Organ Preservation In Bladder Cancer Research Articles

Adaptive Radiotherapy for Bladder Cancer – A Review

Radiotherapy plays an important role in organ preservation for bladder cancer. Delivering radiation accurately can be challenging, in part because the bladder and surrounding organs may change position, volume, and shape between and during the fractions of a treatment course. This variability has been accounted for by increasing the margins around the treatment targets, which can expose more normal tissue to radiation, and increase the likelihood of normal tissue complications. An alternative strategy is to alter, or adapt, the radiotherapy treatment plan to account for such inter-fraction changes, a strategy termed ‘adaptive radiotherapy’ (ART). ART allows smaller target volumes to be treated, and may reduce complications. Approaches to ART include offline adaptation strategies and online strategies, which includes choosing a plan of the day (PoD) based on pre-treatment imaging and magnetic resonance (MR), or with cone-beam CT (CBCT)-guided daily plan re-optimisation. Here, the authors review these ART strategies and trials exploring the dosimetric and clinical benefits of ART relative to non-ART bladder radiotherapy.

Trends and Predictors of Hypofractionated and Intensity-Modulated Radiotherapy for Organ Preservation in Bladder Cancer.

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. 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. 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). 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.

Organ preservation in bladder cancer: an opportunity for truly personalized treatment.

Radical treatment of many solid tumours has moved from surgery to multimodal organ preservation strategies combining systemic and local treatments. Trimodality bladder-preserving treatment (TMT) comprises maximal transurethral resection of the bladder tumour followed by radiotherapy and concurrent radiosensitizing treatment, thereby sparing the urinary bladder. From the patient's perspective, the choice of maintaining quality of life without a negative effect on the chances of cure and long-term survival is attractive. In muscle-invasive bladder cancer (MIBC), the evidence shows comparable clinical outcomes between patients undergoing radical cystectomy and TMT. Despite this evidence, many patients continue to be offered radical surgery as the standard-of-care treatment. Improvements in radiotherapy techniques with adaptive radiotherapy and advances in imaging translate toincreases in the accuracy of treatment delivery and reductions in long-term toxicities. With the advent of novel biomarkers promising improved prediction of treatment response, stratification of patients for different treatments on the basis of tumour biology could soon be a reality. The future of oncological treatment lies in personalized medicine with the combination of technological and biological advances leading to truly bespoke management for patients with MIBC.

SP-0020: Organ preservation in bladder cancer – an evidence-based alternative to radical surgery

SP-0020: Organ preservation in bladder cancer – an evidence-based alternative to radical surgery

Long-Term Outcomes of Organ Preservation for Bladder Cancer in a Large Cohort

Radical cystectomy (RC) still remains the standard of care for patients with muscle-invasive bladder cancer (MIBC), but combined modality therapy (CMT) has been assessed over the past decades as a feasible alternative for patients unfit for surgery or who prefer to preserve their bladder. In this retrospective study, our purpose was to examine radiotherapy (RT) after transurethral resection of bladder tumor (TURBT), and to determine survival, toxicity and bladder conservation outcomes of this approach. From 1992 to 2016, 101 consecutive patients (M/F 82/17; median age 73y) with T2-4a N0-2 M0 MIBC were treated by CMT in our institution. T stage was T2 in 55.6% and T3-4a in 44.4%. N stage was N0 in 89.9% and N1-2 in 10.1%. Hydronephrosis was observed in 24.2% and R2 margin in 61.6%. Average follow-up at the time of analysis was 50.8 months (IQR 13.9-65.7). All patients had 3D RT and/or IMRT. Neoadjuvant or concurrent chemotherapy (QT) was delivered to 25.3% and 54.5% respectively. Average RT doses delivered to the tumor and whole bladder were 62 and 59.4 Gy respectively. 54.5% also received pelvic irradiation. Toxicity was assessed according to CTCAE v3 criteria. After treatment, patients were followed at regular intervals. Endpoints of the study were overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), bladder conservation, acute toxicity and late urinary function. Kaplan-Meier, log-rank test and Pearson’s χ2 were performed for statistical analysis. 99 patients were evaluable for response: 84 achieved CR at first evaluation. 45 patients relapsed during follow-up. 7 of them (15.6%), were non-infiltrant local relapses. 2 and 5-year rates were 77.1 and 52.4% for OS, 57.3 and 44.2% for PFS, and 80.2 and 67.9% for DSS. 2 patients (2%) received salvage cystectomy and remain without evidence of relapse at last control. Multivariate analysis showed that T2 stage, N0 stage and R0 category associate better local control rates (p<0.04). Acute grade ≥ 3 toxicity was observed in 14.1% of patients. 71.4% reported excellent or good late urinary function. According to our data, CMT offers survival and local control rates comparable to modern RC series with the important advantage of bladder function preservation with low rates of salvage cystectomy. This modality should be offered as an alternative to RC in selected patients. The most appropriate cases for CMT are those with T2 R0 N0 disease.

Validation of a trimodalitiy treatment and selective organ preservation for bladder cancer: Influence of clinical different parameters on the 15-year long-term outcome.

4575 Background: To evaluate our 15-year long-term experience with patients treated with transurtehral resection of the bladder (TURBT) and radiochemotherapy (RCT)/radiation (RT) for bladder cancer...

Trimodality Treatment and Selective Organ Preservation for Bladder Cancer

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.

Combined-Modality Treatment and Organ Preservation in Bladder Cancer

Combined-Modality Treatment and Organ Preservation in Bladder Cancer