International Journal of Radiation Oncology*Biology*Physics
Clinical InvestigationPatterns of Failure After Radical Cystectomy for pT3-4 Bladder Cancer: Implications for Adjuvant Radiation Therapy
Introduction
Bladder cancer is the second most common genitourinary cancer in the United States and results in approximately 15,000 deaths each year (1). The most common treatment for muscle-invasive bladder cancer is radical cystectomy, with or without perioperative chemotherapy for more advanced stages of disease (2). Although the predominant site of treatment failure is distant, up to 20% of patients treated with radical cystectomy develop local-regional failure (LF) 3, 4, 5, 6, 7, with increasing risk with more advanced stages (8).The development of LF is associated with inferior cancer-specific survival 8, 9. For select patients, it is possible that adjuvant treatment of patients at risk for LF may improve survival.
Although there is no well-defined role for adjuvant radiation therapy (RT) in the treatment of resectable muscle-invasive bladder cancer, some studies have suggested that adjuvant RT can decrease the incidence of LF 10, 11, 12 and improve cancer-specific survival 11, 12, 13. Patients with the highest risk of LF may be the best candidates for adjuvant RT, and defining patterns of failure could help guide field design of adjuvant RT after radical cystectomy. The goals of this study were to define the patterns of pelvic failure in a high-risk (pT3 to 4N0-1) cohort of patients treated with radical cystectomy, describe the locations of LF, and assess factors associated with LF.
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Methods and Materials
Between January 2007 and June 2014, 334 patients with pathologic T3-4N0-1 bladder cancer were treated with radical cystectomy and bilateral pelvic lymph node dissection (PLND) at a tertiary care center. Radical cystectomy included removal of the bladder, prostate, and seminal vesicles in men and anterior pelvic exenteration in women. Borders of PLND included the genitofemoral nerve laterally, 1 to 2 cm above the bifurcation of the common iliac vessels superiorly, hypogastric vessels inferiorly,
Results
Patient characteristics are presented in Table 1. Of the 334 patients, 243 (73%) were men, and 91 (28%) were women. The median age at cystectomy was 71 years old (IQR: 62-78; range: 26-93 years), and median body mass index was 27 (IQR: 24-31). Platinum-based chemotherapy was administered to 153 patients (46%), either in adjuvant (n=117 [35%]) or neoadjuvant (n=43 [13%]) fashion. Chemotherapy was given in 59 patients (33%) with pN0 disease and 97 patients (63%) with node-positive disease (P
Discussion
In this analysis of patients with pT3-4 bladder cancer treated with radical cystectomy, we demonstrated that LFs occurred in 31% of patients with either T4 or N1 disease at 2 years. Meanwhile, patients with pT3N0 disease had <15% risk of LF at 2 years. The most common sites of pelvic failure are in the external and internal iliac LNs and obturator LN regions. This coincides with the bounds of a standard pelvic lymphadenectomy and the typical treatment field for definitive radiation in
Conclusions
This study of 334 patients with locally advanced bladder cancer provides useful information regarding patterns of failure after radical cystectomy. To our knowledge, this is the first study to assess LF and patterns of LF in a cohort of pT3-4 patients. Patients at the highest risk of LF were those with pT4 stage or LN involvement. The hypothesis that adjuvant RT can improve pelvic relapse-free survival in men with pT3-4N0-2 bladder cancer after radical cystectomy is currently being tested in a
References (19)
- et al.
Local recurrence after radical cystectomy for invasive bladder cancer: An analysis of predictive factors
Urology
(2004) - et al.
A novel risk stratification to predict local-regional failures in urothelial carcinoma of the bladder after radical cystectomy
Int J Radiat Oncol Biol Phys
(2013) - et al.
Urinary diversion-related outcome in patients with pelvic recurrence after radical cystectomy for bladder cancer
Urology
(1999) - et al.
Impact of the number of lymph nodes retrieved on outcome in patients with muscle invasive bladder cancer
J Urol
(2002) - et al.
Local recurrence after cystectomy and survival of patients with bladder cancer: A population based study in greater Amsterdam
J Urol
(2005) - et al.
Postoperative radiotherapy of carcinoma in bilharzial bladder: Improved disease free survival through improving local control
Int J Radiat Oncol Biol Phys
(1992) - et al.
Postoperative radiotherapy of carcinoma in bilharzial bladder using a three-fractions per day regimen
Radiother Oncol
(1986) - et al.
Trimodality bladder-sparing approach without neoadjuvant chemotherapy for node-negative localized muscle-invasive urinary bladder cancer resulted in comparable cystectomy-free survival
Radiat Oncol
(2014) - et al.
Hypofractionated intensity modulated radiation therapy in combined modality treatment for bladder preservation in elderly patients with invasive bladder cancer
Int J Radiat Oncol Biol Phys
(2014)
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Conflict of interest: none.