Abstract
ObjectivesRadical cystectomy (RC) and pelvic lymph-node dissection (LND) is standard treatment for non-metastatic muscle-invasive urothelial bladder cancer (MIBC). However, loco-regional recurrence (LRR) is a common early event associated with poor prognosis. We evaluate 3-year LRR-free (LRRFS), metastasis-free (MFS) and overall survivals (OS) after adjuvant radiotherapy (RT) for pathological high-risk MIBC.Material and methodsWe retrospectively reviewed data from patients in 3 institutions. Inclusion criteria were MIBC, histologically-proven urothelial carcinoma treated by RC and adjuvant RT. Patients with conservative surgery were excluded. Outcomes were evaluated by Kaplan-Meier method. Acute toxicities were recorded according to CTCAE V4.0 scale.ResultsBetween 2000 and 2013, 57 patients [median age 66.3 years (45–84)] were included. Post-operative pathological staging was ≤pT2, pT3 and pT4 in 16%, 44%, and 39%, respectively. PLND revealed 28% pN0, 26% pN1 and 42% pN2. Median number of lymph-nodes retrieved was 10 (2–33). Forty-eight patients (84%) received platin-based chemotherapy. For RT, clinical target volume 1 (CTV 1) encompassed pelvic lymph nodes for all patients. CTV 1 also included cystectomy bed for 37 patients (65%). CTV 1 median dose was 45 Gy (4–50). A boost of 16 Gy (5–22), corresponding to CTV 2, was administered for 30 patients, depending on pathological features. One third of patients received intensity-modulated RT. With median follow-up of 40.4 months, 8 patients (14%) had LRR. Three-year LRRFS, MFS and OS were 45% (95%CI 30–60), 37% (95%CI 24–51) and 49% (95%CI 33–63), respectively. Five (9%) patients had acute grade ≥3 toxicities (gastro-intestinal, genito-urinary and biological parameters). One patient died with intestinal fistula in a septic context.ConclusionsBecause of poor prognosis, an effective post-operative standard of care is needed for pathological high-risk MIBC. Adjuvant RT is feasible and may have oncological benefits. Prospective trials evaluating this approach with current RT techniques should be undertaken.
Highlights
Muscle-invasive urothelial bladder cancer (MIBC) is an aggressive disease with poor 5-year overall survival (OS) of 50% [1, 2]
An effective post-operative standard of care is needed for pathological high-risk MIBC
Current optimal management is based on radical cystectomy (RC) and pelvic lymph node dissection (LND), generally associated with pre-operative cisplatin-based chemotherapy
Summary
Muscle-invasive urothelial bladder cancer (MIBC) (cT2-T4) is an aggressive disease with poor 5-year overall survival (OS) of 50% [1, 2]. Prognosis after LRR appears poor with a possible impact on metastasis-free survival (MFS) [4] and OS [5]. In the 1980’s, peri-operative radiotherapy (RT) was explored, demonstrating benefits in terms of loco-regional control, but associated with significant gastro-intestinal (GI) toxicity. This toxicity, directly dependent on the RT techniques used at the time has limited the development of this approach [6]. The aim of this study is to provide up-to-date estimations of outcomes and toxicity for patients treated by RC and adjuvant RT for MIBC in terms of 3-year LRR-free survival (LRRFS), MFS and OS. We focus on acute toxicities, in particular for patients with neobladders
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