Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta GA.
Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta GA.
Urol Oncol. 2023 Jul;41(7):325.e15-325.e23. doi: 10.1016/j.urolonc.2022.12.011. Epub 2023 Jan 30.
Bladder-sparing chemoradiation therapy (CRT) is a definitive first-line treatment for muscle-invasive bladder cancer. The optimal radiotherapy target volume, either bladder-only (BO) or bladder plus pelvic lymph nodes (BPN), remains unclear.
We identified 2,104 patients in the National Cancer Database with cT2-4N0M0 urothelial cell carcinoma of the bladder treated with CRT following maximal transurethral resection of bladder tumor from 2004 to 2016. The exposure of interest was BO vs. BPN treatment volume. The primary outcome was overall survival (OS), compared between groups using Kaplan-Meier and multivariable Cox proportional hazards. Sensitivity analysis tested an interaction term for clinical T stage (T2 vs. T3-4) and radiation modality (3-dimensional conformal radiotherapy vs. intensity modulated radiotherapy or proton therapy). Annual use of BO vs. BPN from 2004 to 2016 was compared using Cochran-Armitage test.
A total of 578 patients were treated with BO and 1,526 patients treated with BPN CRT. There was a significant increase in BPN use from 2004 to 2016 (66.9%-76.8%, P < 0.0001). With a median follow-up of 6.2 years, there was no survival difference between groups: 5- and 10-year OS 27.4% (95% CI 23.4%-31.4%) in the BO group vs. 31.9% (95% CI 29.3%-34.6%) in the BPN group, and 13.1% (95% CI 9.7%-17.1%) in the BO group vs. 13.2% (95% CI 10.6%-16.0%) in the BPN group, respectively (log-rank P = 0.10). On multivariable analysis, there was no significant association between BPN and OS (adjusted HR 0.90, 95% CI 0.81-1.02, P = 0.09). On sensitivity analysis, we found no differential effect by T stage or radiation modality.
Use of pelvic lymph node radiation has risen in the US but may not impact long-term survival outcomes for patients with node-negative muscle-invasive bladder cancer (MIBC). Optimizing radiation treatment volumes for CRT for MIBC will be important to study under prospective trials, such as the SWOG/NRG 1806.
保留膀胱的放化疗（CRT）是肌层浸润性膀胱癌的一线治疗方法。最佳的放射治疗靶区，无论是膀胱单独（BO）还是膀胱加盆腔淋巴结（BPN），目前仍不清楚。
我们从 2004 年至 2016 年期间，在国家癌症数据库中，确定了 2104 名接受最大限度经尿道膀胱肿瘤切除术（TURBT）后接受 CRT 治疗的 cT2-4N0M0 膀胱尿路上皮癌患者。感兴趣的暴露因素是 BO 与 BPN 治疗体积。主要结局是总生存期（OS），通过 Kaplan-Meier 和多变量 Cox 比例风险进行组间比较。敏感性分析测试了临床 T 期（T2 与 T3-4）和放射方式（三维适形放疗与调强放疗或质子治疗）的交互项。使用 Cochran-Armitage 检验比较 2004 年至 2016 年期间每年 BO 与 BPN 的使用情况。
共有 578 名患者接受 BO 治疗，1526 名患者接受 BPN-CRT 治疗。从 2004 年到 2016 年，BPN 的使用显著增加（66.9%-76.8%，P<0.0001）。中位随访 6.2 年后，两组之间无生存差异：BO 组 5 年和 10 年 OS 分别为 27.4%（95%CI 23.4%-31.4%）和 31.9%（95%CI 29.3%-34.6%），BPN 组 13.1%（95%CI 9.7%-17.1%）和 13.2%（95%CI 10.6%-16.0%）（对数秩 P=0.10）。多变量分析显示，BPN 与 OS 无显著相关性（调整后的 HR 0.90，95%CI 0.81-1.02，P=0.09）。敏感性分析发现，T 分期或放射方式无差异影响。
美国盆腔淋巴结放疗的应用有所增加，但可能不会影响淋巴结阴性肌层浸润性膀胱癌（MIBC）患者的长期生存结果。在 SWOG/NRG 1806 等前瞻性试验中，优化 MIBC 的 CRT 放射治疗体积将是很重要的。
