Bladder function after conservative surgery and high‐dose rate brachytherapy for bladder–prostate rhabdomyosarcoma

Abstract

Background: Conservative surgery (CS) brachytherapy (BT) techniques for local therapy in bladder-prostate rhabdomyosarcoma (BP-RMS) seek to retain organ function. We report bladder function after high-dose rate (HDR) BT combined with targeted CS for any vesical component of BP-RMS. Procedure:Prospective cohort of all BP-RMS patients between 2014 and 2019 receiving HDR-BT (iridium-192, 27.5 Gy in five fractions) with/without percutaneous endoscopic polypectomy (PEP) or partial cystectomy (PC). Functional assessment included frequency-volume chart, voided volumes, post-void residual, flow studies, continence status and ultrasound scanning; abnormalities triggered video urodynamics.Results: Thirteen patients (10 male), aged 9 months to 4 years (median 23 months), presented with localised fusion-negative embryonal BP-RMS measuring 23-140 mm (median 43 mm) in cranio-caudal extent. After induction chemotherapy, local treatment consisted of PC+BT in three, PEP+BT in four and BT alone in six. At a median 3.5 years (range 21 months to 7 years) follow-up, all were alive without relapse. At a median age of 6 years (4-9 years), the median bladder capacity was 86% (47%-144%) of that expected for age, including 75% (74%-114%) after PC. Radiation dose to the bladder was associated with urinary urgency, but not bladder capacity or nocturnal enuresis. Complications occurred in two: one urethral stricture and one vesical decompensation in a patient with pre-existing high-grade vesico-ureteric reflux (VUR). The remaining patients were dry by day; five with anticholinergic medication for urinary urgency. Three patients are enuretic.Conclusions: Day-time dryness at a median 3.5 years after CS-HDR-BT was achieved in 92%, with 85% voiding urethrally, and 62% attaining day-and-night continence aged 4-9 years. We report reduced open surgery with minimally invasive percutaneous surgery, with HDR-BT or BT alone being suitable for many.Abbreviations: BP-RMS, bladder-prostate rhabdomyosarcoma; BT, brachytherapy; CS, conservative surgery; CT, computed tomography; CTV, clinical target volume; D 0.1 cm3 , minimum dose received by 0.1 cm 3 of tissue that receives the highest dose; D 2 cm3 , minimum dose received by the 2 cm 3 of tissue that receives the highest dose; D90, minimum dose to 90% of the volume; EBCA, expected bladder capacity for age; EBR, external beam radiotherapy; EFS, event-free survival; EpSSG, European paediatric Soft tissue sarcoma Study Group; EQD 2 , dosimetric equivalent if the radiation is delivered in 2-Gy fractions and is based on the radiosensitivity of the tissue, quantified by the tissue alpha beta ratio; Fr, French; HDR, high-dose rate; LDR, low-dose rate; MRI, magnetic resonance imaging; OAR, organ at risk; PC, partial cystectomy; PDR, pulsed-dose rate; PEP, percutaneous endoscopic polypectomy; PVR, post-void residual; VUR, vesico-ureteric reflux.

Detailed functional results after bladder-preserving surgery and high-dose-rate brachytherapy in pediatric bladder/prostate rhabdomyosarcoma

“…The variation of the median values was not significant (p = 0.41, Kruskal-Wallis test). There was no significant difference between the two groups (graphs not shown) findings were not provided in detail (Arndt et al 2004;Lobo et al 2022;Martelli et al 2009;Stenman et al 2022), except in one study (Martelli et al 2016).…”

“…Simultaneously, this case emphasizes the importance of timely local therapy. Other studies with longer postoperative follow-up times but smaller study cohorts reported 100% EFS rates after BT in BP-RMS patients (Lobo et al 2022 ; Stenman et al 2022 ).…”

“…A direct comparison of oncological outcomes is compromised, with either no information about the IRS stage being given (Lobo et al 2022 ) or incomplete information about tumor diameters (Stenman et al 2022 ). This emphasizes the importance of accurately describing key oncologic data, even when the focus is on functional outcomes.…”

The Pyrrhic Victory of Bladder Preservation

“…rare disease, there is significant bladder-related morbidity and bladder dysfunction. [1][2][3][4] In this issue of The Journal, Wang et al (page 1202) report that with robust follow-up patients with a more aggressive radical surgery had an improved quality of life than those patients treated with less aggressive upfront initial resection. 5 With increasing survival for some malignancies, it is crucial to involve specialists who will be managing the long-term sequelae of initial therapy from a given organ when developing a treatment plan with the family.…”

“…Even in relatively shorter-term follow-up for this rare disease, there is significant bladder-related morbidity and bladder dysfunction. 1-4 In this issue of The Journal, Wang et al (page 1202) report that with robust follow-up patients with a more aggressive radical surgery had an improved quality of life than those patients treated with less aggressive up-front initial resection. 5…”