Transurethral Resection of Bladder Tumors Followed by Radiotherapy with or without Chemotherapy for Bladder Preservation in Patients with Invasive Bladder Transitional Cell Carcinoma: Preliminary Ntuh

經尿道膀胱腫瘤切除術後之放射治療有無合併化學治療用於膀胱癌病患之膀胱保留療法：初步報告

許峰銘(Feng-Ming Hsu) ； 成佳憲(Jason Chia-Hsien Cheng) ； 蒲永孝(Yeong-Shian Pu) ； 林家齊(Chia-Chi Lin) ； 賴明坤(Ming-Kuen Lai)

《放射治療與腫瘤學》 13卷2期 (2006/06) Pp. 103-116

https://doi.org/10.6316/TRO/200613(2)103

摘要

目的：根除性膀胱切除術是侵襲性膀胱轉型細胞癌的標準治療方式。經尿道膀胱腫瘤切除術合併放射治療提供膀胱切除術之外，保留膀胱的治療選擇。加上前導性及同時性化學治療之三合一療法能進一步改善治療成效。本篇研究報告將評估三合一療法用於膀胱保留療法之短期成效及治療相關之副作用。
材料與方法：本研究收集2000至2004年，37位罹患膀胱轉型細胞癌且接受膀胱保留療法之病人進行回顧分析。其中21位病人只接受經尿道膀胱腫瘤切除術合併放射治療。其餘16位病人在接受經尿道膀胱腫瘤切除術與前導性化學治療後達到完全或部份緩解之後，接受進一步之放射治療或同時性化學治療合併放射治療。在三合一治療組中，放射治療之設計為每天一次1.8Gy，治療劑量為：骨盆腔45Gy，全膀胱50.4Gy，腫瘤部位64.8Gy。未接受化學治療之病人接受之每天一次2.0Gy之放射治療，治療劑量為：骨盆腔40Gy，全膀胱60Gy。接受三合一治療之病人在療程中須接受膀胱鏡檢查以確定是否持續達到完全緩解，得以繼續放射治療之療程。
結果：三合一療法組病人之中位年齡為61.8歲，只接受放射治療組中位年齡為76.8歲。全體病人共有30位男性，7位女性。在三合一治療組中，有14位病人在經尿道膀胱腫瘤切除術與前導性化學治療後達到完全緩解。有7位病人發生第三或第四級急性反應，其中2位因治療毒性而死亡。另外5位在調整化學治療處方後繼續完成療程。只接受放射治療組中則只有1位病人發生第三級急性反應。中位追蹤時間在三合一療法組為14.6個月，只接受放射治療組為21個月。一年局部控制率在三合一療法組為93.3%，只接受放射治療組為72.0%（p值0.11）。三合一療法組與只接受放射治療組之一年遠端轉移控制率，疾病控制率與存活率分別為100%與73.3%（p值0.047），93.3%與62.3%（p值0.05），以及87.5%與79.8%（p值0.23）。
結論：在增加急性反應之代價之下，三合一膀胱保留療法提供較佳之遠端轉移控制率與傾向有較好的疾病控制率。本院目前所使用的療程似乎具有可行性且可為多數病人所承受。在有限的短期之追蹤下，三合一膀胱保留療法之成效在部份病人有令人滿意的成果。但仍須更長時間的追蹤來確認此保留療法的最終成果。

關鍵字

膀胱癌 ； 保留療法 ； 三合一治療

並列摘要

Purpose: Radical cystectomy has been the standard treatment for invasive transitional cell carcinoma (TCC) of urinary bladder. Transurethral resection of bladder tumors (TUR-BT) and radiotherapy (RT) provide an alternative option to cystectomy for organ preservation. The trimodality therapy (TMT) incorporating neoadjuvant and concurrent chemotherapy (CHT) seems to improve the treatment result. This study is to evaluate the short-term outcome and treatment-related toxicity of the TMT for bladder preservation.
Materials and Methods: From 2000 to 2004, 37 patients with invasive bladder TCC undergoing bladder preservation therapy were reviewed retrospectively. Among them, 21 patients received radical TUR-BT followed by RT alone. The other 16 patients who had complete response or good partial response after radical TUR-BT and neoadjuvant CHT received further RT or concurrent chemoradiation. The RT protocol was 45Gy to small pelvis field and 50.4Gy to whole bladder, plus tumor bed boost to a total dose of 64.8Gy with daily fraction size of 1.8Gy in the TMT group. Patients in the RT alone group received 60Gy to whole bladder or 40Gy to whole pelvis plus 20Gy boost to whole bladder with daily fraction size of 2.0 Gy. Interval cystoscopy was performed to confirm the status of complete response for continuation of RT in the TMT group.
Results: The median age was 61.8 in the TMT group and 76.8 in the RT alone group. Thirty patients were male and seven were female. In the TMT group, fourteen patients had complete response after radical TUR-BT and induction CHT. Seven patients (43.7%) in the TMT group had grade 3 or 4 acute toxicity, and two of them died of treatment toxicity. The other five patients completed their treatment course with modification of CHT. In the RT alone group, only one patient (4.7%) had grade 3 acute toxicity. The median follow-up was 14.6 months in the TMT group and 21 months in the RT alone group. In the 14 patients completing TMT, two patients experienced local recurrence and none of 16 patients had distant metastasis. In the RT alone group, eight of 21 patients had local recurrence while 7 patients had distant metastasis. The one-year locoregional control rates were 93.3% in TMT group and 72.0% in RT alone group (p=0.11). The one-year metastasis-free survival, disease-free survival, and overall survival were 100% and 73.3% (p=0.047), 93.3% and 62.3% (p=0.05), and 87.5% and 79.8% (p=0.23), respectively.
Conclusion: At the cost of increased acute toxicity, TMT for bladder preservation provides significant better metastasis-free survival and favorable disease-free survival. Our protocol seems feasible and well tolerated in most patients. With limited follow-up, the result of TMT remains satisfactory in selected patients. Longer observation is needed to confirm the ultimate success of bladder preservation.

並列關鍵字

Bladder cancer ； Preservation ； Trimodality therapy