Radiation for the Treatment of Bladder Cancer
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The role of radiation in the treatment of bladder cancer and a discussion of technique and side effects
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Radiation for the Treatment of Bladder Cancer
- 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
- 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