title: Multimodality therapy including surgical resection and intraoperative electron radiotherapy for recurrent or advanced primary carcinoma of the urinary bladder or ureter.
abstract: OBJECTIVE
  To report outcomes of multimodality therapy incorporating surgical resection and intraoperative electron radiotherapy (IOERT) for patients with locoregionally (LR) recurrent or advanced primary urothelial carcinoma.
  
  
  METHODS
  From 1983 to 2009, 17 patients, consisting of 11 with LR recurrence after cystectomy for bladder carcinoma, 4 with LR recurrence after nephroureterectomy for ureteral carcinoma, and 2 with advanced primary bladder carcinoma were treated with multimodality therapy. In 8 patients with LR recurrence, the multimodality treatment was a second salvage attempt. Sixteen patients received perioperative external beam radiotherapy (median dose, 50.4 Gy; range, 21.6 to 60 Gy). Extent of resection was R0 (n=7), R1 (n=1), and R2 (n=9). The median IOERT dose was 12.5 Gy (range, 10 to 20 Gy). Overall survival (OS) and relapse patterns were determined from the date of resection and IOERT using the Kaplan-Meier method.
  
  
  RESULTS
  The median follow-up for surviving patients was 3.6 years (range, 1.1 to 10 y). OS at 1, 2, and 5 years was 53%, 31%, and 16%, respectively. Central (within the IOERT field), LR (tumor bed or regional lymph nodes), and distant relapses at 2 years were 15%, 49%, and 67%, respectively. On univariate analysis, resection of all gross disease (R0-1) was associated with improved OS (P=0.03). Mortality within 30 days was 0%. Two patients (12%) experienced NCI-CTCAE grades 4 and 5 late adverse events.
  
  
  CONCLUSIONS
  In patients with recurrent or advanced urothelial carcinoma, this multimodality approach yielded a low rate of recurrence within the IOERT field with acceptable toxicity. However, LR and distant relapse were common, indicating a need for better patient selection, LR therapy, and systemic therapy.
authors.affiliation: Departments of *Radiation Oncology †Urology, Mayo Clinic, Rochester, MN ‡Department of Radiation Oncology, Mayo Clinic, Scottsdale, AZ.
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Hallemeier
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Karnes
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Pisansky
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Davis
authors.forename: Leonard L
authors.initials: LL
authors.lastname: Gunderson
authors.forename: Bradley C
authors.initials: BC
authors.lastname: Leibovich
authors.forename: Michael G
authors.initials: MG
authors.lastname: Haddock
authors.forename: Richard
authors.initials: R
authors.lastname: Choo
mesh_terms: D000368:Aged; D002277:Carcinoma / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery*; D003131:Combined Modality Therapy / Q000379:methods; D015653:Cystectomy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007432:Intraoperative Period; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000473:pathology; D009392:Nephrectomy; D016879:Salvage Therapy; D015996:Survival Rate; D016896:Treatment Outcome; D014516:Ureteral Neoplasms / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery*; D001749:Urinary Bladder Neoplasms / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery*