Protocol of Radiotherapy for Urinary Bladder cancer
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I.
Indication of radiotherapy
Definite setting/Bladder preservation
(1) Superficial tumor recurrence and/or progression after BCG instillation(1)
(2) Muscle-invading disease (T2)
(3) Patient refused radical cystectomy
II. Adjuvant setting after radical cystectomy:
(1) the bladder has multiple tumors (>3) with at least one broad base tumor
(2) lymph node (+) or resection margin (+)
III. Palliative purpose
CT simulation
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Supine position
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Urinary bladder must be emptied
Immobilization
Recommend consulting bladder map from TURBT for planning
Use of fiducials and IGRT for reducing set-up errors and organ motion
Treatment planning of radiation therapy
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Common definition of radiation portal of 4-field technique
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Anterior – posterior fields extend laterally 1.5 cm to the bony pelvis;
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exclude the inferior corners to protect femoral heads
Lateral fields extend anteriorly 1.5-2 cm from the most anterior aspect of
the bladder. The posterior border extend 2.5 cm posterior to the most
posterior aspect of the bladder and falls within the rectum.
The inferior border: below the middle of the obturator foramen
The superior border: L5-S1 or at the superior SI joint(2).
IMRT technique (controversial. If used, strongly consider IGRT)
GTV: macroscopic tumor visible on CT / MRI / cystoscopy
CTV: GTV + whole bladder + lymph nodes (obturator, external and internal
iliac region) + proximal urethra
PTV: CTV + 1.5-2 and 2-3 cm superiorly (can probably be reduced to 1
cm and 1.5-2 cm superiorly with the use of fiducials + IGRT
Boost volumes = entire bladder or partial bladder(3).
 CTV = GTV + 0.5 cm. PTV = CTV + 1.5 cm
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The prescription dose
 Dose per fraction
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Once daliy 1.8-2 Gy; Twice daily 1.5-1.6Gy(2, 4)
 Total dose
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60-65Gy to bladder tumor
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40-45 to pelvic lymph nodes
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Normal tissue constraint
 Rectum
 V65 < 17%
 V40 < 35%
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Small bowel
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Maximum dose < 5200cGy
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Mean dose < 23.5 Gy
Femoral head
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V50 < 5-10%
Delivery
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Urinary bladder must be emptied
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Use of fiducials and IGRT for reducing set-up errors and organ motion
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Treatment schema for bladder preservation therapy
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Maximal TURBT → 3weeks → induction chemo-RT to 40-45 Gy/BID or
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QD → 3 weeks → second look cystoscopy with
and urine cytology
If residual tumor ≧T1, salvage cystectomy.
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If CR, consolidation chemo-RT to total dose 60-65G
Frequent follow-up cystoscopy with biopsy and cytology
multiple biopsies
Follow-up
Follow-up with urine cytology and cystoscopy every 3 months × 1 year, every 6
months × 2 year, then annually. CT abdomen and pelvis q 1–2 year.
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2
References:
1.
Weiss C, Wolze C, Engehausen DG, et al. Radiochemotherapy After
Transurethral Resection for High-Risk T1 Bladder Cancer: An
Alternative to Intravesical Therapy or Early Cystectomy? Journal of
Clinical Oncology 2006;24:2318-2324.
2.
Shipley WU, Zietman AL, Kaufman DS, et al. Selective bladder
preservation by trimodality therapy for patients with muscularis
propria-invasive bladder cancer and who are cystectomy candidates?
The Massachusetts General Hospital and Radiation Therapy
Oncology Group experiences. Seminars in radiation oncology
2005;15:36-41.
3.
Huddart RA, James ND, Adab F, et al. BC2001: A multicenter phase
III randomized trial of standard versus reduced volume
radiotherapy for muscle invasive bladder cancer
(ISCRTN:68324339). J Clin Oncol 2009;27: abstr 5022.
4.
Kaufman DS, Winter KA, Shipley WU, et al. Phase I-II RTOG Study
(99-06) of Patients With Muscle-Invasive Bladder Cancer
Undergoing Transurethral Surgery, Paclitaxel, Cisplatin, and
Twice-daily Radiotherapy Followed by Selective Bladder
Preservation or Radical Cystectomy and Adjuvant Chemotherapy.
Urology 2009;73:833-837.
5.
6.
7.
CANCER: Principles & Practice of Oncology, by DeVita, Lawrence
and Rosenberg, 8th Edition, 2008.
RADIATION ONCOLOGY: Principles and Practice, by Perez
and Brady, 5th Edition, 2008.
Handbook of Evidence-Based Radiation Oncology, by E. K. Hansen,
M. Roach, 2nd Edition, 2010.
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