High Dose, Short Course Preoperative Radiation Therapy and Immediate Single Stage Radical Cystectomy with Pelvic Node Dissection in the Management of Bladder Cancer

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Abstract
During a 9-yr interval, 131 patients with high grade invasive or multifocal bladder cancer were treated with high dose, short course preoperative radiation therapy (1600 rad during 4 days) followed immediately by single stage radical cystectomy with pelvic node dissection. The operative mortality was 1 of 131 patients (0.7%), with a major complication rate prolonging hospitalization of 22%. Analysis of the data reveals a surprising incidence of positive nodes in patients thought to have superficially invasive disease: 12% in patients staged clinically to have multifocal stage T1 or T1S cancer. Overall, 34 patients in this series had positive nodes (25%), including 2 of 41 (5%) with stage P1 or P1S, 6 of 20 (30%) with stage P2, 4 of 13 (31%) with stage P3A, 18 of 28 (64%) with stage P3B and 4 of 8 (50%) with stage P4 disease. There was excellent local control of the primary disease with this protocol, since only 6 patients (5%) had pelvic recurrence as the first indication of failure: 1 of 59 patients with pathologic stages O and A, 0 of 23 with stages B1 and B2, 0 of 10 with stage C and 5 of 38 (14%) with pathological stage D cancer. The 5-yr survival according to pathologic stage was 81% for patients with stages P0, P1S and P1 disease, 53% with stage P2, 37% with stage P3, 25% with stage P4, 79% with stages O and A, 58% with stages B1 and B2, 44% with stages B2 and C, 36% with stage D disease and 36% for patients with positive nodes. Survival and pelvic recurrence rates with this combination are similar to those reported using higher doses of short course preoperative radiation therapy or more prolonged standard fractionation protocols, raising questions as to the significance of preoperative therapy. Despite improved surgical techniques with lower morbidity, nearly 50% of the patients with deeply invasive disease die of metastatic disease, implying the need for effective adjuvant systemic therapy.