For patients with high-grade tumors infiltrating the superficial 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 integrated 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 extending 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 chemotherapy regimens would presumably permit a further improvement in survival.

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Presented at the National Bladder Cancer Conference, November 28 to December 1, 1976, Miami Beach, Fla. Work supported in part by National Cancer Institute Grant CA19278, “Multidisciplinary Program in Radiation Oncology.”

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