Yadav B S, Ghoshal S, Sharma S C
Department of Radiotherapy, PGIMER, Chandigarh, India.
Indian J Urol. 2008 Jan;24(1):48-53. doi: 10.4103/0970-1591.38603.
Invasive bladder cancer is a lethal disease with a 50% cancer-related mortality even in the best healthcare systems. Optimum combination of surgery, external beam radiotherapy and platinum-based chemotherapy has yet to be determined.
To audit the outcome of multi-modality treatment and compare this with the existing literature in order to set future priorities and re-audit in patients with invasive carcinoma of urinary bladder.
Between January 2001 and December 2004, 97 patients with invasive carcinoma of urinary bladder were analyzed. Radical surgery was done in 18(18%) patients and adjuvant radiation was given to 20(21%) patients. Radical radiation alone, (>/=50 Gy) was given to 26(27%) and chemoradiation to 33(34%) patients respectively. Patients in the chemoradiation arm were given the same dose of radiation with weekly concomitant cisplatin at 40 mg/ m(2) one hour before radiation during the first phase only. At a median follow-up of 32 months the outcome studied included locoregional failure, distant failure, disease-free survival (DFS) and overall survival (OS) using univariate and multivariate analyses. The OS and DFS were calculated according to Kaplan-Meier. Log rank test was used for statistical significance.
Median age of the patients was 58 years. Males comprised 93% of the total patients. Most (93%) of the patients had transitional cell histology. In patients treated with radiation alone overall response rate was 60%, with a complete response (CR) rate of 42%. The CR in patients treated with chemoradiation was 51%. Bladder was preserved in 61% of patients who received chemoradiation as compared to 42% in patients treated with radical radiation. With radical radiation local recurrence rate was 19% as compared to 22% with surgery and 6% with chemoradiation, respectively. Local recurrence rate was only 5% in patients treated with adjuvant radiation. Distant metastasis rate was least with chemoradiation (9%) as compared to 11.5% in radical radiation: curable dose of radiation and 33% with surgery alone, respectively. Patients with adjuvant radiation had a distant metastases rate of 15%. Median OS was 36 months. Factors affecting OS were histology (P = 0.023) and nodal involvement (P = 0.034). Median DFS was 26 months. Significant factors affecting DFS on univariate analysis were histology (P = 0.046) and nodal involvement (P = 0.004). On multivariate analysis the only factor affecting DFS and OS was nodal involvement (P = 0.01; Hazard Ratio, 0.085-0.719).
In patients with invasive bladder cancer, combined modality in the form of radical cystectomy followed by radiation give best local control. Radiation alone is not effective to control muscle-invasive local disease; however, Chemoradiation is an effective alternative to radical cystectomy to preserve bladder function.
浸润性膀胱癌是一种致命疾病，即使在最好的医疗体系中，其癌症相关死亡率仍达50%。手术、外照射放疗和铂类化疗的最佳组合尚未确定。
审核多模式治疗的结果，并与现有文献进行比较，以便确定未来的重点并对膀胱浸润性癌患者进行再次审核。
分析2001年1月至2004年12月期间97例膀胱浸润性癌患者。18例（18%）患者接受了根治性手术，20例（21%）患者接受了辅助放疗。分别有26例（27%）患者接受单纯根治性放疗（≥50 Gy），33例（34%）患者接受放化疗。放化疗组患者仅在第一阶段放疗前1小时给予每周一次的顺铂，剂量为40 mg/m²，放疗剂量相同。中位随访32个月时，使用单因素和多因素分析研究的结果包括局部区域失败、远处失败、无病生存期（DFS）和总生存期（OS）。OS和DFS根据Kaplan-Meier法计算。采用对数秩检验进行统计学显著性分析。
患者的中位年龄为58岁。男性占患者总数的93%。大多数（93%）患者为移行细胞组织学类型。单纯放疗患者的总体缓解率为60%，完全缓解（CR）率为42%。放化疗患者的CR率为51%。接受放化疗的患者中61%保留了膀胱，而接受根治性放疗的患者中这一比例为42%。根治性放疗后的局部复发率为19%，手术为22%，放化疗为6%。接受辅助放疗的患者局部复发率仅为5%。远处转移率放化疗最低（9%），根治性放疗为11.5%（可治愈剂量放疗），单纯手术为33%。接受辅助放疗的患者远处转移率为15%。中位OS为36个月。影响OS的因素为组织学（P = 0.023）和淋巴结受累（P = 0.034）。中位DFS为26个月。单因素分析中影响DFS的显著因素为组织学（P = 0.046）和淋巴结受累（P = 0.004）。多因素分析中，影响DFS和OS的唯一因素是淋巴结受累（P = 0.01；风险比，0.085 - 0.719）。
对于浸润性膀胱癌患者，根治性膀胱切除术后放疗形式的联合治疗能提供最佳的局部控制。单纯放疗对控制肌肉浸润性局部疾病无效；然而，放化疗是保留膀胱功能的根治性膀胱切除术的有效替代方法。
