Radiation therapy and cystectomy

TABLE 1. Five-year survival experiences oj patients with bladder carcinoma treated by cystectomy and a delay, in some protocols," of four more weeks before cystectomy, some groups moved to a lesser dose given in a week, followed by prompt cystectorny." This therapeutic plan has received acceptance in some centers and rejection in others. Still other urologists question the value of adjuvant radiotherapy in any form unless it is low dose to diminish the incidence of skin and wound implants." Others, particularly radiotherapists, suggest that maximum radiotherapy to normal tissue tolerance be given and that those patients who fail with persistent or recurrent tumor then undergo salvage cystectomy. 17 How did we reach such a parlous state? The answer lies in several recognizable areas, with lack of basic information concerning invasive TeC at the root of the problem. \Ve have failed to acquire the necessary knowledge about the clinical and biological behavior of TCC because the study designs that have been used are inadequate to answer the questions posed. They do raise hypotheses, but few authors add this caveat to their conclusions. Members of the National Bladder Cancer Collaborative Group A (CGA) have been accessioning and characterizing patients with TCC for eight years. Among the data produced by this group is that about 65 % of the patients with invasive TCC In 1946, Jewett and Strong studied patients with bladder carcinoma (transitional cell carcinoma, TCC) and separated them into groups based on the depth of invasion and the potential for curability. 1 The relationship was direct; the more deeply the tumor invaded, the less likely was there chance for cure. This report was the first modern-day effort to make some sense of the confusing data that was being reported concerning the results of the therapy of TCC. Marshall published his classical paper in 1952,2 comparing the clinical stage of patients with TCC who underwent a radical cystectomy with the pathological stage. Thus, Jewett, Strong, and Marshall gave clinicians an O-D2 staging system. Marshall grouped 0, A, and B, as superficial, B2 and C as deep, and D, and D2 as regionally and distantly metastatic. This provided for an important base of communication that is still in use today. With hindsight, it is evident that this trail-blazing left many matters about TCC unrecorded and unconsidered. During this period and in the ensuing years, clinicians focused on grade, the presence/absence of muscle invasion (m.i.), and the presence/absence of positive pelvic nodes. Interest was intense, and with the acceptance of the ileal conduit," radical pelvic surgery was used to treat ever-increasing numbers of patients. However, the results of cystectomy (radical or not) were disheartening (Table 1).4-8 Because of this, radiotherapy was added as an adjuvant to radical surgery by many groups.P:" The five-year survival results were appreciably better than those for cystectomy alone (Table 2). The proponents of adjuvant radiotherapy then began to change the amount of radiotherapy and radiotherapeutic schedules. This was probably a matter of convenience for patient and physician alike. Instead of four-five weeks