Radiation for the Treatment of Bladder Cancer
-
Upload
robert-j-miller-md -
Category
Health & Medicine
-
view
790 -
download
3
description
Transcript of Radiation for the Treatment of Bladder Cancer
Radiation for Cancer of the Bladder
www.aboutcancer.com
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