Tuesday, May 6, 2014

Historical Contribution: 1926, Waters, Deep Roentgen-Ray Therapy in the... Bladder


Deep Roentgen-Ray therapy in the treatment of carcinoma of the bladder C. A. Waters Journal of the American Medical Association 1926  87: 1618-1620

In this short publication in the Journal of the American Medical Association (JAMA), Dr. Waters describes the outcomes of 120 patients with bladder cancer treated with an early form of external beam radiotherapy.  This was a heterogeneous group of patients, comprised of patients with papillomas, non-invasive and infiltrating carcinomas of the bladder.

It's an incredibly interesting article as Dr. Waters makes several commentaries about the treatment of bladder cancer and the use of radiation therapy before presenting his data and conclusions.

First, Dr. Waters describes the side effects and the cumulative effects of repeat treatments: "One of the most serious complications in the treatment of bladder tumors, following irradiation of any kind, is a burn...  the earliest symptoms of radiation intoxication may be mentioned nausea, vomiting, prostration, diarrhea, rectal burning, and tenesmus."

Second, he describes palliation.  Waters and colleagues were faced with patients with advanced urothelial cancers, with symptoms similar to those we see today in patients with advanced disease.  Importantly, he noted that:

"Despite the disturbing reactions that are not wholly avoidable, the relief afforded to two symptoms of bladder cancer, namely, root pains and hematuria, justifies the treatment. Even when no other benefit is obtainable, these two distressing symptoms fail to be relieved with roentgen-ray therapy."

Third, he reviews the treatments available for bladder cancer at this time period and their relative efficacy:

  • radical partial cystectomy - only 10% of infiltrating carcinomas are amenable to complete resection, otherwise "technically difficuly, and now rarely justifiable."
  • fulguration - extremely successful in the treatment of papillomas, "worse than useless in the treatment of papillary carcinomas."
  • radium therapy - a new chapter in the treatment of bladder tumors
    • intravesical application adequately treats superficial papillary tumors (only about 15% of cases though)
    • in combination with fulguration can treat about 75% of presenting cancers
    • in some cases, made it possible to "destroy extensive infiltrating growths that were hopelessly inoperable."

From his observations and treatments, he makes the following five conclusions:

  1. The best treatment for superficial papillary carcinoma, whether localized or extensive, is a combination of deep roentgen-ray therapy with applications of radium applied directly to the surface of the growth.  However, this treatment causes severe ulceration and burns to the bladder mucosa.
  2. By the combination of radium with roentgen-ray treatment as outlined, most of these tumors can be destroyed with a minimum amount of injury to the bladder, and in many instances with but little or no irritation of the bladder mucosa.
  3. Radical resection should be carried out whenever feasible.
  4. Radium and roentgen-ray treatment should be used for inoperable tumors, but the dose should be limited.
  5. Bladder cancers frequently recur, therefore patients should return often for cystoscopic examinations.

Read the entire manuscript using the link above or here.

HISTORICAL CONTRIBUTIONS highlight the greatest academic manuscripts from the Brady Urological Institute over the past 100 years.  As the Brady Urological Institute approaches its centennial, we will present a HISTORICAL CONTRIBUTION from each of the past 100 years.  In the most recent experience, the most highly cited article from each year is selected; older manuscripts were selected based on their perceived impact on the field.  We hope you enjoy! 

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