Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO, USA; Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA.
National Cancer Institute, Cairo, Egypt; Children's Cancer Hospital, Cairo, Egypt.
Clin Oncol (R Coll Radiol). 2021 Jun;33(6):391-399. doi: 10.1016/j.clon.2021.03.020.
Local-regional failure for patients with ≥pT3 urothelial carcinoma after radical cystectomy is a significant clinical challenge. Prospective randomised trials have failed to show that chemotherapy reduces the risk of local-regional recurrences. Salvage treatment for local failures is difficult and often unsuccessful. There is promising evidence, particularly from a recent Egyptian National Cancer Institute trial, that radiation therapy plus chemotherapy can significantly reduce local recurrences compared with chemotherapy alone, and that this improvement in local-regional control may translate to meaningful improvements in disease-free and overall survival with acceptable toxicity. In light of the high rates of local failure following cystectomy for locally advanced disease and the progress that has been made in identifying patients at high risk of failure and the patterns of failure in the pelvis, the National Comprehensive Cancer Network guidelines were revised to include postoperative radiotherapy as an option to consider for patients with ≥pT3 disease. Here we review the problem of local-regional failure after cystectomy, identify patients who would probably benefit from adjuvant radiotherapy, review the patterns of pelvic failure after cystectomy, discuss technical details of radiation treatment and review the modern literature on this topic. Adjuvant radiotherapy should be considered as a treatment option for patients with locally advanced disease, especially those with positive margins or squamous cell carcinoma.
对于根治性膀胱切除术后 ≥pT3 尿路上皮癌患者，局部区域复发是一个重大的临床挑战。前瞻性随机试验未能表明化疗可降低局部区域复发的风险。局部复发的挽救性治疗较为困难，且往往无效。特别是来自最近的埃及国家癌症研究所的一项试验提供了有希望的证据，表明与单独化疗相比，放疗加化疗可显著降低局部复发率，并且这种局部区域控制的改善可能转化为无病生存期和总生存期的显著改善，同时毒性可接受。鉴于局部晚期疾病行膀胱切除术后局部失败率较高，以及在识别高复发风险患者和骨盆失败模式方面取得的进展，美国国家综合癌症网络指南已修订，将术后放疗作为一种选择，考虑用于≥pT3 疾病的患者。本文复习了膀胱切除术后局部区域复发的问题，确定了可能从辅助放疗中获益的患者，回顾了膀胱切除术后骨盆失败的模式，讨论了放射治疗的技术细节，并复习了该主题的现代文献。对于局部进展性疾病患者，尤其是切缘阳性或鳞状细胞癌患者，应考虑辅助放疗作为治疗选择。
