eContour

79 y/o M with high-grade muscle-invasive urothelial carcinoma of the bladder trigone s/p TURBT c/w stage II (T2bN0M0) with no residual tumor on cystoscopy

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He was treated with definitive chemoradiation using IMRT and concurrent 5-FU and mitomycin C (MMC) due to impaired renal function. He received 41.4Gy in 23 fractions to the whole bladder, prostate and low pelvic nodes followed by a boost of 19.8 Gy in 11 fractions to the partial bladder for total dose 61.2Gy in 34 fractions to the post-operative bed.

NOTES:

  • BLADDER BOOST: RTOG 0926 specifies boosting WHOLE bladder. However, this patient's empty bladder was still large, which would have put adjacent small bowel at risk of toxicity if treating to >60Gy. The treating physician opted to boost PARTIAL bladder, given it is an accepted alternative, especially for tumors in the trigone/bladder neck (rather than the dome).
  • CT SIMULATION: Patient was scanned with both a full bladder (see overlay) and an empty bladder. Full bladder scan was used to boost partial bladder.
  • Bilateral ureteral stents placed at time of TURBT were removed after patient recovered from treatment.

 

RT coverage and dose (per RTOG 0926 and NCCN 1.2016):

  • CTV Primary: 39.6-50.4Gy
    • Include entire bladder and prostate (in men) due to multifocal nature of bladder cancer
  • CTV Nodes: 39.6-50.4Gy
    • "Small pelvis" includes distal external and internal iliac, obturator, perivesical, and pre-sacral nodes
    • Upper border: S1/S2 (per RTOG 0926)
    • N0: treating nodes is optional (per NCCN 1.2016)*
    • N+: add common iliacs; boost gross nodes to bowel tolerance
  • CTV Boost: 60-66Gy
    • Whole bladder boost required on RTOG 0926, though may be limited by adjacent bowel
    • Partial bladder boost can be considered*
  • PTV margins: 7mm on nodes and prostate, 1cm on whole bladder

*Daily IGRT recommended when treating whole bladder without nodes and/or partial bladder boost (per NCCN 1.2016). Treating partial bladder NOT recommended for tumors of bladder dome (reproducibility).

 

RT Technique:

  • 3D-CRT is used on RTOG protocols
  • IMRT can be used with daily IGRT

RT Fractionation:

  • Once daily is acceptable (41.4Gy/23 with boost to 61.2Gy/34 per RTOG 0926)
  • Hyperfractionation is an option (per RTOG 0233)
  • Hypofractionation is an alternative (55Gy/20, per NCCN 1.2016)

General Management (per NCCN 1.2016):

  • Maximal TURBT should be attempted prior to RT for bladder preservation.
  • Concurrent chemo-RT is encouraged, usually with cisplatin. For patients with low or moderate renal function, 5-FUand MMC can be used but this should be performed in a multidisciplinary setting.
  • Chemo should NOT be delivered concurrently for >3Gy fractions or palliative intent.

 

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