2012 State of the Art Techniques in IMRT, IGRT, SBRT,

Proton and Brachytherapy: Emphasis on Quality and Safety

May 4 - 6, 2012

GU: Bladder
Kidney/Testis
y
Basics in Anatomy,
Planning and Delivery III
Brian J. Davis, M.D., Ph.D.
Associate Professor Radiation Oncology
Department of Radiation Oncology
Mayo Clinic and Foundation

GU: Bladder/Kidney/Testis
Basics in Anatomy, Planning and Delivery III

Introduction - What is the role of

radiotherapy in treatment of these
primary
i
sites?
i ?
Anatomy Regional
Regional Lymph Nodes and
Surgical Findings
Planning
Pl i andd Delivery
D li
- Recommended
R
d d
Treatment Volumes and Doses

Bladder/Kidney/Testis:
E id i l
Epidemiology
and
d Radiation
R di ti Publications
P bli ti

Cases/yr
Deaths/yr
y
Peer reviewed
articles
RT and Site

Bladder

Kidney

Testis

73,510
14,880
,

64,770
13,570
,

8,590
360

1 353
1,353

67

1 190
1,190

RTOG Clinical Trials

F Localized
For
L li d Disease
Di
Bladder
9706
9906
0233
0524
0712
0926

Kidney

Testis

Bladder Cancer: NCCN Guidelines 2012

Testicular Ca: NCCN Guidelines 2012

Dose Constraints
Quantec dose constraints
Spinal cord: Max: 5200 cGy; 1cc < 5000 cGy
Kidney: Mean < 1500 cGy
V12<55%, V20<32%
V23<30%, V28<20%

Li
Liver: < 30 Gy
G (2 Gy);
G ) < 21 Gy
G (3 Gy)
G )
Small bowel:
V15 G
Gy <120
120 cc ((contouring
i iindividual
di id l bowel
b
l
loops)
195 cc (contour peritoneal space)
V45 Gy <195

Dose Constraints
Quantec dose constraints
Large bowel: V45 Gy <195 cc
Bladder: Whole bladder V80 <15%,
V75 25% V70 < 35%,
V75<25%,V70
35% V65 < 50%
Rectum: V50 < 50%, V60 <35%, V65 < 25%,
V70 < 20%,
20% V75< 15%
Testes:
Testosterone
T t t
production
d ti < 14 Gy
G
Temporary azospermia < 1 Gy

Bladder Cancer

Bladder Anatomyy
4 sides
id
4 angles
g
44 ducts

Bladder Anatomy: 4 Sides

The base or fundus, which is related to the
anterior vaginal wall (females) or the
rectum, seminal vesicles and ductus
deferens (males);
( l )
The superior surface;
And 2 inferolateral surfaces, which is
separated from the pubis and
puboprostatic ligament (male) or
pubovesical
b
i l ligament
li
t (female)
(f
l ) by
b the
th
retropubic fat pad.

Bladder Anatomyy
4 sides
Sup, 2 inferolateral
base

4 angles
Apex, neck, lateral

4 ducts
2 ureters,, urethra,,
and urachus

Bladder Cancer: Primary

Tumor Classification

Bladder Anatomy
L
Lymphatic
h
D
Drainage
The llymph
mph vessels
essels from the superior part
of the bladder pass to the external iliac
lymph nodes.
Those from the inferior part of the bladder
pass the internal iliac lymph nodes.
Some
S
llymph
h vessels
l from
f
the
th neck
k region
i
of the bladder drain into the sacral or
common iliac lymph nodes.

Bladder Cancer - Lymphatic Pathway of Spread

Common iliac
nodes:19 %
External iliac
nodes: 65 %
Perivesical nodes

Internal iliac
nodes: 15 %
Perivesical LN:
75 %

Nodal disease is present in 20-40% at diagnosis

Bladder Ca: Nodal Involvement

Fig. 1 Lymph node packets:
(1) paracaval, (2) para-aortic,
(2) (3, 4) right (R)
and left ((L)) common iliac,,
(5) presacral,
(6, 7) R and L external iliac,
(8 9)R and L obturator/internal
(8,
iliac.

Dorin et al.
al EUROPEAN UROLOGY
60 (2011) 946 952.

Bladder Ca: Nodal Involvement

Dorin et al. 2011

Bladder Ca: Nodal Involvement

Bladder Ca: Nodal Involvement

Bladder Conservation: Evolution of the

MGH and RTOG approach
1986-93

1994-98

1999-2006

Neoadjuvant
chemo

Accelerated
radiation

Enhanced
Radiation
sensitization

Response
evaluation

Adjuvant
chemotherapy

Adjuvant
chemotherapy

MCVx2

bidRT+C/5Fu

bidRT+C/Tax

RT + C

MCV x 3

G+Cx4

RTOG Clinical Trials: Bladder Fields

Bladder
9706
9906
0233
0524
0712
0926

Four fields must be used

to encompass the entire
bladder,prostate, and
pelvic lymph nodes below
the common iliac
bifurcation. The CTV1
( CTV1= pelvic
LN + bladder + prostate)
field margins in the
superior-inferior
dimensions should extend
from mid-sacro-iliac
region
g
to jjust below the
obturator foramen.

Bladder Cancer: Treatment Fields

Small Pelvic Fields byy 3-D

Nodal RT fields (40 to 45 Gy) are designed to conserve

small bowel for urinary diversions should they be needed

Tumor boost fields by 3-D

Only partial bladder to high dose
(total 65 Gy)
Incorporate all TURBT and
radiographic info
Simulate and treat with empty
bl dd
bladder

Bladder Ca: Erlangen Approach

RT was initiated 4 weeks after
TURBT using 66 to 10-MV
10 MV photons
and a four-field box technique with
individually shaped portals and daily
f i
fractions
off 1.8 Gy on 5 consecutive
i
days. Patients were treated with
empty
p y bladder. The total dose to the
whole bladder and pelvic lymph
nodes ranged from 45 and 54 Gy. In
case of R0 resection after TURBT,
TURBT
the whole bladder received a boost to
55.80 Gy with a 2-cm safety margin
i all
in
ll directions.
di i
After
Af R1/2
resection, the boost dose to the
whole bladder was increased to 59.4
Gy.
Rdel C et al. JCO 2006;24:5536-5544

Weiss C., et al. IJROBP, 68(4)

pp. 10721080, 2007

Fused cone-beam CT image performed before and

after conformal external beam radiation therapy
illustrate the changes in clinical target volumes
when patients are irradiated for bladder cancer

Thariat, J. et al. (2011) Image-guided radiation therapy for

muscle-invasive bladder cancer Nat. Rev. Urol.
doi:10 1038/nrurol 2011 173
doi:10.1038/nrurol.2011.173

Main IGRT studies illustrating bladder

g during
g irradiation
changes

Thariat, J. et al. (2011) Image-guided radiation therapy for muscle-invasive

bladder cancerNat. Rev. Urol. doi:10.1038/nrurol.2011.173

FDG-PET/CT for the Preop Lymph

Node Staging of Invasive Bladder Ca

Swinnen et al., EUROPEAN UROLOGY 57 (2010) 641 647

Kidney Cancer

Radiation Therapy
for Kidney Cancer
Primary
Primary
Neoadjuvant/Adjuvant
Treatment
T t
t off
Metastases or Palliation

Radiation Therapy
f Kidney
for
Kid
Cancer
C
Primary:
Pi
no role
l or only
l in
i rare
circumstances
Neoadjuvant/Adjuvant: usually not
indicated, but can be considered in
select cases
cases.
Treatment of Metastases or
Palliation: YES

Kidney: Landmarks

Retrospective Data Supporting

Adj
Adjuvant
tP
Post-Nephrectomy
tN h t
RT
S.
S Rafla Cancer 1970
244 patients:
Surgery alone
Surgery + RT

72% died of cancer

5 yr survival
10 yr survival
5 yr survival
10 yr survival

37%
19%
56%
34%

Retrospective Data Supporting

Adjuvant Post
Post-Nephrectomy
Nephrectomy RT
R.
R Makarewicz et al.
al Neoplasma 45(6): 380,
380 1998.
1998
186 patients treated from 1985-96 with 114 pts
p
EBRT with a median dose of
receivingg ppostoperative
50 Gy.

Surgery alone

DF survival
OS survival

31.3%
29.5%

Surgery
S
+ RT

DF survival
i l
OS survival

35.5%
35
5%
37.9%

Kidney Cancer: Old Phase III Trials

Sh i N
Showing
No B
Benefit
fit tto P
Pre-op EBRT
Preoperative:
Rotterdam Trial.
van der
d Werf
W f Messing
M i Cancer
C
1973 32 1056
1973:32:1056
1965-1972
141 patients total - treated to 30 Gy 1st group and
then 40 Gy
No benefit to preoperative radiotherapy

Swedish Trial. Juusela H. 1968-72

Scand J Urol Neph 11:277:1977.
88 patients
i
(38 received
i d pre-op in
i a randomized
d i d fashion)
f hi )
3300 cGy in 3 weeks. No benefit demonstrated.

Kidney Cancer: Old Phase III

Trials Showing No Benefit to
Post-op EBRT
Danish Trial

Kjaer M. et al Int J Radiat Oncol Biol Phys 1987:13: 665

665-72
72
1979 - 1984. 65 patients randomized.
50 Gy in 20 fractions. 4 fractions per week.
N diff
No
difference iin outcome
t
- significant
i ifi t toxicity
t i it in
i RT arm with
ith
44% of patients having liver, stomach and duodenal problems.
19% of deaths attributed to RT

Newcastle
N
l UK
R. Finney Cancer Cancer 1973:32:1332
100 patients
p
over 9 yyears. Randomized byy birth date. 4 death due
to RT induced hepatotoxiciy - 55 Gy in 2.04 Gy fractions.
No difference in outcome.

Radiation Therapy for Kidney Cancer

Mayo Clinic Rochester Statistics
St
Stage
IV Adj/Primary
Adj/P i
1993-1998:

91

23

1999-2003:

135

13

Potential indications for adjuvant

radiotherapy:
di th
P
Perez 3rd
3 d ed.
d
Unresectable nonmetastatic tumors (preoperative radiation)
Incomplete resection with gross or microscopic residual margin
Locally advanced tumor with perinephric fat extension or adrenal
invasion, T3a or T3c. (Renal vein or inferior vena cava
involvement alone (T3b does not necessarily increase the risk of
local recurrence and should not be considered an indication).
indication)
Lymph node metastases. (LN mets are associated with both a
high
g rate of distant metastasis and local failure. Although
g RT
may decrease the local recurrence rate, an improvement in overall
survival may not be demonstrated in this circumstance.)

Case: 42 yo male

Abdominal pain and hematuria

CT showed a right renal mass
Right radical nephrectomy 1 month later
Pathology: 5.5 cm grade 3, papillary renal cell
carcinoma without capsular invasion. Necrotic
LN immediately adjacent to the vena cava.
Consults in Med Onc and in Rad Onc
Patient advised regarding pros and cons of
adjuvant local therapy

Adjuvant EBRT
for
Kidneyy Cancer
CT simulation
Identify liver, contralateral kidney.
4,500 cGy in 25 fx
include
c ude co
contralateral
aaea
LNs and tumor bed.
13 x 15 cm field.

Testis Cancer

Radical Inguinal Orchiectomy

Transinguinal radical orchiectomy
Diagnosis
Di
i andd therapy
h

www.ucurology.urologydomain.com www.emedicine.com/ med/images/259radorch.jpg

Seminoma: Lymphadenopathy

Radiation Therapy Fields

Fossa et al.
al JCO 1999
MRC trial
pT1-3, 30 Gy / 15 fx
PA (n=236)
DL (n=242)

90% power to exclude 3% 3yr relapse

rate ((one-sided alpha)
p )

Development

Testes originate intra-abdominally

Migrate through the inguinal canal

www.somethingiforgottoreference.com

Lymphatic Anatomy

Hilum of testis spermatic

p
cord
To the internal inguinal ring
Follow testicular veins
PA lymph nodes (retroperitoneal)
T11-L4
L1-L3 has greatest concentration

 C
Continue
ti
superiorly
Thoracic duct
Mediastinum &
Supraclavicular
LNs
PA LNs:
crossover
R to L is
common but L to
R is rare

www.nucleusinc.com

 PA field borders
T10-T11
Ipsilateral
I il t l renall
hilum
Transverse
processes
L5-S1

Prescribed at
midplane
id l

 DL field borders
T10-T11
Ipsilateral renal
hilum down to L5S1, then diagonally to
lateral acetabulum
Transverse processes
Mid-obturator
foramen

Prescribed at
midplane

Radiation Therapy
py Fields
Median f/u 4.5
4 5 yrs
Relapses

3 yr RFS

3 yr OS

N/V,
WBC

Sperm
count

PA

9 (4 pelvic)

96%

99.3%
(1 death)

Better

Higher

DL

9 (no pelvic)

96%

100%

Worse

Lower
p=SS

Conclude PA is standard
standard, but surveillance still
needed for pelvic relapses
DL reservedd for
f prior
i surgery

Radiation Therapy Dose

Jones et al.
al JCO 2005
MRC/EORTC
pT1-3, randomized to:
30 Gy / 15 fx (n=313)
20 Gy / 10 fx (n=312)

90% power to detect 3-4% difference

between arms ((one-sided alpha)
p )

Radiation Therapy
py Dose
PA fields (88%)
T10-T11
Contralateral transverse process
Ipsilateral renal hilum
L5-S1

DL allowed
ll
d if prior
i surgery
Q
QOL qquestionnaires

Radiation Therapy Dose

Median f/u 5 years

30 Gy
20 Gy

Relapses
10 (3.2%)
11 (3.5%)

More acute SE with 30 Gy (p=SS)

Lethargy,
Letharg inability
inabilit to work,
ork leukopenia
le kopenia
N/V, thrombocytopenia (trends)

Conclude 20 Gy should be standard

Death
0
1

Treatment
Seminoma Stage IIA
90% curable
Radiation Therapy Ipsilateral
pelvic and paraaortic fields
Boost 500 cGyy / 4 fractions
Involved nodes
2 cm margin
i

Treatment
Seminoma Stage IIB
85%
% curable
XRT Dogleg
Some MDs treat inverted Y
Size similar to stage I and II A
Boost of 500 1500 cGy
2 cm margin

Radiation Techniques
Clamshell
Reduce dose to contralateral testis
Cannot
C
fully
f ll eliminate
li i
dose
d
Internal scatter (patient)
(p
)
External scatter (collimator)

Clamshell alone 1.6%

1 6% Rx dose
Additional shielding 0.1%
Kubo H., Shipley W. IJROBP 8:17418:1741-1745,1982

Radiation Techniques
Most patients think of this:

www.revelstokemuseum.ca

Radiation Techniques
Actual clamshell shielding

www.tcrc.acor.org

Radiation Techniques
Clamshell shield stand

www.tcrc.acor.org

Stage II Seminoma

Stage II Seminoma

Thank You!