21 Urinary Bladder Cancer

Urinary Bladder Cancer

3

THE GEC ESTRO HANDBOOK OF BRACHYTHERAPY | Part II: Clinical Practice Version 1 - 21/04/2015

21 Urinary Bladder Cancer

Bradley Pieters, Elzbieta van der Steen-Banasik, Erik Van Limbergen

1. Summary 2. Introduction

3 3 4 4 4 5 5 5

9. Treatment planning

8 9 9

10. Dose, Dose rate and Fractionation

3. Anatomical Topography

11. Monitoring

4. Pathology 5. Work Up

12. Results

10 10 11 12

13. Adverse Side Effects

6. Indications and Contraindications

14. Key messages 15. References

7. Target volume 8. Techniques

1. SUMMARY

Brachytherapy for bladder cancer was introduced several decades ago as a treatment to preserve bladder function. The original technique and one that is still used is the suprapubic approach. With this technique it is necessary to perform a suprapubic or Pfannenstiel incision to do a cystotomy. This technique has never gained worldwide acceptance despite the good clinical outcome. Local control rates of 70-80% have been reported. The bladder conservation rate is 85%-90%. A new and evolving technique is by performing the implant with laparoscopy or robot-assistance. In the majority of cases, the bladder does not need to be opened with this technique. There is extensive experience with LDR and PDR. The experience with HDR is less, but it seems that fractionated therapy with doses less than 2.5 Gy per fraction will result in a similar outcome as with LDR/PDR.

2. INTRODUCTION

Urology) guidelines provide an extensive description of the man- agement of non-muscle invasive bladder cancer (1). In case of muscle invasion (pT2 and greater) cystectomy (partial or total) and/or radiotherapy is the treatment of choice. Radi- cal cystectomy with lymph node dissection is considered as the standard treatment (2). However, new developments in the field of radiotherapy provide the possibility of bladder preservation. Better tumour delineation with lipiodol markers and position verification on the treatment machines for external beam radio- therapy have increased the accuracy of treatment. Randomized studies have shown better local control and overall survival with the addition of chemotherapy to radiotherapy (3, 4). James et al found after a median follow-up of 69.9 months a 67% lo- coregional disease free survival at 2 years with the addition of concomitant 5-FU and mitomycin compared with 54% without chemotherapy (4). The overall survival at 5 years was 48% vs. 35%, respectively. Only 11% of the patients in the chemoradia- tion group needed salvage cystectomy because of a relapse. Another modality for bladder sparing is the combination of lim- ited surgery with external beam radiotherapy and brachytherapy as mentioned in the Dutch and French national guidelines (5, 6).

Bladder cancer occurs after the fourth decade with a peak inci- dence at 75 years. It is more frequent in men than in women (3- 4:1). It has been associated mainly with use of tobacco, but also with occupational exposure to carcinogens such as aniline dyes, phenacetin-containing analgesics, artificial sweeteners, and chronic irritation of the bladder mucosa due to bladder stones, or schistosomiasis. The main symptoms are painless haematuria, urinary frequency, urgency, dysuria, and recurrent urinary tract infections, particularly in men. Other less common symptoms are suprapubic pain or pain in the flank and a palpable suprapu- bic mass. The tumour originates as non-muscle invasive confined to the mucosa or submucosa (pTa) of the bladder wall. These are usual- ly papillary tumours on cystoscopy. Erythematous coloured areas can also be distinguished which are compatible with carcinoma in situ (pTis). The next step in the evolution of bladder cancer is invasion of the muscularis mucosae (pT1). Non-muscle invasive bladder tumours are treated with excision and bladder instillations with chemotherapeutical agents or immunotherapy with Bacillus Calmette-Guérin (BCG). The EAU (European Association of