The role of irradiation in the management of clinical stage B1 (grades II and III) and stages B2 and C bladder cancer.

For patients with high-grade tumors infiltrating the super ficial bladder wall musculature or with tumors of any grade invading deep muscle or the perivesical space, the evidence is now quite solid that integrated treatment with irradiation and cystectomy (or a lesser resection in rare, selected cases) results in a significantly higher survival rate than does either approach alone. Several questions still remain unanswered regarding inte grated therapy, however. (a) Should the irradiation be done preoperatively or postoperatively? The pros and cons of each approach are discussed. (b) What is the appropriate dose of irradiation? A dose that has a high probability of eradicating minimal disease in lymph nodes or elsewhere in the pelvis (4600 rads/23 treatments/4.5 weeks to 5040 rads/ 28 treatments/5.5 weeks) is recommended. (C)What volume should be irradiated? Since the irradiation is intended to control disease not removed at operation and the lymph nodes in the pelvis are at risk, whole pelvis treatment ex tending from the bottom of the obturator foramen to the sacral promontory (bifurcation of the common iliac artery) is used. With integrated therapy patients now most frequently succumb because of disseminated disease, not detected at the time of such treatment. Effective adjuvant chemother apy regimens would presumably permit a further improve ment in survival. Patients with bladder tumors confined to the mucosa or infiltrating to or through the superficial musculature only (if low grade) can usually be managed by conservative meas ures, either transurethral fulguration or resection or seg mental resection. However, patients with more aggressive lesions [Clinical Stage B, (Grade II or III histology) or Clini cal Stage B2 or C tumors] have cancers that seriously threaten their survival, and hence conservative measures are not indicated. The subsequent comments regarding the management of bladder cancer will refer to patients with this group of aggressive tumors. Crucial to treatment decision-making is accurate staging and grading of the tumor (Table 1). The assessment at the time of cystoscopy preferably should be done under general anesthesia to allow adequate relaxation for satisfactory evaluation of the extent of intravesical and extravesical disease. Information from an excretory urogram (i.v. pyelo gram) may be helpful, and a chest X-ray, of course, should be obtained to rule out evident metastases in the lungs. The role of lymphangiography has not been adequately evalu ated; although false negative examinations are relatively common (perhaps as high as 20%), false positive examina tions are …