Elsevier

Radiotherapy and Oncology

Volume 93, Issue 2, November 2009, Pages 352-357
Radiotherapy and Oncology

Bladder cancer radiotherapy
Brachytherapy versus cystectomy in solitary bladder cancer: A case control, multicentre, East-Netherlands study

https://doi.org/10.1016/j.radonc.2009.04.020Get rights and content

Abstract

Purpose

Comparing the outcome of surgery and brachytherapy-based radiotherapy in patients with solitary T1G3/T2 bladder tumour in, a retrospective case-control study, because efforts for a randomised clinical trial comparing these modalities have failed.

Materials and methods

Cystectomy group. Patients were selected using the pathological registration system (PALGA). 289 cases of TURT followed by cystectomy, indicated by a muscle – invading bladder tumour were performed in three East-Netherlands medical centres between 1991 and 2001. Out of this group 179 patients with clinical T2N0M0 bladder tumour were selected. All the consecutive files were analysed by a urologist and a radiation oncologist and 65 of those patients (mean age 63.7 years) would have been eligible for brachytherapy, based on an initial analysis: cystoscopy estimated tumour size, post-TURT pathological report, completed by CT-scan and/or, MRI-scan. A final pathological report after radical cystectomy was not considered for patients’ selection.

Brachytherapy group. Patients were selected using a prospective registration study aiming at determination of our treatment results. 89 Patients (mean age 68.4 years) underwent TURT followed by a course of external beam irradiation and interstitial brachytherapy from 1983 till 2005 in the Arnhem Radiotherapy Institute.

Results

The median follow-up for the brachytherapy group was 5.7 years (range 0.2–21.4 years), for the cystectomy group was 5.05 years (range: 0.04–16.8 years). No difference in disease-specific survival (DSS) could be detected with a 5- and 10-year DSS of 71% and 66% in the brachytherapy group and 60% and 57% in the cystectomy group, respectively. Five-year overall survival (OS) was 57% in the brachytherapy group and 52% in the cystectomy group, however, the 10-year OS was better in the cystectomy than in the brachytherapy group (42% and 33%, respectively). This is caused by the significant age difference in favour of the cystectomy group. Cystectomy-free survival in the brachytherapy group was 70%.

Conclusion

Radical cystectomy is the treatment of choice for patients with muscle-invasive bladder carcinoma. However, in a selected patient population a bladder sparing treatment, i.e. a combination of transurethral tumour resection (TURT), external beam irradiation and interstitial brachytherapy, can be applied successfully. This concerns a solitary, T1G3 or T2 bladder tumour, with a diameter < 5 cm.

Section snippets

Patients and methods

The Arnhem Radiotherapy Institution has a long history of brachytherapy and bladder tumour is a consistent indication under the following conditions: solitary T1, Grade 3 or T2 tumours < 5 cm in patients fit for surgery and with sufficient bladder function. In order to create two comparable groups we made a selection of the patient population who underwent radical cystectomy in the same geographic area.

Patient characteristics

The patient characteristics are summarised in Table 1. In the brachytherapy group one patient was lost to follow-up, so 76 patients were analysed in the brachytherapy group, 65 patients were analyzed in the cystectomy group.

The follow-up duration appears to be comparable for the two groups: the median follow-up for the brachytherapy group was 5.7 years (range 0.2–21.4 years), for the cystectomy group was 5.05 years (range: 0.04–16.8 years).

As shown in Table 1, significant differences between the

Cystectomy

Twenty-two patients developed recurrences. Time to development of recurrences ranged between 1 and 51 months with a majority of recurrences within 2 years after cystectomy.

Seven patients developed local recurrence only, nine patients developed distant metastases only and six patients suffered from local recurrence combined with distant metastases. Of the patients who experienced lymph node metastases, five had lymph node dissections.

Brachytherapy

Thirty-five patients developed recurrences. All recurrences

Cystectomy

Cystectomy-related adverse events were seen in a total of 47 patients (72%). Acute toxicity (<3 months after cystectomy) was observed in 34 patients (52%) and late toxicity (>3 months after cystectomy) was seen in 30 patients (46%). We analysed and described the adverse events using the Common Toxicity Criteria for Adverse Events 3.0 (see Table 3).

In total two patients died due to cystectomy. One patient died 6 weeks postoperatively because of sepsis after multiple perforations and leakage of the

Discussion

In the urological world there is a broad consensus supporting radical cystectomy for invasive transitional cell carcinoma. Radical cystectomy and pelvic lymph node dissection are considered to be superior to radiation therapy or organ conserving surgery with regard to local control and ultimate cure of muscle-invasive bladder tumours [4]. Five-year survival is dependent upon the pathological stage and nodal status. Five-year survival for patients with muscle-invasive bladder cancer is

Conclusion

Cancer treatment is a matter of multidisciplinary approach. Cystectomy is certainly a widely applicable treatment of choice in infiltrating bladder cancer and improvement of the technique resulting in improvement of the quality of life is impressive. However, a selected group of patients can benefit from an organ sparing procedure by means of a brachytherapy-based combined treatment. The treatment has a very limited, predominantly minor toxicity and the costs are low: hospitalisation of on the

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