONCOLOGY 2001; 20:24-32. [PMID: 11291129 DOI: 10.1002/ssu.1013] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Organ preservation has been investigated in muscle-invasive bladder cancer over the past decades as an alternative to standard radical cystectomy. The results of large prospective protocols and population-based studies suggest that an organ-preserving approach is possible without deferring the survival probability. Organ preservation requires a trimodal schedule, including transurethral surgery (transurethral resection of bladder tumor (TURBT)), radiation, and chemotherapy. A complete TURBT is the most important single prognostic factor, and should be attempted. Radiotherapy, in conjunction with concurrent platinum-based chemotherapy, can control the vast majority of urothelial bladder tumors. The histologically-proven complete remission rates of macroscopic tumors (unresectable by TURBT) lie in the range of about 70%. After radiochemotherapy, a histological response evaluation with repeated TURBT is recommended. Patients with residual tumor require salvage cystectomy. In cases of complete remission, patients can maintain their bladders but they should be closely followed over years. The risk of severe late-radiation sequelae is low, in the range of less than 5%. About 75% of long-term survivors maintain a normally functioning bladder.
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Affiliation(s)
- J Dunst
- Department of Radiation Oncology, Martin Luther University, Halle, Germany.
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34
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Pavone-Macaluso M, Hall RR, Hirao Y, Kamidono S, Miyanaga N, de Mulder PH, Naito S, Shipley WU, Tsushima T. The role of neoadjuvant or adjuvant chemotherapy for invasive bladder cancer Is there a benefit for survival or preserving the bladder? Urol Oncol 1998; 4:154-67. [PMID: 21227221 DOI: 10.1016/s1078-1439(99)00010-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/1999] [Indexed: 10/18/2022]
Affiliation(s)
- M Pavone-Macaluso
- Universita di Palermo, Department of Urology, via Villa Trabia 9, 90141, Palermo, Italy
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35
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Sumiyoshi Y, Hashine K, Karashima T, Kasahara K, Inoue Y. Preliminary results of bladder preservation by concurrent intraarterial chemotherapy and radiotherapy for muscle-invasive bladder cancer. Int J Urol 1998; 5:225-9. [PMID: 9624552 DOI: 10.1111/j.1442-2042.1998.tb00594.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND We previously reported favorable results of intraarterial doxorubicin chemotherapy in combination with low-dose radiotherapy for locally-advanced bladder cancer. We have now designed a new intraarterial chemotherapy regimen to achieve a higher tumor response rate while preserving a functional bladder. METHODS Twenty-one patients with muscle-invasive bladder cancer (T2,10; T3,7; T4,4) were treated with concurrent intraarterial chemotherapy and radiotherapy after an initial complete transurethral resection. Induction therapy consisted of concomitant pirarubicin (THP; 15 mg/m2/day on days 1 to 3), cisplatin (CDDP; 25 mg/m2/day on days 8 to 10) and irradiation (2 Gy/session on days 1 to 3 and 8 to 10). Maintenance treatment consisted of THP administered at 20 or 30 mg with or without 50 mg CDDP every month for 2 years. RESULTS Nineteen of the 21 patients (90.5%) achieved a complete response (CR). One of these 19 relapsed with lung metastases 24 months after treatment and was treated surgically. The 2 patients who did not achieve a CR died of cancer, while the remaining 19 patients are alive with preservation of a functional bladder. CONCLUSION These findings suggest that a higher tumor response rate with bladder preservation for patients with muscle-invasive bladder cancer is achieved by intraarterial THP/CDDP chemotherapy plus radiotherapy.
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Affiliation(s)
- Y Sumiyoshi
- Department of Urology, National Shikoku Cancer Center Hospital, Matsuyama, Japan
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36
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Muscle-Invasive Bladder Cancer: Transurethral Resection and Radiochemotherapy as an Organ-Sparing Treatment Option. ACTA ACUST UNITED AC 1998. [DOI: 10.1007/978-3-642-60258-0_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Shipley WU, Zietman AL, Kaufman DS, Althausen AF, Heney NM. Invasive bladder cancer: treatment strategies using transurethral surgery, chemotherapy and radiation therapy with selection for bladder conservation. Int J Radiat Oncol Biol Phys 1997; 39:937-43. [PMID: 9369144 DOI: 10.1016/s0360-3016(97)00461-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE Combined modality therapy has become the standard oncologic approach to achieve organ preservation in many malignancies. METHODS AND MATERIALS Although radical cystectomy has been considered as standard treatment for invasive bladder carcinoma in the United States, good results have been recently reported from several centers using multimodality treatment, particularly in patients with clinical T2 and T3a disease who do not have a ureter obstructed by tumor. RESULTS The components of the combined treatment are usually transurethral resection of the bladder tumor (TURBT) followed by concurrent chemotherapy and radiation therapy. Following an induction course of therapy a histologic response is evaluated by cystoscopy and rebiopsy. Clinical "complete responders" (tumor site rebiopsy negative and urine cytology with no tumor cells present) continue with a consolidation course of concurrent chemotherapy and radiation. Those patients not achieving a clinical complete response are recommended to have an immediate cystectomy. Individually the local monotherapies of radiation, TURBT, or multidrug chemotherapy each achieve a local control rate of the primary tumor of from 20 to 40%. When these are combined, clinical complete response rates of from 65 to 80% can be achieved. Seventy-five to 85% of the clinical complete responders will remain with bladders free of recurrence of an invasive tumor. CONCLUSIONS Bladder conservation trials using combined modality treatment approaches with selection for organ conservation by response of the tumor to initial treatment report overall 5-year survival rates of approximately 50%, and a 40-45% 5-year survival rate with the bladder intact. These modern multimodality bladder conservation approaches offer survival rates similar to radical cystectomy for patients of similar clinical stage and age. Bladder-conserving therapy should be offered to patients with invasive bladder carcinoma as a realistic alternative to radical cystectomy by experienced multimodality teams of urologic oncologists.
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Affiliation(s)
- W U Shipley
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA
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38
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Mokarim A, Uetani M, Hayashi N, Sakamoto I, Minami K, Ogawa Y, Ochi M, Matsuoka Y, Hayashi K, Nomata K. Combined intraarterial chemotherapy and radiotherapy in the treatment of bladder carcinoma. Cancer 1997; 80:1776-85. [PMID: 9351547 DOI: 10.1002/(sici)1097-0142(19971101)80:9<1776::aid-cncr12>3.0.co;2-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The combination of radiotherapy and cisplatin-based chemotherapy has proved to be an effective treatment for bladder carcinoma in many clinical studies. Intra-arterial approaches to chemotherapy have been developed to reduce systemic toxicities and improve response rates. This study was designed to determine the effectiveness of intra-arterial chemotherapy with cisplatin and doxorubicin combined with radiotherapy in the treatment of patients with invasive bladder carcinoma. The objectives were to evaluate the response rate, bladder preservation rate, toxicity, and survival rate. METHODS Thirty-five patients with muscle-invasive bladder carcinoma at clinical stage T2-T4N0M0 were each treated with 2courses of intra-arterial cisplatin and doxorubicin at 3-week intervals, whereas radiotherapy was administered for 4 weeks (2 gray [Gy] given a total of 20 times, at 5 fractions per week). Patients with complete responses were given an additional course of chemotherapy (intra-arterial cisplatin and doxorubicin) and irradiation (20 Gy), and patients with residual tumor after the initial chemoradiotherapy underwent cystectomy. RESULTS A clinical complete response was observed in 26 patients (74%; 95% confidence interval, 59-89%), and an incomplete response was observed in 9 (26%; 95% confidence interval, 11-41%). The bladder was preserved in all patients with a complete response, and it was tumor free in 19 of them (54% of all patients). The actuarial survival rate was 76.6% at 5 years. After a median follow-up interval of 45 months, 28 patients (80%) were alive and 7 (20%) had died due to disease progression. The regimen was well tolerated, with no severe systemic or local toxicities. CONCLUSIONS The high rates of response, survival, and bladder preservation observed indicate that this combined intra-arterial chemotherapy and radiotherapy regimen would be useful in the management of invasive bladder carcinoma. This was a small Phase II trial; the results are preliminary, and the utility of this treatment modality in patient management remains to be proven.
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Affiliation(s)
- A Mokarim
- Department of Radiology, Nagasaki University School of Medicine, Japan
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39
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Abstract
The last several decades have witnessed an exponential growth in the understanding of the biology of human neoplasms. As a consequence, a number of new strategies for the treatment of urologic cancers are currently under evaluation. We provide an overview of promising new treatment approaches as they apply to the management of transitional cell carcinoma of the urinary bladder.
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Affiliation(s)
- W A See
- Department of Urology, University of Iowa, Iowa City 52242-1089, USA. william-see/uiowa.edu
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40
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Management of invasive bladder cancer: Strategies of combined modality treatment. Semin Radiat Oncol 1997. [DOI: 10.1016/s1053-4296(97)80059-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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42
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Warde P, Gospodarowicz MK. New approaches in the use of radiation therapy in the treatment of infiltrative transitional-cell cancer of the bladder. World J Urol 1997; 15:125-33. [PMID: 9144903 DOI: 10.1007/bf02201984] [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: 02/04/2023] Open
Abstract
Organ preservation using primary radical radiation therapy (RT) is a viable treatment option for many patients with invasive bladder cancer, and there is no evidence that survival is compromised by this approach. However, the survival and local control rates in patients with bladder cancer currently treated with radical RT are not optimal. Combined modality therapy, altered radiation-fractionation approaches, and exciting new approaches such as the application of gene therapy and the use of hypoxic cell sensitisers, among others, may well improve the results of treatment in the future. Ongoing clinical research, including prospective randomised trials, will be required to evaluate these new approaches to therapy.
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Affiliation(s)
- P Warde
- Department of Radiation Oncology, Princess Margaret Hospital, Toronto, Canada
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43
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Abstract
BACKGROUND: Bladder cancer is one of the most common malignancies in Western society. In the United States, approximately 10,000 of these patients present with invasive disease, and more progress from superficial bladder cancer. METHODS: The authors review the literature on systemic treatment for both localized and metastatic bladder cancer, and they include their experience in defining approaches to various stages of disease. RESULTS: Cisplatin-based combination chemotherapy is the most effective systemic approach for advanced bladder cancers, although few patients are cured. Neoadjuvant, perspective, and adjuvant trials, as well as concurrent chemoradiation studies, are in progress to attempt to demonstrate better outcomes. CONCLUSIONS: The combination of systemic chemotherapy and definitive local therapy may have a useful role in the management of locally advanced bladder cancers, but optimal schedules and true survival benefit have not been established.
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Affiliation(s)
- M Javle
- Division of Medicine, Roswell Park Cancer Institute, Buffalo, NY 14263, USA
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44
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Igawa M, Urakami S, Shirakawa H, Shiina H, Kishi H, Himeno Y, Ishibe T, Kadena H, Usui T. Preliminary results of concurrent methotrexate, cisplatin and radiation treatment for locally advanced urothelial cancers. Int Urol Nephrol 1996; 28:189-94. [PMID: 8836787 DOI: 10.1007/bf02550859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Ten patients with invasive bladder cancer and one with locally advanced renal pelvic cancer were treated with concurrent methotrexate, cisplatin and radiotherapy. Methotrexate 30 mg/m2 was administered intravenously on the day of the initiation of radiotherapy and cisplatin 70 mg/m2 on the second day. The number of chemotherapy cycles delivered was 1 in 7 patients and 2 in 4. The median dose of radiation was 50 Gy. Of 11 patients, 7 (64%) achieved a partial response and 4 had no change in disease. The median duration of response was 16 months for patients with a partial response. Six patients with a partial response (55%) are alive for a median of 22.5 months and 2 of 4 with no change are alive for 4 and 15 months, respectively. Leukopenia less than 3000 cell/mm3 was observed in 4 (36%) and thrombocytopenia less than 100,000 cells/mm3 in 3 (27%). Local control could be achieved safely with concurrent methotrexate, cisplatin and radiation therapy in patients with locally advanced urothelial cancer who were unsuitable for surgery.
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Affiliation(s)
- M Igawa
- Department of Urology, Shimane Medical University, Izumo, Japan
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45
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Koiso K, Shipley W, Keuppens F, Baert L, Hall R, Hudson MA, Khoury S, Kubota Y, Kubota Y, van Poppel H. The status of bladder-preserving therapeutic strategies in the management of patients with muscle-invasive bladder cancer. Int J Urol 1995; 2 Suppl 2:49-57. [PMID: 7553305 DOI: 10.1111/j.1442-2042.1995.tb00479.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The recommended treatment for medically fit patients with muscle-invading bladder cancer is usually radical cystectomy. However, transurethral resection of the tumor, partial cystectomy, irradiation and systemic chemotherapy are each effective in some patients. These latter treatments allow bladder preservation and cure as an alternative to radical cystectomy although when used unselectively the survival rates are inferior to those of radical cystectomy. The updated results of conservative surgery, radiation therapy and systemic chemotherapy as monotherapy, as well as strategies of combined modality treatment were reviewed. Based on this review many areas of consensus were reached which include: 1. The primary goal of any treatment for a patient with muscle-invading bladder cancer is survival; bladder preservation in the interest of quality of life is a secondary objective. 2. Only a small proportion of carefully selected patients may be cured by transurethral surgery alone, or by partial cystectomy alone. 3. Radiation therapy is currently the standard bladder-preserving therapy against which all other bladder-preserving methods must be compared. 4. Systemic chemotherapy as monotherapy is inadequate and cannot be recommended. 5. The addition of cisplatin-containing systemic chemotherapy to radiation therapy or conservative surgery appears to improve local control. While no multi-modality therapeutic regimen has yet been shown to be clearly optimal with regard to local efficacy and minimizing toxicity, monotherapy for bladder preservation is probably not desirable as a routine approach. 6. Deferring the patient from immediate cystectomy does not appear to compromise survival, nor does the addition of primary systemic chemotherapy appear to significantly increase the morbidity of cystectomy or radiotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- K Koiso
- University of Tsukuba Institute of Clinical Medicine, Department of Urology, Ibaraki, Japan
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46
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Marks LB, Carroll PR, Dugan TC, Anscher MS. The response of the urinary bladder, urethra, and ureter to radiation and chemotherapy. Int J Radiat Oncol Biol Phys 1995; 31:1257-80. [PMID: 7713787 DOI: 10.1016/0360-3016(94)00431-j] [Citation(s) in RCA: 265] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A comprehensive review of the physiological and clinical response of the urinary bladder, ureter, and urethra to radiation and chemotherapy is presented. The clinical syndromes that follow therapy for cancer of the bladder, prostate, and cervix are reviewed in detail. Methods of assessing, scoring, and managing toxicity are discussed.
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Affiliation(s)
- L B Marks
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
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47
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c KK, cc WS, cc FK, Baert L, Hall R, Hudson MA, Khoury S, Kubota Y, Kubota Y, Poppel HV. THE STATUS OF BLADDER. P. RESERVING THERAPEUTIC STRATEGIES IN THE MANAGEMENT OF PATIENTS WITH MUSCLE-INVASIVE BLADDER CANCER. Int J Urol 1995. [DOI: 10.1111/j.1442-2042.1995.tb00072.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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48
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Kuten A, Liu L, Glicksman AS. Organ and functional preservation in the management of genitourinary cancer: bladder, prostate, and penis. Cancer Invest 1995; 13:108-24. [PMID: 7834465 DOI: 10.3109/07357909509024901] [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: 01/27/2023]
Affiliation(s)
- A Kuten
- Department of Radiation Oncology, Roger Williams Cancer Center/Brown University, Providence, Rhode Island
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Dunst J, Sauer R, Schrott KM, Kühn R, Wittekind C, Altendorf-Hofmann A. Organ-sparing treatment of advanced bladder cancer: a 10-year experience. Int J Radiat Oncol Biol Phys 1994; 30:261-6. [PMID: 7928455 DOI: 10.1016/0360-3016(94)90003-5] [Citation(s) in RCA: 135] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE Radical cystectomy is considered as standard therapy for muscle-invasive bladder cancer. We present 10-year results of bladder-sparing treatment by conservative surgery and radiotherapy +/- chemotherapy. METHODS AND MATERIALS From 1982 through 1991, 245 consecutive patients, mean age 66 years, with invasive bladder cancer (T2-3 or poor prognostic T1, no distant metastases) entered a prospective protocol with the objective of bladder preservation. Treatment consisted of transurethral resection (complete, if possible) and definitive radiotherapy with 56 Gy maximum dose (50.4 Gy minimum target dose) in 28 fractions. Since 1985, 139 patients received a simultaneous chemotherapy on 5 days in the first and fifth treatment week with either 25 mg/m2 cisplatin daily (79 patients) or 65 mg/m2 carboplatin (60 patients). Cystectomy was performed as salvage treatment for residual or recurrent invasive disease. The median follow-up at the date of analysis (12-31-92) was 5.9 years. RESULTS The overall survival was 47% after 5 years and 26% after 10 years. The 5-year survival according to the initial T-category was 60% for T1 (44 patients), 64% for T2 (47 patients), 43% for T3 (127 patients), and 16% for T4 (23 patients). The most important single prognostic factor was the amount of residual tumor after TUR (5-year survival 80% after R0, 53% after R1, and 31% after R2 resection, p < 0.01). Chemotherapy increased the rate of complete remission, but had no impact on 5-year survival (52% vs. 50%). Fifty-three salvage cystectomies were performed, all without severe complications, and 192 patients (79%) maintained a normal functioning bladder. The bladder preservation rate in 5-year survivors was 83%. CONCLUSIONS Organ-sparing treatment of advanced bladder cancer by transurethral surgery and definitive radiotherapy or radiochemotherapy is feasible and effective. The survival in this series is as good as in any comparable cystectomy series. Eighty-three percent of long-term survivors maintained their functioning bladders.
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Affiliation(s)
- J Dunst
- Department of Radiotherapy, University of Erlangen, Germany
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Bosl GJ, Fair WR, Herr HW, Bajorin DF, Dalbagni G, Sarkis AS, Reuter VE, Cordon-Cardo C, Sheinfeld J, Scher HI. Bladder cancer: advances in biology and treatment. Crit Rev Oncol Hematol 1994; 16:33-70. [PMID: 8074800 DOI: 10.1016/1040-8428(94)90041-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Integrating systemic chemotherapy in the treatment of patients with invasive bladder cancer is essential to improve survival because the majority of deaths are from systemic relapse. However, as experience with invasive tumors evolves, it is clear that treatment recommendations need to be tailored to an individual patient based on metastatic risk and, ideally, sensitivity to treatment. For those with tumors that do not extend through the bladder wall, standard therapy remains radical surgery. Nevertheless, encouraging results are being reported with increasing frequency using strategies designed to preserve bladder function through a variety of means. Crucial to the recommendation of a specific approach for an individual is improving our ability to define prognosis prior to initiating treatment. Patients with a high risk of systemic recurrence generally require chemotherapy, although the optimal route of integration, pre vs. post-operatively, remains controversial. In those patients who require it, chemotherapy can be administered more safely with the concomitant administration of hematopoietic growth factors. These factors alone, however, are unlikely to improve overall survival. Crucial to the latter effort will be the identification of more active agents, improving our understanding of intrinsic and acquired resistance to chemotherapy, and better delivery of the chemotherapeutic agents currently available. Of equal importance, is the enrollment of patients in clinical trials. These can include large scale randomized comparisons with using a survival end-point, as well as new therapies in high risk populations. The latter would include patients with advanced T3b, T4 and N+ disease, with a high risk of metastatic failure, and low complete response proportions to presently available regimens.
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Affiliation(s)
- G J Bosl
- Division of Solid Tumor Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021
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