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
Bladder Kidney Testis

Cases/yr 73,510 64,770 8,590

Deaths/yr
y 14,880
, 13,570
, 360
Peer reviewed
articles 1 353
1,353 67 1 190
1,190
‘RT and Site’
RTOG Clinical Trials
F Localized
For L li d Disease
Di
Bladder Kidney Testis
9706
9906
0233
0524
0712
0926
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)
• V45 Gy <195
195 cc (contour peritoneal space)
 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 %

Internal iliac
Perivesical nodes
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 Accelerated Enhanced

chemo radiation Radiation
sensitization
Response Adjuvant Adjuvant
evaluation chemotherapy chemotherapy

MCVx2 bidRT+C/5Fu bidRT+C/Tax

RT + C MCV x 3 G+Cx4
RTOG Clinical Trials: Bladder Fields
Four fields must be used
to encompass the entire
Bladder bladder,prostate, and
9706 pelvic lymph nodes below
the common iliac
9906 bifurcation. The CTV1
( CTV1= pelvic
0233 LN + bladder + prostate)
0524 field margins in the
superior-inferior
0712 dimensions should extend
0926 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 6- 6 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.
Weiss C., et al. IJROBP, 68(4)
Rödel C et al. JCO 2006;24:5536-5544 pp. 1072–1080, 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
changes g irradiation

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
tPPost-Nephrectomy
tN h t RT
• S.
S Rafla Cancer 1970
– 244 patients: 72% died of cancer
– Surgery alone 5 yr survival 37%
10 yr survival 19%
– Surgery + RT 5 yr survival 56%
10 yr survival 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
receivingg ppostoperative
p EBRT with a median dose of
50 Gy.
– Surgery alone DF survival 31.3%
OS survival 29.5%

– Surgery
S + RT DF survival
i l 35.5%
35 5%
OS survival 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, contra-
lateral 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 Æ 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 L5-
S1, 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, Sperm
WBC count
PA 9 (4 pelvic) 96% 99.3% Better Higher
(1 death)
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 priori 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

Relapses Death
30 Gy 10 (3.2%) 0
20 Gy 11 (3.5%) 1

• 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
 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 MD’s 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 8:1741-

8:1741-1745,1982
 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!