H. Emama M.D.

(Radiation Therapy)

By:H. Emami

Assistant professor of Radiation Oncology,Isfahan University of Medical Sciences,

Isfahan, IRAN.

Superficial tumors TUR (standard)

Interavesical therapyOr

Radical CystectomyOr

Bladder preserving

Low grade, Low stage Observation

High grade,High stage,Multifocal CISMultifocal Tumors Tumor associated with CISIf rapidly recur

Muscle invasion(T2)

Radical Cystectomy (standard) + CTCT + Radical Cystectomy if nodes are Negative (NCCN) category 1

Chemoradiation + CT

CT + Chemoradiation

Partial Cystectomy + CT

CT + Partial Cystectomy (NCCN)

Bladder Preservation

Muscle invasion (T2)TURBT

Chemo-radiation(40 - 45 Gy)

CystoscopicEvaluation

Consolidation Chemo-radiation

(64 – 66 Gy)

RadicalCystectomy

CR In-CR

Recurrence

Perivesical fatinvasion (T3)

CT + Chemoradiation

CT + Radical Cystectomy (NCCN) category 1

Pre-op. Chemoradiation + Cystectomy + Post op. Chemotherapy

Adjacent organ (s)involvement(T4a)

CT + Chemoradiation

CT + Radical Cystectomy in selected patient

Involvement of pelvic or Abdominal wall (T4b)

ChemoradiationPalliative therapy Radiation therapy Chemotherapy

T2T3Selected T4a

Pre-op. Chemoradiation or Chemotherapy

(for down staging)

Post op. Chemoradiation(In high risk patients)

Residue

Positive LN(s)

(Chemoradiation Therapy)

Node negative

NoNew Bladder

1)-5000 cGy to the whole pelvis.2)-Lateral boost to the bladder (1000 cGy). 3)-Cystectomy (4 to 6 week later).

1)-4500-5000 cGy to the whole pelvis + bladder boost Total dose 6400-6600 cGy +Cisplatin, Carboplatin, Paclitaxel, 5FU, Gemcitabine (low dose )(33mg/m2 twice weekly)Mytomycin-C + 5FU (NCCN) 2)- Two course MCV , then Chemoradiation

Pre-op. Radiation therapyOr Chemoradiation(for down staging)

Chemoradiation therapy(for bladder preservation)

(Radiation Therapy)

Bone metastasis

Hematuria

Lung and Liver Met. Chemotherapy

3000 CGY in 10 fractions.4000 CGY in 20 fractions.

1000 cGy in one fraction.1000 cGy every 3-4 week for 3 times600 cGy every week for 5 weeks

(Palliative Therapy)

1)-Convential (180-200 cGy/day) (Total 6400 cGy)

2)-Hyper fractionation (100 cGy X 3 times/day) (total 8400 cGy)

1000 cGy in one fraction 2100 cGy in 3 fractions 3)-Hypo fractionation 3500 cGy in 10 fractions 600 cGy weekly (total 3000 cGy 600 cGy weekly (total 3600 cGy)

(Radiation Therapy Schedule)

(Radiation Therapy Techniques)

Anterior-posterior portal Right lateral portal

Box Tech. (whole pelvis) Box Tech. (Bladder)

(Radiation Therapy Techniques)

Two Lateral Arc Technique Three Field Arrangement

(Radiation Therapy Techniques)

-External beam radiation is rarely appropriate for patients with recurrent Ta and T1 tumor or diffuse Tis.

-simulate and treat patients with bladder empty.

-use multiple fields from high-energy linear accelerator beams.

-Treat the whole bladder with or without pelvic lymph nodes with 45-50 Gy and then boost the bladder tumor to total dose

of 64-66 Gy.

-Consider low-dose pre-operative radiation prior to segmental resection for invasive tumors .

(Radiation Therapy)