- 作者：Brian C. Baumann ; AB&lowast ; ; Thomas J. Guzzo ; MD ; MPH&dagger ; ; Jiwei He ; MS&Dagger ; ; David J. Vaughn ; MD§ ; ; Stephen M. Keefe ; MD§ ; ; Neha Vapiwala ; MD&lowast ; ; Curtiland Deville ; MD&lowast ; ; Justin E. Bekelman ; MD&lowast ; ; Kai Tucker&lowast ; ; Wei-Ting Hwang ; PhD&Dagger ; ; S. Bruce Malkowicz ; MD&dagger ; ; John P. Christodouleas ; MD ; MPH&lowast ; ; christojo@uphs.upenn.edu
- 刊名：International Journal of Radiation Oncology*Biology*Physics
- 出版年：2013
- 出版时间：1 February, 2013
- 年：2013
- 卷：85
- 期：2
- 页码：363-369
- 全文大小：280 K
Purpose
Local-regional failures (LFs) after cystectomy with or without chemotherapy are common in locally advanced disease. Adjuvant radiation therapy (RT) could reduce LFs, but toxicity has discouraged its use. Modern RT techniques with improved normal tissue sparing have rekindled interest but require knowledge of pelvic failure patterns to design treatment volumes.Methods and Materials
Five-year LF rates after radical cystectomy plus pelvic node dissection with or without chemotherapy were determined for 8 pelvic sites among 442 urothelial bladder carcinoma patients. The impact of pathologic stage, margin status, nodal involvement, and extent of node dissection on failure patterns was assessed using competing risk analysis. We calculated the percentage of patients whose sites of LF would have been completely encompassed within various hypothetical clinical target volumes (CTVs) for postoperative radiation.
Results
Compared with stage ¡ÜpT2, stage ¡ÝpT3 patients had higher 5-year LF rates in virtually all pelvic sites. Among stage ¡ÝpT3 patients, margin status significantly altered the failure pattern whereas extent of node dissection and nodal positivity did not. In stage ¡ÝpT3 patients with negative margins, failure occurred predominantly in the iliac/obturator nodes and uncommonly in the cystectomy bed and/or presacral nodes. Of these patients in whom failure subsequently occurred, 76 % would have had all LF sites encompassed within CTVs covering only the iliac/obturator nodes. In stage ¡ÝpT3 with positive margins, cystectomy bed and/or presacral nodal failures increased significantly. Only 57 % of such patients had all LF sites within CTVs limited to the iliac/obturator nodes, but including the cystectomy bed and presacral nodes in the CTV when margins were positive increased the percentage of LFs encompassed to 91 % .
Conclusions
Patterns of failure within the pelvis are summarized to facilitate design of adjuvant RT protocols. These data suggest that RT should target at least the iliac/obturator nodes in stage ¡ÝpT3 with negative margins; coverage of the presacral nodes and cystectomy bed may be necessary for stage ¡ÝpT3 with positive margins.