Advances in biology and management of bladder cancerCurrent Role of Radiation Therapy for Bladder Cancer
Section snippets
Role of Radiation in Superficial Bladder Cancer
Patients with superficial bladder cancer account for about 70% of all newly diagnosed cases of bladder cancer. In the absence of muscle invasion, endoscopic transurethral resection (TURBT) with or without intravesical therapy is the treatment of choice. Any additional therapy decisions are usually predicated upon the likelihood of disease progression. The majority of patients with superficial bladder cancer will eventually experience recurrence, but most of these recurrences remain
Muscle-Invasive Bladder Cancer
Muscle-invasive bladder cancers constitute 20%–25% of all newly diagnosed bladder cancers. Although radical cystectomy has long been considered the standard treatment, organ-preserving regimens using predominantly combined modality therapy are slowly emerging as an acceptable alternative. The main rationale for pursuing bladder preservation is to maximize quality of life for patients without compromising disease-specific survival. Operative mortality from cystectomy in modern series ranges from
Radiation as an Adjunct to Cystectomy
The recognition that moderate-dose radiation may reduce the volume of gross disease and eradicate microscopic tumor cells led to its frequent use before cystectomy,18 Doses ranging from 25–50 Gy were used in this setting, and would typically reduce the frequency of metastasis to lymph nodes by about 50%. As the surgical technique evolved to include more thorough lymphadenectomy, the need for radiation in this setting was questioned. The main rationale for omitting radiation was that it resulted
Quality of Life
Radical cystectomy causes profound changes in many specific areas that affect a patient's quality of life, including but not limited to urinary, sexual, and social functioning. Sexual function has been particularly emphasized because of the very high prevalence of erectile dysfunction. Until recently, there has been very little comparative data available for comparing this approach with CRT. There has been reluctance on the part of urologists and oncologists to recommend CRT for bladder cancer
Palliation
When bladder cancer has spread to the adjacent organs or spread to pelvic lymph nodes, the cure rate is low. In this setting, surgery is reserved for the improvement of urinary function and/or to reduce bleeding, and chemotherapy is the standard of care. Percutaneous urinary drainage is also used frequently in this setting. For patients with locally advanced primary tumors, or locally recurrent tumors, palliative radiation therapy has an established role. Duchesne and colleagues reported a
Techniques of Radiation Therapy
For bladder cancer, the preferred method of radiation delivery is three-dimensional conformal, which involves arranging multiple beams of high-energy radiation around the delineated target volume (Figure 1). Usually, a four-field approach is used to encompass the entire bladder and first echelon lymph nodes. After the first 22–25 treatments deliver a dose of approximately 40–45 Gy to the bladder and true pelvis, the patient should undergo cystoscopic evaluation with biopsy and urine cytology.
Intensity-Modulated Radiation Therapy
IMRT improves the ability to conform the treatment volume to concave tumor shapes,25 for example, when the tumor is wrapped around a vulnerable structure such as the bladder or rectum. The pattern of radiation delivery is determined using highly tailored computing applications to perform optimization and treatment simulation. The radiation dose is consistent with the three-dimensional shape of the tumor by controlling, or modulating, the radiation beam's intensity. The radiation dose-intensity
Image-Guided Radiation Therapy
IGRT is the process of frequent two- and three-dimensional imaging, during a course of radiation treatment, used to direct radiation therapy utilizing the imaging coordinates of the actual radiation treatment plan. The patient is localized in the treatment room in the same position as planned from the reference imaging dataset. An example of IGRT would include localization of a cone-beam computed tomography (CT) dataset with the planning CT dataset from planning. Similarly (two-dimensional)
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