The role of radiation in the treatment of bladder cancer and a discussion of technique and side effects

1. Radiation for Cancer
of the Bladder
www.aboutcancer.com

2. CT scan is obtained at the time of
simulation
CT images are then imported
into the treatment planning
computer

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

4. The CT Images Are Contoured and
Labelled to Identify The Structures

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

6. Phase 1
Initial Large
Radiation
Zone in
Blue
Includes
the whole
bladder and
lymph
nodes
bowel
Whole
bladder
rectum
Radiation
zone

7. bowel
rectum
Hits a large area of the bowel and rectum
Radiation
zone
Whole
bladder

8. Small
bowel
bladder
rectum
cancer
radiation
Phase 2
target just
the cancer
area in the
bladder

9. Hits much less area of the bowel and rectum
bowel
bladder
rectum
radiation
cancer

10. 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)

11. 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)

12. 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 response
3.If Complete response then more
chemoradiation 19.8/ 24.8Gy (total dose
64.8Gy) to gross bladder tumor

13. Lymphatics of the Bladder
External iliac
Lymphatics
from the
bladder
Common iliac
artery
Sacral
Hypogastric
Ureter
Lymphatics
from the
bladder

14. Bladder Lymph Nodes
Para-aortic
Lateral External
Iliac
Deep
InguinalSuperficial
Inguinal
Obturator
Medial External
Iliac
Internal Iliac
Sacral
Highest Deep
Inguinal (Cloquet)
Sacral
Common Iliac

15. Pelvic Nodes

16. 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

17. RTOG 8903 Muscle Invasion
45Gy then Boost to 64.8Gy

18. RTOG 8903 Muscle Invasion
45Gy then Boost to 64.8Gy

19. Area Covered to 45Gy
bladder
cancer
femur
coccyx
radiation

20. Area Covered to 45Gy
bladder
cancer
femur
coccyx
radiation

21. Boost Field

22. Total Dose Distribution

23. 50 Gy Dose Area

24. 64.8Gy Dose Area

25. 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)

26. 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

27. 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

28. Side Effects of
Radiation 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

29. Side Effects of Pelvic Radiation

30. Small
bowel
Bowel frequency,
cramping or diarrhea,
may need to modify diet
or take Imodium or lomotil

31. Rectum
Rectal irritation or
bleeding may benefit from
rectal ointments or sitz
baths

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

33. Side Effects in Men

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

35. Long Term Side Effects of
Radiation
None 75 – 80% BC2001
Grade 3 <10%
Grade 4 < 5%
GI 3 + 1.9% RTOG
GU 3+ 5.7%
Mean change in bladder capacity at 1-2
years was < 5ml