Abstract
Background of the Study: Bladder cancer is the 2nd most common Genitourinary cancer. There are 424082 male Bladder cancer cases and 125311 female bladder cancer cases worldwide. In India, there were 14729 male and 4197 female patients who had Bladder cancer. According to HBCR (2016) there were 71 male and 21 female bladder cancer patients. Radical cystectomy has been considered as the gold standard treatment of choice and only curative therapy for Bladder cancer, thereby underutilizing the trimodality therapy consisting of Transurethral Resection of Bladder Tumor (TURBT) and Chemoradiation,which helps in maintaining patient’s native bladder and improving quality of life. Radical cystectomy with pelvic node dissection is associated with potential morbidity and can be avoided in selected group of patients. This study is to assess the Urinary bladder cases who underwent treatment and the outcomes of Bladder Preservation Therapy (BPT) and quality of life.
Materials and Methods: Bladder cancer patients who reported to Department of Radiation Oncology in Kidwai Memorial Institute of Oncology were analyzed from January 2019 to February 2019. A total of 17 patients were referred for Radiotherapy treatment which included Haemostatic Radiotherapy, Adjuvant Radiotherapy, Radical Radiotherapy, Palliative Radiotherapy. All the Patients underwent basic investigations and work up was done. Based on the Clinical stage of disease and general condition of Patients, Radiotherapy was planned. Conformal Radiotherapy technique was delivered and Clinical outcomes were analysed.
Results: 4 patients received hemostatic radiotherapy and had good bleeding control within 24 to hours, 4 patients received Radical radiotherapy of which 2 patients had stable disease and 2 patients had complete response. 2 patients underwent Trimodality treatment and 1 patient received adjuvant radiotherapy, all of them had no evidence of disease on cystoscopy. 3 patients received Palliative radiotherapy and had good pain relief from bone metastasis. About 76% of patients had gastrointestinal toxicity (grade.1- 46% and grade.2- 30%) and 70% of patients had genitourinary toxicity (grade.1- 30% and grade.2- 40%).
Conclusions: Trimodality therapy provides equal oncologic outcomes and reduces the morbidity associated with radical cystectomy. Selection of cases is the most crucial step for better tumour control and improving quality of life and hence Trimodality therapy must be judiciously advocated to the ideal bladder cancer cases. Organ preservation therapy for bladder cancer is an effective alternate approach in specific subset of patients. The need for multidisciplinary clinics must be emphasized and each case must be dealt critically for bladder preservation therapy. Radical cystectomy must be reserved for recurrent cases and non-responders of chemoradiotherapy. The optimal usage of radiation technique, fractionation schedule, chemotherapeutic agent individualized for the patients and also targeted therapy will definitely bring about better results in management of bladder cancer.
Keywords: Bladder Preservation Therapy, Muscle-Invasive Bladder Cancer, Radical Cystectomy, Image Guided Radiotherapy, Transurethral Resection of Bladder Tumour.
References
- Global cancer statistics 2018: GLOBOCAN estimates of bladder cancer.
- Hospital Based Cancer Registry 2016: KMIO Data.
- Shipley WU, Kaufman DS, Heney NM et al. An update of combined modality therapy for patients with muscle invading bladder cancer using selective bladder preservation or cystectomy. J. Urol.162, 445–451 (1999).
- Walker M, French SD, Doiron RC et al, Bladder sparing radiotherapy for muscle invasive bladder cancer: A survey of providers to determine barriers and enablers. Radiotherapy Oncol.2017:125:351-356.
- Robert Huddart et al. Royal Marsden NHS Foundation Trust Study, Source- UK clinical trials gateway.
- Smith Z.L, Christodouleas, J.P, Keefe SM, Malkowicz S.B, Guzzo T.J. Bladder preservation in the treatment of muscle-invasive bladder cancer: a review of the literature and a practical approach to therapy.BJU Int. 2013; 112: 13-25
- Ploussard G, Daneshmand S, Efstathiou J.A et al. Critical analysis of bladder sparing with trimodal therapy in muscle-invasive bladder cancer: a systematic review. Eur Urol. 2014; 66: 120-137.
- Garry D. Lewis, Waqar Haque et al.The Role Of Adjuvant Radiation Therapy in Locally Advanced Bladder Cancer,vol.4no.2pp.205-213,2018.
- Benjamin W. Fischer-Valuk, Jeff M. Michalski et al. Effectiveness of postoperative radiotherapy after radical cystectomy for locally advanced bladder cancer. Cancer Medicine, published by John Wiley and Sons Ltd.
- Chahal R, Sundaram SK, Iddenden R, Forman DF, Weston PMT, Harrison SCW. A study of the morbidity, mortality and long-term survival following radical cystectomy and radical radiotherapy in the treatment of invasive bladder cancer in Yorkshire. Eur Urol 2003;43:246–57.
- Galvin JM, Ezzell G, Eisbrauch A. Implementing IMRT in clinical practice: a joint document of ASTRO and AAPM. Int. J. Radiat. Oncol. Biol. Phys.58(5), 1616–1634 (2002).
- Cossmann PH. Advances in image-guided radiotherapy – the future is in motion. Eur. Oncol. Rev.62–66 (2005)
- Naslund I, Nilsson B, Littbrand B. Hyperfractionated radiotherapy of bladder cancer. Acta Oncol.33, 397–402 (1994).
- Stuschke M, Thames HD. Hyperfractionated radiotherapy of human tumors: overview of the randomized clinical trials. Int. J. Radiat. Oncol. Biol. Phys. 37, 259–267 (1997).
- Kaufman D, Winter KA, Shipley WU et al. Muscle-invading bladder cancer, RTOG protocol 99–06: initial report of a Phase I/II trial of selective bladder-conservation employing TURBT, accelerated irradiation sensitized with cisplatin and paclitaxel followed by adjuvant cisplatin and gemcitabine chemotherapy (abstract). J. Clin. Oncol.26, 379S (2008).
- Little FA, Howard GC. Sexual function following radical radiotherapy for bladder cancer. Radiother. Oncol.49, 157–161 (1998).
- Koga F, Kihara K. Selective bladder preservation with curative intent for muscle invasive bladder cancer: A contemporary review. Int. J. Urol 2012:19:388-401.
- Zietman Al, Saeco D, Skowronski V, Gomery P et al. Organ conservation in invasive bladder cancer by transurethral resection, chemotherapy and radiation: Results of urodynamic and quality of life study on long term survivors. J. Urol 2003;170:1772-1776.
- Flaig TW et al and the Southwest Oncology Group and National Cancer Institute. S1314, Co-expression Extrapolation (COXEN) Program to Predict Chemotherapy Response in Patients with Bladder Cancer. In: Clinical trials.gov. NCT02177695, 2015.
- Geynisman DM et al and the Fox Chase Cancer Center. Trimodal Bladder Preservation Therapy: Maximal Transurethral Resection Followed by Accelerated Methotraxate, Vinblastine, Doxorubicin, and Cisplatin (AMVAC) and Concurrent Chemoradiation with Intensity Modulated Radiation Therapy for Muscle Invasive Bladder Cancer. In: Clinicaltrials.gov. NCT02710734, 2016.
- Chakravarti A, Winter K, Wu CL et al. Expression of the EGFR and Her-2 are predictors of favorable outcome and reduced complete response rates, respectively, in patients with muscle-invading bladder cancers treated by concurrent radiation and cisplatin-based chemotherapy: a report from the RTOG. Int. J. Radiat. Oncol. Biol. Phys. 62, 309–317 (2005).
- Tsai YC, Pei-Yin H, Tzen KY et al. Synergistic Blockade of EGFR and HER2 by New Generation EGFR Tyrosine Kinase Inhibitor Enhances Radiation Effect in Bladder Cancer Cells. Mol Cancer Ther 2015; 14(3):810-20.
Corresponding Author
Dr Mahantesh A.S
Assistant Surgeon, Kidwai Memorial Institute of Oncology, Bangalore-29, India
DOI: https://dx.doi.org/10.18535/jmscr/v8i4.26
