Radiation for Cancer of the Bladder

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CT scan is obtained at the time of simulation

CT images are then imported into the treatment planning computer

In the simulation process the CT and other images are used to create a computer plan

The CT Images Are Contoured and Labelled to Identify The Structures

In the treatment lasers are used to line up the beam and the patient receives the radiation treatment

Phase 1Initial Large Radiation Zone in Blue

Includes the whole bladder and lymph nodes

bowel

Wholebladder

rectum

Radiationzone

bowel

rectum

Hits a large area of the bowel and rectum

Radiationzone

Wholebladder

Smallbowel

bladder

rectum

cancer

radiation

Phase 2

target just the cancer area in the bladder

Hits much less area of the bowel and rectum

bowel

bladder

rectumradiation

cancer

Bladder Radiation from NCCN

• Treat with the bladder empty• Treat whole bladder +/- nodes to

40-45Gy• Boost the bladder tumor to 66Gy• Combine radiation with

chemotherapy (cisplatin or 5FU Mitomycin)

Bladder Radiation from RTOG

• In the early trials (8903 – 9906) the radiation dose was whole bladder to 55Gy then boost (if possible) another 10-12Gy

• In the new T1 trial (0926) the dose is whole bladder 61.2Gy plus chemoRx (reduce off nodes after 41.4Gy)

RTOG 8903 Bladder Preservation for muscle invading bladder

1.After TURB chemoradiation to 40Gy (45Gy) to pelvic field (whole bladder, prostate, prostate urethra lymph nodes adjacent to the bladder (perivesical, obturator, external iliac, internal iliac)

2.Cystoscopy to evaluate response3.If Complete response then more

chemoradiation 19.8/ 24.8Gy (total dose 64.8Gy) to gross bladder tumor

Lymphatics of the Bladder

External iliac

Lymphatics from the bladder

Common iliac artery

Sacral

Hypogastric

Ureter

Lymphatics from the bladder

Bladder Lymph Nodes

Para-aortic

Lateral ExternalIliac

DeepInguinalSuperficial

Inguinal

Obturator

Medial ExternalIliac

Internal Iliac

Sacral

Highest DeepInguinal (Cloquet)

Sacral

Common Iliac

Pelvic Nodes

lymph node metastases were most commonly found in the obturator spaces and adjacent to the iliac vessels; additionally, 16% of lymph node metastases included nodes above the aortic bifurcation, and 8% of nodal metastases were in the presacral region 

RTOG 8903 Muscle Invasion45Gy then Boost to 64.8Gy

RTOG 8903 Muscle Invasion45Gy then Boost to 64.8Gy

Area Covered to 45Gy

bladder

cancer

femur

coccyx

radiation

Area Covered to 45Gy

bladder

cancer

femur

coccyx

radiation

Boost Field

Total Dose Distribution

50 Gy Dose Area

64.8Gy Dose Area

RTOG 0524 for muscle invading bladder cancer

• Radiation combined with chemoRx (taxol +/- Herceptin)

• Whole bladder plus nodes to 36Gy (1.8 X 22)

• Then whole bladder alone to 54Gy (1.8 X 8)

• The boost to 64.8Gy (1.8 X 6)

Overall survival

Cancer survival

Hypofractionated Intensity Modulated Radiation Therapy in Combined Modality Treatment for Bladder Preservation in Elderly Patients With Invasive Bladder Cancer (50Gy/20fx plus gemzar or cisplatin)71% 3 Year Survival

IJROBP 2014:88:326

Months

Outcomes of Selective Bladder Preservation in the Elderly Treated With Conservative Surgery and Chemoradiation. Patients 75 y or older

Outcome Younger Elderly

complete response 77% 67%cancer survival 69%/5y 60%/5y

61%/10y 56%/10y

IJROBP 2013;87:S83 from Mass General

Side Effects ofRadiation Therapy

• Generally the course is daily radiation for 6 weeks and most people feel increasing fatigue over the course

• Many people have a loss of appetite and sometimes nausea particularly if combined with chemotherapy

• Some patients get a skin burn or reaction in the treated area, depending on the radiation technique used (less so with IMRT)

• Other side effects relate to the normal organs that are in the field of treatment as noted below

Side Effects of Pelvic Radiation

Smallbowel

Bowel frequency, cramping or diarrhea, may need to modify diet or take Imodium or lomotil

Rectum

Rectal irritation or bleeding may benefit from rectal ointments or sitz baths

Bladder

Urinary frequency or burning, may benefit from cranberry juice or medications like pyridium or ditropan

Side Effects in Men

Side Effects in MenTreating the prostate may cause a dry ejaculate and the risk of erectile impotence

Long Term Side Effects of Radiation

None 75 – 80% BC2001Grade 3 <10%Grade 4 < 5%

GI 3 + 1.9% RTOGGU 3+ 5.7%

Mean change in bladder capacity at 1-2 years was < 5ml