1
|
Dennis K, Linden K, Gaudet M. A shift from simple to sophisticated: using intensity-modulated radiation therapy in conventional nonstereotactic palliative radiotherapy. Curr Opin Support Palliat Care 2023; 17:70-76. [PMID: 36695868 DOI: 10.1097/spc.0000000000000639] [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: 01/26/2023]
Abstract
PURPOSE OF REVIEW The authors aimed to highlight trends in, and evidence underlying the use of highly conformal radiotherapy (RT) techniques in conventional nonstereotactic palliative RT. The authors reviewed palliative-intent and curative-intent studies relevant to the use of intensity-modulated radiation therapy (IMRT) for the delivery of nonstereotactic conventional regimens to the brain, head and neck, thorax, abdomen and pelvis, and bone metastases. RECENT FINDINGS The use of IMRT has become standard with certain indications for brain metastases such as hippocampus-avoiding/limiting whole brain RT. IMRT in the treatment of bone metastases is increasing at many institutions despite limited data comparing its effectiveness with that of fluoroscopy-based and three-dimensional conformal radiation therapy techniques. There is scant data describing the use of IMRT for palliation in other extracranial anatomic sites; guidance for its use in these settings must be gleaned almost exclusively from curative-intent randomized trials, consensus recommendations and contouring atlases. SUMMARY Consistent with historical technology shifts in RT practice, the uptake of highly conformal techniques such as IMRT for conventional palliative RT will likely outpace rigorous evaluations of their advantages and disadvantages relative to simpler techniques. Opportunities exist in virtually all anatomic sites for observational and randomized studies to evaluate the clinical impacts of these modern techniques in the palliative setting.
Collapse
Affiliation(s)
- Kristopher Dennis
- Division of Radiation Oncology, The Ottawa Hospital and the University of Ottawa
| | - Kelly Linden
- Radiation Medicine Program, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Marc Gaudet
- Division of Radiation Oncology, The Ottawa Hospital and the University of Ottawa
| |
Collapse
|
2
|
Åström LM, Behrens CP, Calmels L, Sjöström D, Geertsen P, Mouritsen LS, Serup-Hansen E, Lindberg H, Sibolt P. Online adaptive radiotherapy of urinary bladder cancer with full re-optimization to the anatomy of the day: initial experience and dosimetric benefits. Radiother Oncol 2022; 171:37-42. [DOI: 10.1016/j.radonc.2022.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 03/14/2022] [Accepted: 03/24/2022] [Indexed: 12/25/2022]
|
3
|
Xiang M, Chang AJ, Chamie K, Drakaki A, Pollom EL, Steinberg ML, Kishan AU. Trends and Predictors of Hypofractionated and Intensity-Modulated Radiotherapy for Organ Preservation in Bladder Cancer. Clin Genitourin Cancer 2021; 20:e94-e103. [PMID: 34866018 DOI: 10.1016/j.clgc.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/01/2021] [Accepted: 11/03/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Use of hypofractionated radiation (HFRT) and intensity-modulated radiation (IMRT) for organ preservation in bladder cancer is controversial and highly variable. We investigated practice patterns, trends, and predictors of HFRT and IMRT. PATIENTS AND METHODS The National Cancer Database was queried for patients with muscle-invasive, non-metastatic urothelial bladder cancer, treated with definitive (chemo)radiotherapy between 2004 and 2017. HFRT was defined as 50 to 60 Gy at >2 Gy/fraction. Multivariable logistic regression was used to identify predictors of receiving HFRT or IMRT. Multivariable Cox regression was used to model overall survival (OS), adjusting for potential confounders such as age, comorbidity, and chemotherapy. RESULTS Of 5132 patients identified, 490 (9.5%) received HFRT, and only 334 (6.5%) received ≥2.5 Gy/fraction. HFRT patients were significantly older, less fit, and less likely to receive chemotherapy relative to CFRT, even after controlling for age and comorbidity (adjusted odds ratio 0.36, 95% confidence interval [CI] 0.29-0.45, P < .0001). Utilization of HFRT and IMRT increased over time (P < .0001), reaching 22.5% and 47.7%, respectively, by 2017. Among patients treated with CFRT, OS was similar with or without IMRT (P = .46). Among patients treated with HFRT, IMRT was associated with increased survival (3-year OS 35% vs. 24%, P = .03), which persisted in multivariable analysis (adjusted hazard ratio 0.71, 95% CI 0.52-0.98, P = .04). CONCLUSION HFRT is largely underutilized, being primarily reserved for older, frailer patients. Chemotherapy is significantly underused with HFRT relative to CFRT. IMRT is used frequently and was associated with equivalent or modestly increased overall survival.
Collapse
Affiliation(s)
- Michael Xiang
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA.
| | - Albert J Chang
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Karim Chamie
- Department of Urology, University of California Los Angeles, Los Angeles, CA
| | - Alexandra Drakaki
- Department of Urologic Oncology, University of California Los Angeles, Los Angeles, CA
| | - Erqi L Pollom
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | - Michael L Steinberg
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Amar U Kishan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| |
Collapse
|
4
|
Khalifa J, Supiot S, Pignot G, Hennequin C, Blanchard P, Pasquier D, Magné N, de Crevoisier R, Graff-Cailleaud P, Riou O, Cabaillé M, Azria D, Latorzeff I, Créhange G, Chapet O, Rouprêt M, Belhomme S, Mejean A, Culine S, Sargos P. Recommendations for planning and delivery of radical radiotherapy for localized urothelial carcinoma of the bladder. Radiother Oncol 2021; 161:95-114. [PMID: 34118357 DOI: 10.1016/j.radonc.2021.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/05/2021] [Accepted: 06/03/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE Curative radio-chemotherapy is recognized as a standard treatment option for muscle-invasive bladder cancer (MIBC). Nevertheless, the technical aspects for MIBC radiotherapy are heterogeneous with a lack of practical recommendations. METHODS AND MATERIALS In 2018, a workshop identified the need for two cooperative groups to develop consistent, evidence-based guidelines for irradiation technique in the delivery of curative radiotherapy. Two radiation oncologists performed a review of the literature addressing several topics relative to radical bladder radiotherapy: planning computed tomography acquisition, target volume delineation, radiation schedules (total dose and fractionation) and dose delivery (including radiotherapy techniques, image-guided radiotherapy (IGRT) and adaptive treatment modalities). Searches for original and review articles in the PubMed and Google Scholar databases were conducted from January 1990 until March 2020. During a meeting conducted in October 2020, results on 32 topics were presented and discussed with a working group involving 15 radiation oncologists, 3 urologists and one medical oncologist. We applied the American Urological Association guideline development's method to define a consensus strategy. RESULTS A consensus was obtained for all 34 except 4 items. The group did not obtain an agreement on CT enhancement added value for planning, PTV margins definition for empty bladder and full bladder protocols, and for pelvic lymph-nodes irradiation. High quality evidence was shown in 6 items; 8 items were considered as low quality of evidence. CONCLUSION The current recommendations propose a homogenized modality of treatment both for routine clinical practice and for future clinical trials, following the best evidence to date, analyzed with a robust methodology. The XXX group formulates practical guidelines for the implementation of innovative techniques such as adaptive radiotherapy.
Collapse
Affiliation(s)
- Jonathan Khalifa
- Department of Radiotherapy, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse Oncopole, France
| | - Stéphane Supiot
- Department of Radiotherapy, Institut de Cancérologie de l'Ouest, Nantes Saint-Herblain, France
| | - Géraldine Pignot
- Department of Urology, Institut Paoli Calmettes, Marseille, France
| | | | - Pierre Blanchard
- Department of Radiotherapy, Institut Gustave Roussy, Villejuif, France
| | - David Pasquier
- Department of Radiotherapy, Centre Oscar Lambret, Lille, France
| | - Nicolas Magné
- Department of Radiotherapy, Institut de Cancérologie Lucien Neuwirth, Saint Priest en Jarez, France
| | | | - Pierre Graff-Cailleaud
- Department of Radiotherapy, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse Oncopole, France
| | - Olivier Riou
- Department of Radiotherapy, Institut du Cancer de Montpellier, France
| | | | - David Azria
- Department of Radiotherapy, Institut du Cancer de Montpellier, France
| | - Igor Latorzeff
- Department of Radiotherapy, Clinique Pasteur, Toulouse, France
| | | | - Olivier Chapet
- Department of Radiotherapy, Hospices Civils de Lyon, France
| | - Morgan Rouprêt
- Department of Urology, Hôpital Pitié-Salpétrière, APHP Sorbonne Université, Paris, France
| | - Sarah Belhomme
- Department of Medical Physics, Institut Bergonié, Bordeaux, France
| | - Arnaud Mejean
- Department of Urology, Hôpital Européen Georges-Pompidou, Paris, France
| | - Stéphane Culine
- Department of Medical Oncology, Hôpital Saint-Louis, Paris, France
| | - Paul Sargos
- Department of Radiotherapy, Institut Bergonié, Bordeaux, France.
| |
Collapse
|
5
|
Busch K, Dahl B, Petersen SE, Rønde HS, Bentzen L, Pilskog S, Muren LP. Anatomically robust proton therapy using multiple planning computed tomography scans for locally advanced prostate cancer. Acta Oncol 2021; 60:598-604. [PMID: 33646069 DOI: 10.1080/0284186x.2021.1892181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Proton therapy (PT) is sensitive towards anatomical changes that may occur during a treatment course. The aim of this study was to investigate if anatomically robust PT (ARPT) plans incorporating patient-specific target motion improved target coverage while still sparing normal tissues, when applied on locally advanced prostate cancer patients where pelvic irradiation is indicated. MATERIAL AND METHODS A planning computed tomography (CT) scan used for dose calculation and two additional CTs (acquired on different days) were used to make patient-specific targets for the ARPT plans on the eight included patients. The plans were compared to a conventional robust PT plan and a volumetric modulated arc therapy (VMAT) photon plan, which were derived from the planning CT (pCT). Worst-case robust optimisation was used for all proton plans with a setup uncertainty of 5 mm and a range uncertainty of 3.5%. Target coverage (V95% and D95%) and normal tissue doses (V5-75 Gy) were evaluated on 6-8 rCTs per patient. RESULTS The ARPT plans improved the prostate target coverage for the most challenging patient compared to conventional robust PT plans (20% point increase for V95% and 31 Gy increase for D95%). Across the whole cohort the estimated mean value for V95% was 97% for the ARPT plans and 95% for the conventional robust PT plans. The ARPT plans had a slight, statistically insignificant increase in normal tissue doses compared to the conventional robust proton plans. Compared to VMAT, the ARPT plans significantly reduced the normal tissue doses in the low-to-intermediate dose range. CONCLUSIONS While both proton plans reduced the low-to-intermediate normal tissue doses compared to VMAT, ARPT plans improved the target coverage for the most challenging patient without significantly increasing the normal tissue doses compared to conventional robust PT plans.
Collapse
Affiliation(s)
- Kia Busch
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Benjamin Dahl
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Stine E. Petersen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Heidi S. Rønde
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Lise Bentzen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Sara Pilskog
- Department of Physics and Technology, University of Bergen, Bergen, Norway
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
| | - Ludvig P. Muren
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| |
Collapse
|
6
|
Varughese M. Overcoming the Chasm Between Evidence and Routine Practice for Bladder Cancer; Just a Quixotic Notion? Clin Oncol (R Coll Radiol) 2021; 33:e274-e284. [PMID: 33840534 DOI: 10.1016/j.clon.2021.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/16/2021] [Accepted: 03/11/2021] [Indexed: 12/18/2022]
Abstract
There has been a failure to improve outcomes in bladder cancer over the last 30 years. This is despite clinical trial evidence showing a benefit of interventions such as neoadjuvant chemotherapy or concurrent radiosensitisation for non-metastatic muscle-invasive bladder cancer. The bladder cancer population is characteristically elderly, who typically suffer from multiple comorbidities. Historically, radical cystectomy has been heralded as the treatment of choice, with radiotherapy being reserved for those with inoperable tumours or those unfit for major pelvic surgery, despite a lack of robust comparative or quality of life data to support one treatment recommendation over the other. Although patients with non-metastatic muscle-invasive bladder cancer have potentially curable disease, a growing body of population-based analyses persistently highlights that most patients do not undergo curative-intent treatments - a trend that remains static. The causes for the disparity between evidence and routine practice is not clearly understood. Here, the facets of patient-centred evidence-based care, with respect to bladder conservation therapy, are examined, with proposals to reverse this unacceptable status quo.
Collapse
Affiliation(s)
- M Varughese
- Department of Oncology, Royal Devon & Exeter Hospital, Exeter, UK.
| |
Collapse
|
7
|
Hijab A, Tocco B, Hanson I, Meijer H, Nyborg CJ, Bertelsen AS, Smeenk RJ, Smith G, Michalski J, Baumann BC, Hafeez S. MR-Guided Adaptive Radiotherapy for Bladder Cancer. Front Oncol 2021; 11:637591. [PMID: 33718230 PMCID: PMC7947660 DOI: 10.3389/fonc.2021.637591] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 01/11/2021] [Indexed: 12/14/2022] Open
Abstract
Radiotherapy has an important role in the curative and palliative treatment settings for bladder cancer. As a target for radiotherapy the bladder presents a number of technical challenges. These include poor tumor visualization and the variability in bladder size and position both between and during treatment delivery. Evidence favors the use of magnetic resonance imaging (MRI) as an important means of tumor visualization and local staging. The availability of hybrid systems incorporating both MRI scanning capabilities with the linear accelerator (MR-Linac) offers opportunity for in-room and real-time MRI scanning with ability of plan adaption at each fraction while the patient is on the treatment couch. This has a number of potential advantages for bladder cancer patients. In this article, we examine the technical challenges of bladder radiotherapy and explore how magnetic resonance (MR) guided radiotherapy (MRgRT) could be leveraged with the aim of improving bladder cancer patient outcomes. However, before routine clinical implementation robust evidence base to establish whether MRgRT translates into improved patient outcomes should be ascertained.
Collapse
Affiliation(s)
- Adham Hijab
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom.,Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Boris Tocco
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom.,Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Ian Hanson
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom.,Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Hanneke Meijer
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| | | | | | - Robert Jan Smeenk
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Gillian Smith
- Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Jeff Michalski
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Brian C Baumann
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Shaista Hafeez
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, United Kingdom.,Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| |
Collapse
|
8
|
Swinton M, Choudhury A, Kiltie AE, Chung P, Billfalk-Kelly A, James N, Kamran SC, Efstathiou JA. Trimodal Therapy. Bladder Cancer 2021. [DOI: 10.1007/978-3-030-70646-3_22] [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]
|
9
|
Tholomier C, Souhami L, Kassouf W. Bladder-sparing protocols in the treatment of muscle-invasive bladder cancer. Transl Androl Urol 2020; 9:2920-2937. [PMID: 33457265 PMCID: PMC7807363 DOI: 10.21037/tau.2020.02.10] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 11/29/2019] [Indexed: 01/06/2023] Open
Abstract
Bladder-sparing protocols (BSP) have been gaining widespread popularity as an attractive alternative to radical cystectomy (RC) for muscle-invasive bladder cancer. Unimodal therapies are inferior to multimodal regimens. The most promising regimen is trimodal therapy (TMT), which is a combination of maximal transurethral resection of bladder tumor (TURBT), radiotherapy, and chemotherapy. In appropriately selected patients (low volume unifocal T2 disease, complete TURBT, no hydronephrosis and no carcinoma-in-situ), comparable oncological outcomes to RC have been reported in large retrospective studies, with a potential improvement in overall quality of life (QOL). TMT also offers the possibility for definitive therapy for patients who are not surgically fit to undergo RC. Routine biopsy of previous tumor resection is recommended to assess response. Prompt salvage RC is required in non-responders and for recurrent muscle-invasive disease, while non-muscle-invasive recurrence can be managed conservatively with TURBT +/- intravesical BCG. Long-term follow-up consisting of routine cystoscopy, urine cytology, and cross-section imaging is required. Further studies are warranted to better define the role of neoadjuvant or adjuvant chemotherapy in the setting of TMT. Finally, future research on predictive markers of response to TMT and on the integration of immunotherapy in bladder sparing protocols is ongoing and is highly promising.
Collapse
Affiliation(s)
- Côme Tholomier
- Department of Surgery, Division of Urology, McGill University, McGill University Health Centre, Montréal, Québec, Canada
| | - Luis Souhami
- Department of Radiation Oncology, McGill University, McGill University Health Centre, Montréal, Québec, Canada
| | - Wassim Kassouf
- Department of Surgery, Division of Urology, McGill University, McGill University Health Centre, Montréal, Québec, Canada
| |
Collapse
|
10
|
Cardoso M, Choudhury A, Christie D, Eade T, Foroudi F, Hayden A, Holt T, Kneebone A, Sasso G, Shakespeare TP, Sidhom M. FROGG patterns of practice survey and consensus recommendations on radiation therapy for MIBC. J Med Imaging Radiat Oncol 2020; 64:882-893. [DOI: 10.1111/1754-9485.13120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/17/2020] [Accepted: 09/29/2020] [Indexed: 12/29/2022]
Affiliation(s)
- Michael Cardoso
- Cancer Therapy Centre Liverpool Hospital New South Wales Australia
- Centre for Medical Radiation Physics University of Wollongong Wollongong New South Wales Australia
- South Western Sydney Clinical School University of New South Wales New South Wales Australia
| | - Ananya Choudhury
- Division of Cancer Sciences University of Manchester Manchester UK
- The Christie NHS Foundation Trust Manchester UK
| | - David Christie
- Genesis Cancer Care Queensland Australia
- Department of Health Sciences and Medicine Bond University Gold Coast Queensland Australia
| | - Thomas Eade
- Northern Sydney Cancer CentreRoyal North Shore Hospital New South Wales Australia
- Northern Medical School University of Sydney Sydney New South Wales Australia
| | - Farshad Foroudi
- Department of Radiation Oncology Newton‐John Cancer Wellness and Research CentreAustin Health Heidelberg Victoria Australia
- Latrobe University Melbourne Victoria Australia
| | - Amy Hayden
- Sydney West Radiation Oncology Westmead Hospital Sydney New South Wales Australia
| | - Tanya Holt
- Princess Alexandra Hospital‐ROPART Brisbane Queensland Australia
- University of Queensland Queensland Australia
| | - Andrew Kneebone
- Northern Sydney Cancer CentreRoyal North Shore Hospital New South Wales Australia
- Northern Medical School University of Sydney Sydney New South Wales Australia
- Central Coast Cancer Centre Gosford Hospital Gosford New South Wales Australia
- Genesis Cancer Care New South Wales Australia
| | - Giuseppe Sasso
- Radiation Oncology Department Auckland District Health Board Auckland New Zealand
- Faculty of Medical and Health Sciences University of Auckland Auckland New Zealand
| | - Thomas P. Shakespeare
- Department of Radiation Oncology Mid North Coast Cancer Institute Coffs Harbour New South Wales Australia
- University of New South Wales Rural Clinical School Coffs Harbour Australia
| | - Mark Sidhom
- Cancer Therapy Centre Liverpool Hospital New South Wales Australia
- South Western Sydney Clinical School University of New South Wales New South Wales Australia
| |
Collapse
|
11
|
Dinh TKT, Mitin T, Bagshaw HP, Hoffman KE, Hwang C, Jeffrey Karnes R, Kishan AU, Liauw SL, Lloyd S, Potters L, Showalter TN, Taira AV, Vapiwala N, Zaorsky NG, D'Amico AV, Nguyen PL, Davis BJ. Executive Summary of the American Radium Society Appropriate Use Criteria for Radiation Treatment of Node-Negative Muscle Invasive Bladder Cancer. Int J Radiat Oncol Biol Phys 2020; 109:953-963. [PMID: 33127490 DOI: 10.1016/j.ijrobp.2020.10.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/19/2020] [Accepted: 10/22/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Definitive radiation therapy (RT), with or without concurrent chemotherapy, is an alternative to radical cystectomy for patients with localized, muscle-invasive bladder cancer (MIBC) who are either not surgical candidates or prefer organ preservation. We aim to synthesize an evidence-based guideline regarding the appropriate use of RT. METHODS AND MATERIALS We performed a Preferred Reporting Items for Systematic Reviews and Meta-analyses literature review using the PubMed and Embase databases. Based on the literature review, critical management topics were identified and reformulated into consensus questions. An expert panel was assembled to address key areas of both consensus and controversy using the modified Delphi framework. RESULTS A total of 761 articles were screened, of which 61 were published between 1975 and 2019 and included for full review. There were 7 well-designed studies, 20 good quality studies, 28 quality studies with design limitations, and 6 references not suited as primary evidence. Adjuvant radiation therapy after cystectomy was not included owing to lack of high-quality data or clinical use. An expert panel consisting of 14 radiation oncologists, 1 medical oncologist, and 1 urologist was assembled. We identified 4 clinical variants of MIBC: surgically fit patients who wish to pursue organ preservation, patients surgically unfit for cystectomy, patients medically unfit for cisplatin-based chemotherapy, and borderline cystectomy candidates based on age with unilateral hydronephrosis and normal renal function. We identified key areas of controversy, including use of definitive radiation therapy for patients with negative prognostic factors, appropriate radiation therapy dose, fractionation, fields and technique when used, and chemotherapy sequencing and choice of agent. CONCLUSIONS There is limited level-one evidence to guide appropriate treatment of MIBC. Studies vary significantly with regards to patient selection, chemotherapy use, and radiation therapy technique. A consensus guideline on the appropriateness of RT for MIBC may aid practicing oncologists in bridging the gap between data and clinical practice.
Collapse
Affiliation(s)
- Tru-Khang T Dinh
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Timur Mitin
- Department of Radiation Medicine, Oregon Health Sciences University, Portland, Oregon.
| | - Hilary P Bagshaw
- Department of Radiation Oncology, Stanford University Clinics, Palo Alto, California
| | - Karen E Hoffman
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Clara Hwang
- Department of Hematology/Oncology, Henry Ford Health System, Detroit, Michigan
| | | | - Amar U Kishan
- Department of Radiation Oncology, University of California at Los Angeles Medical Center, Los Angeles, California
| | - Stanley L Liauw
- Department of Radiation Oncology, University of Chicago, Chicago, Illinois
| | - Shane Lloyd
- Department of Radiation Oncology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Louis Potters
- Department of Radiation Oncology, Northwell Health, New Hyde Park, New York
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia
| | - Al V Taira
- Sutter Health Radiation Oncology, San Mateo, California
| | - Neha Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State University Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Anthony V D'Amico
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana Farber Cancer, Institute, Boston, Massachusetts
| | - Paul L Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana Farber Cancer, Institute, Boston, Massachusetts
| | - Brian J Davis
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
12
|
Witjes JA, Bruins HM, Cathomas R, Compérat EM, Cowan NC, Gakis G, Hernández V, Linares Espinós E, Lorch A, Neuzillet Y, Rouanne M, Thalmann GN, Veskimäe E, Ribal MJ, van der Heijden AG. European Association of Urology Guidelines on Muscle-invasive and Metastatic Bladder Cancer: Summary of the 2020 Guidelines. Eur Urol 2020; 79:82-104. [PMID: 32360052 DOI: 10.1016/j.eururo.2020.03.055] [Citation(s) in RCA: 1077] [Impact Index Per Article: 269.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 03/31/2020] [Indexed: 01/11/2023]
Abstract
CONTEXT This overview presents the updated European Association of Urology (EAU) guidelines for muscle-invasive and metastatic bladder cancer (MMIBC). OBJECTIVE To provide practical evidence-based recommendations and consensus statements on the clinical management of MMIBC with a focus on diagnosis and treatment. EVIDENCE ACQUISITION A broad and comprehensive scoping exercise covering all areas of the MMIBC guideline has been performed annually since its 2017 publication (based on the 2016 guideline). Databases covered by the search included Medline, EMBASE, and the Cochrane Libraries, resulting in yearly guideline updates. A level of evidence and a grade of recommendation were assigned. Additionally, the results of a collaborative multistakeholder consensus project on advanced bladder cancer (BC) have been incorporated in the 2020 guidelines, addressing those areas where it is unlikely that prospective comparative studies will be conducted. EVIDENCE SYNTHESIS Variant histologies are increasingly reported in invasive BC and are relevant for treatment and prognosis. Staging is preferably done with (enhanced) computerised tomography scanning. Treatment decisions are still largely based on clinical factors. Radical cystectomy (RC) with lymph node dissection remains the recommended treatment in highest-risk non-muscle-invasive and muscle-invasive nonmetastatic BC, preceded by cisplatin-based neoadjuvant chemotherapy (NAC) for invasive tumours in "fit" patients. Selected men and women benefit from sexuality sparing RC, although this is not recommended as standard therapy. Open and robotic RC show comparable outcomes, provided the procedure is performed in experienced centres. For open RC 10, the minimum selected case load is 10 procedures per year. If bladder preservation is considered, chemoradiation is an alternative in well-selected patients without carcinoma in situ and after maximal resection. Adjuvant chemotherapy should be considered if no NAC was given. Perioperative immunotherapy can be offered in clinical trial setting. For fit metastatic patients, cisplatin-based chemotherapy remains the first choice. In cisplatin-ineligible patients, immunotherapy in Programmed Death Ligand 1 (PD-L1)-positive patients or carboplatin in PD-L1-negative patients is recommended. For second-line treatment in metastatic disease, pembrolizumab is recommended. Postchemotherapy surgery may prolong survival in responders. Quality of life should be monitored in all phases of treatment and follow-up. The extended version of the guidelines is available at the EAU website: https://uroweb.org/guideline/bladder-cancer-muscle-invasive-and-metastatic/. CONCLUSIONS This summary of the 2020 EAU MMIBC guideline provides updated information on the diagnosis and treatment of MMIBC for incorporation into clinical practice. PATIENT SUMMARY The European Association of Urology Muscle-invasive and Metastatic Bladder Cancer (MMIBC) Panel has released an updated version of their guideline, which contains information on histology, staging, prognostic factors, and treatment of MMIBC. The recommendations are based on the current literature (until the end of 2019), with emphasis on high-level data from randomised clinical trials and meta-analyses and on the findings of an international consensus meeting. Surgical removal of the bladder and bladder preservation are discussed, as well as the use of chemotherapy and immunotherapy in localised and metastatic disease.
Collapse
Affiliation(s)
- J Alfred Witjes
- Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
| | - Harman Max Bruins
- Department of Urology, Zuyderland Medical Center, Sittard-Geleen-Heerlen, The Netherlands
| | - Richard Cathomas
- Department of Medical Oncology, Kantonsspital Graubünden, Chur, Switzerland
| | - Eva M Compérat
- Department of Pathology, Sorbonne University, Assistance Publique-Hôpitaux de Paris, Hopital Tenon, Paris, France
| | - Nigel C Cowan
- Department of Radiology, The Queen Alexandra Hospital, Portsmouth, UK
| | - Georgios Gakis
- Department of Urology and Pediatric Urology, University of Würzburg, Würzburg, Germany
| | - Virginia Hernández
- Department of Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | | | - Anja Lorch
- Department of Medical Oncology and Hematology, University Hospital Zürich, Zürich, Switzerland
| | - Yann Neuzillet
- Department of Urology, Foch Hospital, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France
| | - Mathieu Rouanne
- Department of Urology, Foch Hospital, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France
| | - George N Thalmann
- Department of Urology, Inselspital, University Hospital Bern, Switzerland
| | - Erik Veskimäe
- Department of Urology, Tampere University Hospital, Tampere, Finland
| | - Maria J Ribal
- Department of Urology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | |
Collapse
|
13
|
Sherry AD, Stewart A, Luo G, Kirschner AN. Intensity-Modulated Radiotherapy is Superior to Three-Dimensional Conformal Radiotherapy in the Trimodality Management of Muscle-Invasive Bladder Cancer with Daily Cone Beam Computed Tomography Optimization. ACTA ACUST UNITED AC 2019; 8:395-403. [PMID: 33343830 DOI: 10.1007/s13566-019-00411-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Objective Intensity modulated radiation therapy (IMRT) using a volumetric-modulated arc therapy technique may offer dosimetric and clinical benefits compared to the historical standard of care 3D-conformal radiotherapy (3D-CRT) in definitive treatment of bladder cancer. We hypothesized that IMRT with CBCT would reduce dose to the rectum, bowel, and bladder compared to 3D-CRT. Methods We reviewed nineteen patients treated with maximal transurethral resection of bladder tumor followed by concurrent chemotherapy with IMRT. All patients received 45 Gy to the entire empty bladder followed by 19.8 Gy tumor boost treated with full bladder. 3D-CRT treatment plans were created for the same prescription. Paired t-test or Wilcoxon matched-pairs signed rank test analyzed dosimetry and bladder volumes. Results The rectum and bowel V40, V45, V50, V55, and V60 were reduced by over 50% in the IMRT plans compared to 3D-CRT (p<0.0001). IMRT also reduced volume of bladder irradiated compared to 3D-CRT (p<0.01). After CBCT, patients were likely to undergo clinically significant shifts ≥ 0.5 cm before boost delivery (p=0.001). Bladder volumes were significantly lower during boost treatments compared to pre-treatment simulation (p=0.002). There were 4 (21%) grade 3 genitourinary toxicities and 1 (5%) grade 3 gastrointestinal toxicity. Conclusion IMRT is superior to 3D-CRT for bladder cancer and spares dose to bowel, rectum, and bladder with improved acute toxicity compared to published clinical literature. For boost treatment, daily full bladder volume and positioning are not always reproducible, supporting the need for CBCT for optimal localization of the primary bladder tumor.
Collapse
Affiliation(s)
| | | | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN USA
| | - Austin N Kirschner
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN USA
| |
Collapse
|
14
|
Datta NR, Stutz E, Puric E, Eberle B, Meister A, Marder D, Timm O, Rogers S, Wyler S, Bodis S. A Pilot Study of Radiotherapy and Local Hyperthermia in Elderly Patients With Muscle-Invasive Bladder Cancers Unfit for Definitive Surgery or Chemoradiotherapy. Front Oncol 2019; 9:889. [PMID: 31552192 PMCID: PMC6746906 DOI: 10.3389/fonc.2019.00889] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 08/27/2019] [Indexed: 12/27/2022] Open
Abstract
Purpose: To present the outcomes of a pilot study with hyperthermia (HT) and radiotherapy (RT) in elderly patients of muscle-invasive bladder cancers (MIBC) unfit for surgery or chemoradiotherapy (CTRT). Methods: Sixteen elderly patients with unifocal or multifocal MIBCs received a total dose of 48 Gy/16 fractions/4 weeks or 50 Gy/20 fractions/4 weeks, respectively. HT with a radiofrequency HT unit was delivered once weekly for 60 min before RT and a mean temperature of 41.3°C was attained (maximum temperature 41.1–43.5°C). Local control was assessed using RECIST criteria at 3-monthly intervals by cystoscopy with or without biopsy. Results: The median age, KPS and age-adjusted Charlson comorbidity index were 81 years, 70 and 5, respectively. At median follow-up of 18.5 months (range: 4–65), bladder preservation was 100% with satisfactory function. 11/16 patients (68.7%) had no local and/or distant failure, while isolated local, distant and combined local and distant failures were evident in 2, 2, and 1 patient, respectively. Two local failures were salvaged by TUR-BT resulting in a local control rate of 93.7%. The 5-year cause-specific (CS) local disease free survival (LDFS), disease free survival (DFS), and overall survival (OS) were 64.3, 51.6, and 67.5%, respectively while 5-year non-cause-specific (NCS)-LDFS, NCS-DFS, and NCS-OS were 26.5, 23.2, and 38%, respectively. None of the patients had acute or late grade 3/4 gastrointestinal or genitourinary toxicities. Conclusions: The outcomes from this pilot study indicate that thermoradiotherapy is a feasible therapeutic modality in elderly MIBC patients unfit for surgery or CTRT. HTRT is well-tolerated, allows bladder preservation and function, achieves long-term satisfactory locoregional control and is devoid of significant treatment-related morbidity. This therapeutic approach deserves further evaluation in randomized studies.
Collapse
Affiliation(s)
- Niloy Ranjan Datta
- Center for Radiation Oncology KSA-KSB, Kantonsspital Aarau, Aarau, Switzerland
| | - Emanuel Stutz
- Center for Radiation Oncology KSA-KSB, Kantonsspital Aarau, Aarau, Switzerland
| | - Emsad Puric
- Center for Radiation Oncology KSA-KSB, Kantonsspital Aarau, Aarau, Switzerland
| | - Brigitte Eberle
- Center for Radiation Oncology KSA-KSB, Kantonsspital Aarau, Aarau, Switzerland
| | - Andreas Meister
- Center for Radiation Oncology KSA-KSB, Kantonsspital Aarau, Aarau, Switzerland
| | - Dietmar Marder
- Center for Radiation Oncology KSA-KSB, Kantonsspital Aarau, Aarau, Switzerland
| | - Olaf Timm
- Center for Radiation Oncology KSA-KSB, Kantonsspital Aarau, Aarau, Switzerland
| | - Susanne Rogers
- Center for Radiation Oncology KSA-KSB, Kantonsspital Aarau, Aarau, Switzerland
| | - Stephen Wyler
- Department of Urology, Kantonsspital Aarau, Aarau, Switzerland
| | - Stephan Bodis
- Center for Radiation Oncology KSA-KSB, Kantonsspital Aarau, Aarau, Switzerland.,Department of Radiation Oncology, University Hospital Zürich, Zurich, Switzerland
| |
Collapse
|
15
|
Tan MBBS, MRCP, FRCR, MD LT, Tanderup PhD K, Kirisits PhD C, de Leeuw PhD A, Nout MD, PhD R, Duke MBBS, FRCR S, Seppenwoolde PhD Y, Nesvacil PhD N, Georg PhD D, Kirchheiner PhD K, Fokdal MD, PhD L, Sturdza MD, FRCPC A, Schmid MD M, Swamidas PhD J, van Limbergen MD, PhD E, Haie-Meder MD C, Mahantshetty MD U, Jürgenliemk-Schulz MD, PhD I, Lindegaard DM, DMSc JC, Pötter MD R. Image-guided Adaptive Radiotherapy in Cervical Cancer. Semin Radiat Oncol 2019; 29:284-298. [DOI: 10.1016/j.semradonc.2019.02.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
|
16
|
Walshaw RC, Honeychurch J, Illidge TM, Choudhury A. The anti-PD-1 era - an opportunity to enhance radiotherapy for patients with bladder cancer. Nat Rev Urol 2018; 15:251-259. [PMID: 29089607 DOI: 10.1038/nrurol.2017.172] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
An urgent need exists to improve the outcomes of patients with muscle-invasive bladder cancer (MIBC), and especially of those with metastatic disease. Treatments that enhance antitumour immune responses - such as immune-checkpoint inhibition - provide an opportunity to do this. Despite initial success, durable response rates in patients with advanced-stage MIBC treated with novel inhibitory antibodies targeting programmed cell death protein 1 (PD-1) or its endogenous ligand programmed cell death 1 ligand 1 (PD-L1) remain low. Radiotherapy is part of the management of bladder cancer in many patients. Evidence that radiotherapy has immunogenic properties is now available, but radiotherapy-induced immune responses are often negated by immunosuppression within the tumour microenvironment. Anti-PD-1 or anti-PD-L1 antibodies might enhance radiotherapy-induced antitumour immunity. This effect has been demonstrated in preclinical models of bladder cancer, and clinical trials involving this approach are currently recruiting. Combination treatment strategies provide an exciting opportunity for urological oncologists to not only improve the chances of cure in patients undergoing radical treatment for MIBC, but also to increase long-term response rates in those with metastatic disease.
Collapse
Affiliation(s)
- Richard C Walshaw
- Targeted Therapy Group, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre, 555 Wilmslow Road, Withington, Manchester M20 4BX, UK
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester Academic Health Sciences Centre, 555 Wilmslow Road, Withington, Manchester M20 4BX, UK
| | - Jamie Honeychurch
- Targeted Therapy Group, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre, 555 Wilmslow Road, Withington, Manchester M20 4BX, UK
| | - Timothy M Illidge
- Targeted Therapy Group, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre, 555 Wilmslow Road, Withington, Manchester M20 4BX, UK
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester Academic Health Sciences Centre, 555 Wilmslow Road, Withington, Manchester M20 4BX, UK
| | - Ananya Choudhury
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester Academic Health Sciences Centre, 555 Wilmslow Road, Withington, Manchester M20 4BX, UK
- Translational Radiobiology Group, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, University of Manchester, Manchester Academic Health Sciences Centre, 555 Wilmslow Road, Withington, Manchester M20 4BX, UK
| |
Collapse
|
17
|
6 - Terapia Trimodale Nel Trattamento Conservativo Della Neoplasia Vescicale. TUMORI JOURNAL 2018; 104:S23-S27. [DOI: 10.1177/0300891618766109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
18
|
Pötter R, Tanderup K, Kirisits C, de Leeuw A, Kirchheiner K, Nout R, Tan LT, Haie-Meder C, Mahantshetty U, Segedin B, Hoskin P, Bruheim K, Rai B, Huang F, Van Limbergen E, Schmid M, Nesvacil N, Sturdza A, Fokdal L, Jensen NBK, Georg D, Assenholt M, Seppenwoolde Y, Nomden C, Fortin I, Chopra S, van der Heide U, Rumpold T, Lindegaard JC, Jürgenliemk-Schulz I. The EMBRACE II study: The outcome and prospect of two decades of evolution within the GEC-ESTRO GYN working group and the EMBRACE studies. Clin Transl Radiat Oncol 2018; 9:48-60. [PMID: 29594251 PMCID: PMC5862686 DOI: 10.1016/j.ctro.2018.01.001] [Citation(s) in RCA: 406] [Impact Index Per Article: 67.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 01/09/2018] [Accepted: 01/09/2018] [Indexed: 02/07/2023] Open
Abstract
The publication of the GEC-ESTRO recommendations one decade ago was a significant step forward for reaching international consensus on adaptive target definition and dose reporting in image guided adaptive brachytherapy (IGABT) in locally advanced cervical cancer. Since then, IGABT has been spreading, particularly in Europe, North America and Asia, and the guidelines have proved their broad acceptance and applicability in clinical practice. However, a unified approach to volume contouring and reporting does not imply a unified administration of treatment, and currently both external beam radiotherapy (EBRT) and IGABT are delivered using a large variety of techniques and prescription/fractionation schedules. With IGABT, local control is excellent in limited and well-responding tumours. The major challenges are currently loco-regional control in advanced tumours, treatment-related morbidity, and distant metastatic disease. Emerging evidence from the RetroEMBRACE and EMBRACE I studies has demonstrated that clinical outcome is related to dose prescription and technique. The next logical step is to demonstrate excellent clinical outcome with the most advanced EBRT and brachytherapy techniques based on an evidence-based prospective dose and volume prescription protocol. The EMBRACE II study is an interventional and observational multicentre study which aims to benchmark a high level of local, nodal and systemic control while limiting morbidity, using state of the art treatment including an advanced target volume selection and contouring protocol for EBRT and brachytherapy, a multi-parametric brachytherapy dose prescription protocol (clinical validation of dose constraints), and use of advanced EBRT (IMRT and IGRT) and brachytherapy (IC/IS) techniques (clinical validation). The study also incorporates translational research including imaging and tissue biomarkers.
Collapse
Affiliation(s)
- Richard Pötter
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Denmark
| | - Christian Kirisits
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | - Astrid de Leeuw
- Department of Radiation Oncology, University Medical Centre Utrecht, The Netherlands
| | - Kathrin Kirchheiner
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | - Remi Nout
- Department of Radiation Oncology, Leiden University Medical Center, The Netherlands
| | - Li Tee Tan
- Departments of Oncology, Radiology and Gynae-oncology, Addenbrooke’s Hospital, Cambridge University Hospitals National Health Service Trust, United Kingdom
| | | | | | - Barbara Segedin
- Department of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia
| | - Peter Hoskin
- Cancer Centre, Mount Vernon Cancer Centre, United Kingdom
| | - Kjersti Bruheim
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Bhavana Rai
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Fleur Huang
- Department of Oncology, Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Erik Van Limbergen
- Department of Radiation Oncology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Max Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | - Nicole Nesvacil
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | - Lars Fokdal
- Department of Oncology, Aarhus University Hospital, Denmark
| | | | - Dietmar Georg
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | | | - Yvette Seppenwoolde
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | - Christel Nomden
- Department of Radiation Oncology, University Medical Centre Utrecht, The Netherlands
| | - Israel Fortin
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
- Department of Radiation Oncology, Centre Hospitalier de l’Université de Montréal, Montreal University, Montreal, Canada
| | - Supriya Chopra
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | - Uulke van der Heide
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Tamara Rumpold
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Austria
| | | | | | | |
Collapse
|
19
|
Ahamad A, Martinez A, Salenius S, Ross R, Efstathiou J, Fernandez E. Routine bladder cancer treatment dictates divergence from trial-derived regimens: Results of treatment at 44 radiotherapy centers. Urol Oncol 2017; 36:9.e19-9.e25. [PMID: 28993060 DOI: 10.1016/j.urolonc.2017.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 08/21/2017] [Accepted: 09/08/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess characteristics and outcome of patients treated with radiotherapy for muscle-invasive bladder cancer at 44 community-based radiotherapy centers and compare these to those on clinical trials. MATERIALS AND METHODS We reviewed 155 patients who had been treated from 2010 to 2014. Overall survival and progression-free survival were estimated using the Kaplan-Meier method. Results were compared to a pooled analysis of 6 Radiation Therapy Oncology Group (RTOG) protocols. RESULTS What stood out was that our patients' characteristics were significantly inferior than those on RTOG studies: lower rate of complete transurethral resection of bladder tumor: 36.8% vs. 70% (P<0.0001), higher median age: 79 years vs. 66 (P<0.0001), more medically inoperable: (51.0%) vs. 0% in RTOG (P<0.001), and 46.9% had refused surgery. Fewer patients underwent concurrent chemotherapy: 56.1% vs. 100% (P<0.0001). It was also striking that at median follow-up 12.6 months (range: 3.1-49.2), the 36-month overall survival was 51.3% for those who refused surgery vs. 24.5% for medically inoperable (P = 0.009); 58.1% with complete transurethral resection of bladder tumor vs. 29.8% if incomplete (P = 0.07); 54.3% with chemoradiotherapy (CRT) vs. 17.2% without (P = 0.03); 66.3% for those who refused surgery and had CRT vs. 38.9% for medically inoperable who had CRT (P = 0.04). CONCLUSIONS The cohort at community-based centers was older, more medically inoperable, and less likely to receive CRT than clinical trial patients. This suggests that we may not be able to apply trial-derived regimens for many patients in this setting. There is a pressing need to find treatment options for such patients, especially given the aging population. Survival of medically operable CRT patients was comparable to results of RTOG protocols notwithstanding this study's smaller sample size, retrospective nature and suboptimal documentation of patient characteristics.
Collapse
Affiliation(s)
- Anesa Ahamad
- Department of Radiation Oncology, 21st Century Oncology, Key West, FL.
| | - Alvaro Martinez
- Department of Radiation Oncology, 21st Century Oncology, Troy, MI
| | - Sharon Salenius
- Department of Research and Education, 21st Century Oncology, Fort Myers, FL
| | - Rudi Ross
- Department of Research and Education, 21st Century Oncology, Fort Myers, FL
| | - Jason Efstathiou
- Department of Radiation Oncology, Harvard Medical School, Bertucci Center for GU Cancers, Massachusetts General Hospital, Boston, MA
| | - Eduardo Fernandez
- Department of Radiation Oncology, 21st Century Oncology, Plantation, FL
| |
Collapse
|
20
|
Korpics M, Block AM, Altoos B, Martin B, Carey K, Welsh J, Harkenrider MM, Solanki AA. Maximizing survival in patients with muscle-invasive bladder cancer undergoing curative bladder-preserving radiotherapy: the impact of radiotherapy dose escalation. ACTA ACUST UNITED AC 2017. [DOI: 10.1007/s13566-017-0319-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
21
|
Canlas R, McVicar N, Nakano S, Sahota H, Mahajan P, Tyldesley S. Assessment of Adaptive Margins Using a Single Planning Computed Tomography Scan for Bladder Radiotherapy. J Med Imaging Radiat Sci 2016; 47:227-234. [DOI: 10.1016/j.jmir.2016.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 04/28/2016] [Accepted: 05/04/2016] [Indexed: 11/29/2022]
|
22
|
Lutkenhaus LJ, Vestergaard A, Bel A, Høyer M, Hulshof MCCM, van Leeuwen CM, Casares-Magaz O, Petersen JB, Søndergaard J, Muren LP. A biological modeling based comparison of two strategies for adaptive radiotherapy of urinary bladder cancer. Acta Oncol 2016; 55:1009-15. [PMID: 27100215 DOI: 10.3109/0284186x.2016.1151548] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Adaptive radiotherapy is introduced in the management of urinary bladder cancer to account for day-to-day anatomical changes. The purpose of this study was to determine whether an adaptive plan selection strategy using either the first four cone beam computed tomography scans (CBCT-based strategy) for plan creation, or the interpolation of bladder volumes on pretreatment CT scans (CT-based strategy), is better in terms of tumor control probability (TCP) and normal tissue sparing while taking the clinically applied fractionation schedules also into account. Material and methods With the CT-based strategy, a library of five plans was created. Patients received 55 Gy to the bladder tumor and 40 Gy to the non-involved bladder and lymph nodes, in 20 fractions. With the CBCT-based strategy, a library of three plans was created, and patients received 70 Gy to the tumor, 60 Gy to the bladder and 48 Gy to the lymph nodes, in 30-35 fractions. Ten patients were analyzed for each adaptive plan selection strategy. TCP was calculated applying the clinically used fractionation schedules, as well as a rescaling of the dose from 55 to 70 Gy for the CT-based strategy. For rectum and bowel, equivalent doses in 2 Gy fractions (EQD2) were calculated. Results The CBCT-based strategy resulted in a median TCP of 75%, compared to 49% for the CT-based strategy, the latter improving to 72% upon rescaling the dose to 70 Gy. A median rectum V30Gy (EQD2) of 26% [interquartile range (IQR): 8-52%] was found for the CT-based strategy, compared to 58% (IQR: 55-73%) for the CBCT-based strategy. Also the bowel doses were lower with the CT-based strategy. Conclusions Whereas the higher total bladder TCP for the CBCT-based strategy is due to prescription differences, the adaptive strategy based on CT scans results in the lowest rectum and bowel cavity doses.
Collapse
Affiliation(s)
- L. J. Lutkenhaus
- Department of Radiation Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | - A. Vestergaard
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - A. Bel
- Department of Radiation Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | - M. Høyer
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - M. C. C. M. Hulshof
- Department of Radiation Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | - C. M. van Leeuwen
- Department of Radiation Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | - O. Casares-Magaz
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - J. B. Petersen
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - J. Søndergaard
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - L. P. Muren
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|
23
|
Alfred Witjes J, Lebret T, Compérat EM, Cowan NC, De Santis M, Bruins HM, Hernández V, Espinós EL, Dunn J, Rouanne M, Neuzillet Y, Veskimäe E, van der Heijden AG, Gakis G, Ribal MJ. Updated 2016 EAU Guidelines on Muscle-invasive and Metastatic Bladder Cancer. Eur Urol 2016; 71:462-475. [PMID: 27375033 DOI: 10.1016/j.eururo.2016.06.020] [Citation(s) in RCA: 1051] [Impact Index Per Article: 131.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 06/13/2016] [Indexed: 12/20/2022]
Abstract
CONTEXT Invasive bladder cancer is a frequently occurring disease with a high mortality rate despite optimal treatment. The European Association of Urology (EAU) Muscle-invasive and Metastatic Bladder Cancer (MIBC) Guidelines are updated yearly and provides information to optimise diagnosis, treatment, and follow-up of this patient population. OBJECTIVE To provide a summary of the EAU guidelines for physicians and patients confronted with muscle-invasive and metastatic bladder cancer. EVIDENCE ACQUISITION An international multidisciplinary panel of bladder cancer experts reviewed and discussed the results of a comprehensive literature search of several databases covering all sections of the guidelines. The panel defined levels of evidence and grades of recommendation according to an established classification system. EVIDENCE SYNTHESIS Epidemiology and aetiology of bladder cancer are discussed. The proper diagnostic pathway, including demands for pathology and imaging, is outlined. Several treatment options, including bladder-sparing treatments and combinations of treatment modalities (different forms of surgery, radiation therapy, and chemotherapy) are described. Sequencing of these modalities is discussed. Potential indications and contraindications, such as comorbidity, are related to treatment choice. There is a new paragraph on organ-sparing approaches, both in men and in women, and on minimal invasive surgery. Recommendations for chemotherapy in fit and unfit patients are provided including second-line options. Finally, a follow-up schedule is provided. CONCLUSIONS The current summary of the EAU Muscle-invasive and Metastatic Bladder Cancer Guidelines provides an up-to-date overview of the available literature and evidence dealing with diagnosis, treatment, and follow-up of patients with metastatic and muscle-invasive bladder cancer. PATIENT SUMMARY Bladder cancer is an important disease with a high mortality rate. These updated guidelines help clinicians refine the diagnosis and select the appropriate therapy and follow-up for patients with metastatic and muscle-invasive bladder cancer.
Collapse
Affiliation(s)
- J Alfred Witjes
- Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
| | - Thierry Lebret
- Hôpital Foch, Department of Urology, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France
| | - Eva M Compérat
- Department of Pathology, Hôpital La Pitié Salpetrière, UPMC, Paris, France
| | - Nigel C Cowan
- Radiology Department, Queen Alexandra Hospital, Portsmouth, UK
| | - Maria De Santis
- University of Warwick, Cancer Research Unit, Coventry, UK; Queen Elizabeth Hospital, Birmingham, UK
| | - Harman Maxim Bruins
- Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Virginia Hernández
- Department of Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | | | - James Dunn
- Department of Urology, Derriford Hospital, Plymouth, UK
| | - Mathieu Rouanne
- Hôpital Foch, Department of Urology, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France
| | - Yann Neuzillet
- Hôpital Foch, Department of Urology, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France
| | - Erik Veskimäe
- Department of Urology, Tampere University Hospital, Tampere, Finland
| | | | - Georgios Gakis
- Department of Urology, Eberhard-Karls University, Tübingen, Germany
| | - Maria J Ribal
- Department of Urology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| |
Collapse
|
24
|
Lutkenhaus LJ, van Os RM, Bel A, Hulshof MCCM. Clinical results of conformal versus intensity-modulated radiotherapy using a focal simultaneous boost for muscle-invasive bladder cancer in elderly or medically unfit patients. Radiat Oncol 2016; 11:45. [PMID: 26993980 PMCID: PMC4797227 DOI: 10.1186/s13014-016-0618-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 03/10/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND For elderly or medically unfit patients with muscle-invasive bladder cancer, cystectomy or chemotherapy are contraindicated. This leaves radical radiotherapy as the only treatment option. It was the aim of this study to retrospectively analyze the treatment outcome and associated toxicity of conformal versus intensity-modulated radiotherapy (IMRT) using a focal simultaneous tumor boost for muscle-invasive bladder cancer in patients not suitable for cystectomy. METHODS One hundred eighteen patients with T2-4 N0-1 M0 bladder cancer were analyzed retrospectively. Median age was 80 years. Treatment consisted of either a conformal box technique or IMRT and included a simultaneous boost to the tumor. To enable an accurate boost delivery, fiducial markers were placed around the tumor. Patients were treated with 40 Gy in 20 fractions to the elective treatment volumes, and a daily tumor boost up to 55-60 Gy. RESULTS Clinical complete response was seen in 87 % of patients. Three-year overall survival was 44 %, with a locoregional control rate of 73 % at 3 years. Toxicity was low, with late urinary and intestinal toxicity rates grade ≥ 2 of 14 and 5 %, respectively. The use of IMRT reduced late intestinal toxicity, whereas fiducial markers reduced acute urinary toxicity. CONCLUSIONS Radical radiotherapy using a focal boost is feasible and effective for elderly or unfit patients, with a 3-year locoregional control of 73 %. Toxicity rates were low, and were reduced by the use of IMRT and fiducial markers.
Collapse
Affiliation(s)
- Lotte J Lutkenhaus
- Department of Radiation Oncology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Rob M van Os
- Department of Radiation Oncology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Arjan Bel
- Department of Radiation Oncology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Maarten C C M Hulshof
- Department of Radiation Oncology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| |
Collapse
|
25
|
A review of the 2014 English Language publications pertinent to the treatment of invasive bladder cancer by radiotherapy. Curr Opin Support Palliat Care 2015; 9:245-8. [DOI: 10.1097/spc.0000000000000151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|