Selection of high-risk bladder cancer patients for adjuvant chemotherapy by response to preoperative radiotherapy

Abstract

With the availability of new chemotherapeutic agents for patients with bladder carcinoma, there is an attempt to select high-risk patient populations who may benefit from a clinical trial of adjuvant chemotherapy by response to preoperative irradiation. We have reviewed our experience in treating 160 patients with preoperative irradiation followed by a radical cystectomy and ileal conduit urinary diversion without pelvic lymphadenectomy at the M.D. Anderson Hospital and Tumor Institute from January 1, 1969 and December 5, 1977. Radiotherapy consisted of external megavoltage irradiation (25 MeV x-rays) to a dose of 5000 rads in 5 weeks. Persistent or recurrent local disease was documented in 10 patients (6%). 31 patients (19.4%) developed distant metastases. 114 patients (71.3%) are alive with no evidence of disease with a minimum follow-up of one year. There was no remaining malignant disease in 55 patients (34%) after each surgical specimen was carefully examined for the presence or absence of residual tumor. There was a significant difference in survival in the disease-free interval between those patients in whom malignant disease remained. It is apparent that careful pathologic examination of the cyctectomy specimen removed from patients receiving more protracted preoperative radiotherapy provides a method for selecting high-risk patients which might justify a trial of combination chemotherapy. Under current investigation is the use of combination chemotherapy utilizing cis-platinum, cyclophosphamide and adriamycin.