Department of Radiation Oncology, University of Washington, Seattle, Washington.
Department of Radiation Medicine, Oregon Health Sciences University, Portland, Oregon.
Int J Radiat Oncol Biol Phys. 2021 Mar 15;109(4):953-963. doi: 10.1016/j.ijrobp.2020.10.031. Epub 2020 Oct 27.
Definitive radiation therapy (RT), with or without concurrent chemotherapy, is an alternative to radical cystectomy for patients with localized, muscle-invasive bladder cancer (MIBC) who are either not surgical candidates or prefer organ preservation. We aim to synthesize an evidence-based guideline regarding the appropriate use of RT.
We performed a Preferred Reporting Items for Systematic Reviews and Meta-analyses literature review using the PubMed and Embase databases. Based on the literature review, critical management topics were identified and reformulated into consensus questions. An expert panel was assembled to address key areas of both consensus and controversy using the modified Delphi framework.
A total of 761 articles were screened, of which 61 were published between 1975 and 2019 and included for full review. There were 7 well-designed studies, 20 good quality studies, 28 quality studies with design limitations, and 6 references not suited as primary evidence. Adjuvant radiation therapy after cystectomy was not included owing to lack of high-quality data or clinical use. An expert panel consisting of 14 radiation oncologists, 1 medical oncologist, and 1 urologist was assembled. We identified 4 clinical variants of MIBC: surgically fit patients who wish to pursue organ preservation, patients surgically unfit for cystectomy, patients medically unfit for cisplatin-based chemotherapy, and borderline cystectomy candidates based on age with unilateral hydronephrosis and normal renal function. We identified key areas of controversy, including use of definitive radiation therapy for patients with negative prognostic factors, appropriate radiation therapy dose, fractionation, fields and technique when used, and chemotherapy sequencing and choice of agent.
There is limited level-one evidence to guide appropriate treatment of MIBC. Studies vary significantly with regards to patient selection, chemotherapy use, and radiation therapy technique. A consensus guideline on the appropriateness of RT for MIBC may aid practicing oncologists in bridging the gap between data and clinical practice.
对于局部浸润性膀胱癌（MIBC）患者，根治性放疗（RT）联合或不联合同期化疗是根治性膀胱切除术的替代方案，这些患者要么不适合手术，要么选择保留器官。我们旨在综合制定有关 RT 合理应用的循证指南。
我们使用 PubMed 和 Embase 数据库进行了系统评价和荟萃分析的首选报告项目文献综述。根据文献综述，确定了关键的管理主题，并将其重新制定为共识问题。一个专家小组使用改良 Delphi 框架解决了共识和争议的关键领域。
共筛选出 761 篇文章，其中 1975 年至 2019 年发表的有 61 篇，并进行了全面审查。有 7 项设计良好的研究，20 项高质量研究，28 项设计有限的质量研究，以及 6 项不适合作为主要证据的参考文献。由于缺乏高质量的数据或临床应用，未包括膀胱切除术后辅助放疗。一个由 14 名放射肿瘤学家、1 名肿瘤内科医生和 1 名泌尿科医生组成的专家小组。我们确定了 MIBC 的 4 种临床变异型：希望保留器官的手术适应患者，手术不适应膀胱切除术的患者，不适合顺铂为基础化疗的患者，以及基于年龄单侧肾积水和正常肾功能的临界膀胱切除术候选者。我们确定了争议的关键领域，包括对具有阴性预后因素的患者使用确定性放疗、适当的放疗剂量、分割、照射野和技术，以及化疗的顺序和药物的选择。
指导 MIBC 适当治疗的一级证据有限。研究在患者选择、化疗应用和放疗技术方面存在显著差异。MIBC RT 适宜性的共识指南可能有助于实践肿瘤学家缩小数据与临床实践之间的差距。
