Palliative radiation therapy of symptomatic recurrent bladder cancer

Palliative radiation therapy (RT) is an established tool in the management of symptoms caused by malignancies. RT is effective at palliating both locally advanced and metastatic cancer, including related symptoms of pain, bleeding, or obstruction. Most data on palliative RT is in regard to its use in the treatment of painful bone metastases. There are also data that support RT palliation for locally advanced or recurrent rectal, prostate, and gynecological cancers. With regard to bladder cancer there is some evidence of the benefit of palliative RT for the control of urinary symptoms and hematuria; however, there is little evidence for the use of palliative RT for pain associated with locally recurrent bladder cancer. We report a case of locally advanced recurrent bladder cancer which was refractory to medical pain management, and was found to be highly responsive to palliative RT.

An 80-year-old woman with recurrent bladder cancer and intractable pelvic pain refractory to oral and transdermal pain medications, received palliative pelvic RT to a dose of 50 Gy (5000 cGy) in 25 fractions with complete resolution of pain. The patient was originally found to have dysuria, frequency, and hematuria, secondary to an invasive high grade transitional cell carcinoma of the bladder with an adenocarcinoma component, AJCC pT2b N1 M0 Stage IV, for which she underwent a radical cystectomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, partial vaginectomy, and ileal conduit reconstruction. After undergoing 4 cycles of adjuvant chemotherapy, the patient did well for 5 months with no evidence of symptomatic, clinical, or radiographic recurrence of disease. Repeat staging CT of the abdomen and pelvis confirmed tumor recurrence in the left pelvis. The patient was treated with another course of chemotherapy and pain was managed with relatively low doses of opioid medication (25mcg transdermal fentanyl patch, and oxycodone 5mg bid). However at the fourth month, there was rapid escalation of severe pain with the patient becoming bed bound due to pain with an associated decrease in ambulation and anorexia. Ultimately a pain medication regimen of 200mcg transdermal fentanyl patch q2 days, oxycontin 20mg bid, oxycodone 5 - 10mg q 4 hours, ibuprofen 400mg q 8 hours, and gabapentin 600mg TID was not effective in controlling pain. The patient was then referred to Radiation Oncology 6 months after the pain initially began for evaluation. She received a total of 5000cGy over 25 fractions to a small pelvis field over 5 weeks and reported complete pain resolution. She was able to decrease pain medications, increase overall activity, and gain significant improvement in sleep quality and appetite even early on in the course of her radiation therapy.

Palliative radiation therapy has been well studied in the setting of bone metastases and treatment of hematuria for locally advanced bladder cancer. There is little data that we are aware of on the use of RT for pain control with patients that have recurrent, locally advanced bladder cancer. We have presented a case in which an excellent outcome in pain control was seen for a patient with medically unmanageable pain. RT is an excellent option for pain management in recurrent bladder cancer and should be offered to patients whose pain is not otherwise optimally controlled. Palliative RT is an important component in the multimodality approach to cancer pain management and optimization of quality of life.