International Journal of Radiation Oncology*Biology*Physics
Clinical InvestigationA Novel Risk Stratification to Predict Local-Regional Failures in Urothelial Carcinoma of the Bladder After Radical Cystectomy
Introduction
Localized, muscle-invasive urothelial bladder cancer is usually treated with radical cystectomy (RC) plus pelvic lymph node dissection (PLND) with or without chemotherapy. There is no defined role for radiation therapy (RT) although local-regional failure (LF) after surgery with or without chemotherapy is increasingly recognized as a more significant problem than was previously appreciated (1).
Use of postoperative RT was explored decades ago and demonstrated robust local control 2, 3, 4, but serious gastrointestinal toxicity using pre-1980s RT techniques 2, 3, 5 discouraged its use. Improvements in targeting radiation have rekindled interest in adjuvant RT for high-risk patients. This study’s goals were to assess the risk of pelvic failure and to determine those factors that predict LF to identify patients most likely to benefit from adjuvant RT.
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Methods and Materials
Between 1990 and 2008, 486 consecutive patients undergoing RC plus PLND with or without chemotherapy were followed prospectively at the University of Pennsylvania. None of the patients had distant metastases on preoperative imaging of the chest, abdomen, pelvis, and bones. Cystectomy included en bloc excision of the bladder, prostate, and seminal vesicles in men and uterus, ovaries, and anterior vagina in women. All patients had bilateral PLND to the inferior common iliac nodes proximally, the
Results
Of 486 cystectomy patients, 37 patients were excluded because they did not have transitional cell carcinoma and 7 because they had received radiation. Table 1 characterizes the remaining 442 patients, 130 (29%) of whom received chemotherapy. Mean age was 65.8 years (median, 67.0 years; range, 34.3-84.2 years). Mean follow-up was 44.1 months (median, 26.4 months) with a minimum of 1 year follow-up. Eighty patients developed pelvic recurrences. The 5-year cumulative incidence of LF for the entire
Discussion
Invasive urothelial bladder cancer causes 14,000 deaths annually in the United States. Radical cystectomy and PLND provide 5-year survival rates of ∼60% for organ-confined disease (≤pT2N0) and ∼40% when disease extends beyond the bladder (≥pT3N0) (8).
The high risk of distant relapse has encouraged investigations of the use of chemotherapy. Randomized trials of neoadjuvant chemotherapy have demonstrated improved survival 8, 9, while adjuvant chemotherapy trials had mixed results (10).
Conclusions
Local-regional failure after radical cystectomy is a significant problem. The risk of such failure can be stratified into 3 groups: low-risk (≤pT2), intermediate-risk (≥pT3 and ≥10 nodes removed), and high-risk (≥pT3 and<10 nodes) disease with 5-year LF rates of 8%, 23%, and 42%, respectively. This study provides a simple rubric to identify patients most at risk for pelvic recurrence who are most likely to benefit from adjuvant local-regional therapy.
Acknowledgment
We gratefully acknowledge Dr. Eli Glatstein for assistance.
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Conflict of interest: none.