Bladder cancer.Superiority of preoperative irradiation and cystectomy in clinical stages B2 and C

60Cobalt gamma rays or 22 MeV x-rays were used in the radiotherapeutic management of 724 patients treated for bladder cancer at the M.D. Anderson Hospital and Tumor Institute between 1954 and 1970. Cystoscopy and bimanual palpation for clinical stage classification during anesthesia were routinely the joint effort of urologist and radiotherapist. All living patients have been followed at least 5 years; for all who have expired at least the date of death has been established. For patients managed with radiotherapy alone, postoperative irradiation, or with preoperative irradiation and cystectomy, respective major complication rates were: 14%, 25% and 48%; local failure rates 45%, 33% and 16%; 10-year all-stage survival rates 8%, 14% and 20%. Five-year survival rates had only limited prognostic value when management was with radiotherapy alone or with postoperative irradiation, because in these two groups loss rates between the fifth and tenth post radiation years were high; late attrition was due in important part to failure to control cancer within the irradiated tissue volume, a type of failure not yet apparent in the group managed with preoperative irradiation and cystectomy. Among patients managed with radiotherapy alone, there was valid evidence that with increasing dose the incidence of local failure decreased. In the same group, rectal complications increased with higher doses, but the rate of bladder complications was independent of dose within the range studied, suggesting that still higher doses may safely be tolerable if surrounding normal structures can adequately be protected. Because of the higher complication rate (despite a dose smaller than that for radiotherapy alone), the dose for postoperative irradiation probably should be lowered to 5000 rad/25 fractions/5 weeks. Preoperative irradiation (at the 5000 rad level) followed in 6 weeks by cystectomy (node dissection not included, operative mortality rate 3.3%) was clearly superior to radiotherapy alone for clinical Stages B2 and C. A randomized prospective study resulted in 5-year survival of 46% of such patients managed with the combined modality (53% if patients who failed to undergo the intended cystectomy were excluded) as against 16% for patients managed with radiotherapy alone. For the preoperative group as a whole, there was no demonstrable residual tumor in 29% of the cystectomy specimens, and of the 26 patients in this category (Stage B2 in 12, Stage C in 14) 54% survived 5 years.