背景:膀胱癌主要发生在老年人中,当存在老年病和合并症时,手术并不总是可行的。在此类患者中,三模态治疗(TMT)结合经尿道膀胱肿瘤切除术(TURBT),然后进行同步放化疗(CRT)将是一种治疗方法。
方法:对所有年龄75岁及以上的非转移性肌层浸润性膀胱癌(MIBC)患者进行回顾性分析。诱导性CRT联合每天两次针对膀胱和骨盆的大分割放射治疗,总剂量为24Gy(Gy),同时伴有铂盐和5-氟尿嘧啶。建议在诱导期后经活检证实完全缓解的患者以及患有持续性肿瘤的患者进行抢救性膀胱切除术,将CRT的总剂量定为44Gy。我们使用Kaplan-Meier方法评估总生存期(OS),癌症特异性生存率(CSS)侵入性无复发生存率(IRFS),无转移生存率(MFS),保留膀胱的存活率(SBP),和毒性。利用OS的Cox模型和次要终点竞争风险的精细灰色方法,我们在单变量(u)和多变量(m)分析中分析了肿瘤特征和患者特征的影响:性别,年龄,年龄调整后的Charlson合并症指数,多药,和营养不良。
结果:从1988年到2017年,共纳入85例患者。感应后,完全缓解率为83.5%.中位随访时间为63个月,5year-OS,CSS,IRFS,MFS和SBP为61.0%,77.6%,71%,82.9%,分别为70.2%。诱导后持续性肿瘤影响SBP(SHRm3.61;p=0.004),CSS(SHRm3.27;p=0.023),和MFS(3.68英镑;p=0.018)。晚期3级泌尿和胃肠道毒性分别为3.5%和1.2%。
结论:我们在此报告了75年来最大规模的膀胱保留治疗。与手术系列和使用经典分割的CRT研究相比,选定的老年人的结局和耐受性良好。
BACKGROUND: Bladder cancer occurs mainly in older adults and surgery is not always possible when there are geriatric conditions and comorbidities. Trimodal treatment (TMT) combining trans-urethral resection of bladder tumour (TURBT) followed by concurrent chemoradiation (CRT) would be a curative alternative in such patients.
METHODS: All consecutive patients 75 years of age and older with non-metastatic muscle-invasive bladder cancer (MIBC) treated with TMT by Georges Pompidou European Hospital team were retrospectively analysed. Induction CRT combined hypofractionated twice-daily radiotherapy targeting bladder and pelvis to a total dose of 24 Gy (Gy) with concurrent platinum salt and 5-fluorouracil. Consolidation CRT to a total dose of 44 Gy was proposed to patients with biopsy-proven complete response after induction phase and those with persistent tumour underwent salvage cystectomy. We assessed using Kaplan-Meier method overall survival (OS), cancer specific survival (CSS), invasive recurrence-free survival (IRFS), metastasis-free survival (MFS), survival with bladder preserved (SBP), and toxicities. With a Cox model for OS and the Fine Gray method of competing risk for secondary endpoints, we analysed in univariate (u) and multivariate (m) analysis the impact of tumour characteristics and patient profiles: gender, age, age-adjusted Charlson comorbidity index, polypharmacy, and malnutrition.
RESULTS: From 1988 to 2017, 85 patients were included. After induction, complete response rate was 83.5%. With a median follow-up of 63 months, 5 year-OS, CSS, IRFS, MFS and SBP were 61.0%, 77.6%, 71%, 82.9%, and 70.2% respectively. A persistent tumour after induction impacted SBP (SHRm 3.61; p = 0.004), CSS (SHRm 3.27; p = 0.023), and MFS (SHRm 3.68; p = 0.018). Late grade 3 urinary and gastrointestinal toxicities were 3.5% and 1.2%.
CONCLUSIONS: We report here the largest series of bladder preservation over 75 years in a curative intent. Outcomes and tolerance in selected older adults compared favourably with surgical series and with CRT studies using classical fractionation.