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the setting of breast reconstruction to optimize treatment.

2003 Nov 6;349(19):1880]. New England Journal of Medicine 349:859-866, 2003 5. Griffiths G, Hall R, Sylvester R, et al: International phase III trial assessing neoadjuvant cisplatin, methotrexate, and vinblastine chemotherapy for muscle- invasive bladder cancer: long-term results of the BA06 30894 trial. J Clin Oncol 29:2171-7, 2011 6. James ND, Hussain SA, Hall E, et al: Radiotherapy with or without chemotherapy in muscle-invasive bladder cancer. The New England journal of medicine 366:1477- 88, 2012 7. Zehnder P, Studer UE, Skinner EC, et al: Unaltered oncological outcomes of radical cystectomy with extended lymphadenectomy over three decades. BJU Int 112:E51-8, 2013 8. Jahnson S, Damm O, Hellsten S, et al: A population- based study of patterns of care for muscle-invasive bladder cancer in Sweden. Scand J Urol Nephrol 43:271- 6, 2009 9. Konety BR, Joslyn SA: Factors influencing aggressive therapy for bladder cancer: an analysis of data from the SEER program. J Urol 170:1765-71, 2003 10. Hoskin P, Rojas A, Bentzen S, et al: Radiotherapy With Concurrent Carbogen and Nicotinamide in Bladder Carcinoma. J Clin Onc 28:4912-4918, 2010 11. Choudhury A, Swindell R, Logue JP, et al: Phase II study of conformal hypofractionated radiotherapy with concurrent gemcitabine in muscle-invasive bladder cancer. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 29:733-8, 2011 12. Efstathiou JA, Spiegel DY, Shipley WU, et al: Long- term outcomes of selective bladder preservation by combined-modality therapy for invasive bladder cancer: the MGH experience. European urology 61:705-11, 2012 SP-0021 Technical aspects of radiation therapy for muscle-invasive bladder cancer. V. Fonteyne 1 1 Ghent University Hospital, Radiation-Oncology, Ghent, Belgium Nowadays, the standard treatment of patients with muscle invasive bladder cancer (MIBC) is a radical cystectomy with extended pelvic lymph node dissection. Peri-operative mortality rate is ± 2% and major toxicity such as ileus, atelectasis, thrombosis and blood loss is reported in up to 30% of the patients. A re-intervention is required in 15% of the patients. In order to reduce toxicity and increase quality of life of MIBC patients, bladder-preserving therapies, combining external beam radiotherapy (EBRT) and chemotherapy, are gaining interest. Results Beside a proper patient selection many factors play an important role in improving the clinical outcome of MIBC patients treated with EBRT. Among them, there are many technical considerations: 1) So is EBRT only a valuable alternative if sufficiently high doses are delivered. With modern radiation techniques and imaging, dose escalation with simultaneous integrated boost to the initial tumor region becomes feasible while sparing intestinal loops and rectal mucosa. So far many treatment regimens have been proposed but the optimal treatment schedule is unknown. 2) Also the optimal treatment volume remains a matter ofdebate. 3) Another major problem of EBRT for MIBC patients is bladder displacement due to different daily bladder filling and this despite fixed protocols to control for bladder volume. Target displacements have led to large planning margins to compensate for positioning misses. Abstract text Background

Symposium: Current issues in the treatment of muscle- invasive bladder cancer

SP-0020 Organ preservation in bladder cancer – an evidence-based alternative to radical surgery N. James 1 1 University of Birmingham, Institute of Cancer and Genomic Sciences, Birmingham, United Kingdom Abstract text Surgical removal of the bladder is considered by some as the ‘gold standard’ in many countries with series citing very high success rates. However, when data from registry series are examined, the 5 year survival from both surgical and radiotherapy series is similar at around 45-50% 1,2 , suggesting single centre series are driven by case selection. Evidence for this is the age distribution in the widely cited paper by Stein et al from University of Southern California – median age in this large series was 66 years 3 with a similar median in the two largest neoadjuvant chemotherapy trials 4,5 , whereas 55% of UK cases are aged over 75 years at diagnosis (CRUK Cancerstats) This lack of data supporting a survival advantage for surgery does not stop its proponents presenting it as the gold standard 3,7 . It is, however, more likely that survival in bladder cancer is driven by the presence or absence of distant spread at the time of local therapy and will not be affected by the means adopted for local control. Furthermore, all patients undergoing surgery will need reconstructive bladder surgery. Thus there are many patients for whom radical surgery is simply not suitable and hence bladder-preserving techniques are appropriate. Despite this, use of radiotherapy varies enormously worldwide with possibly a majority receiving radiotherapy in the UK 2 , around 25% in Scandinavia 8 but only around 10% in the USA 9 . Radiotherapy alone suffers from a relatively high rate of incomplete response or local recurrence (up to 50% or more). The addition of synchronous chemotherapy with 5 fluouro-uracil and mitomycin C (5FU/MMC) reduces the invasive recurrence rate by 45% with improved bladder cancer specific survival. Furthermore long-term quality of life was excellent, with no penalty from adding 5FU/MMC to standard dose radiotherapy 6 . Similar results were seen in the BCON trial using carbogen/nicotinamide as hypoxic cell sensitizers 10 and in a non-randomised trial using gemcitabine 11 . The more complicated North American “trimodality therapy” schedules show similar outcomes 12 . Radiotherapy should thus always be given, wherever possible, with a simultaneous radio-sensitiser, the most robust data with UK fractionation being with 5FU/MMC or the BCON schedule. 1. Hayter CR, Paszat LF, Groome PA, et al: The management and outcome of bladder carcinoma in Ontario, 1982-1994. Cancer 89:142-51, 2000 2. Munro NP, Sundaram SK, Weston PM, et al: A 10-year retrospective review of a nonrandomized cohort of 458 patients undergoing radical radiotherapy or cystectomy in Yorkshire, UK. International journal of radiation oncology, biology, physics 77:119-24, 2010 3. Stein JP, Lieskovsky G, Cote R, et al: Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1,054 patients. Journal of Clinical Oncology 19:666-675, 2001 4. Grossman HB, Natale RB, Tangen CM, et al: Neoadjuvant chemotherapy plus cystectomy compared with cystectomy alone for locally advanced bladder cancer.[see comment][erratum appears in N Engl J Med.