Preferred bladder approach

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PhotonBomb

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I feel like definitive bladder is one of the most variable things in terms of how people treat. Dose/fx, fields, empty or full, IMRT or 3D?


How do you guys prefer to do it?
 
Bladder empty. Treat entire bladder the entire way. 55 Gy in 20 fractions ala James.
 
medgator said:
Bladder empty for initial, boost with full bladder, cbct during boost. Can't imagine anyone is doing 3D these days, esp for boost. 64-66 total
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Depends on tumor location. If at trigone (which most are) agree. If in the dome or multi focal (which I keep getting stuck with recently) empty all the way and boost the whole thing.
 
Evicore hard stop on IMRT bladder. What are you willing to take small bowel to?
 
radmonckey said:
Evicore hard stop on IMRT bladder. What are you willing to take small bowel to?
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They will approve if you do a comparison and show the small bowel getting toasted in the boost, sometimes even without, depends on the p2p reviewer and insurance plan, evicore is just the third party entity
 
radtothebone said:
55 in 20 is to the whole, empty bladder for me too. Most my patients get 5FU/MMC, some cis.

meta-analysis suggests better outcomes with 55/20 over standard frac.

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Patients who received 55Gy had a 29% lower risk of invasive ILRR than those who received the 64Gy schedule (adjusted HR=0.71, [CI 0.52, 0.96]); this benefit was seen when analysis was restricted to patients receiving RT alone
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Sounds like it is a good regimen for non-chemo candidates....
 
I most often do sequential boost like medgator but did my last case 55/20.

With that said, only evicore denial I’ve had in months was a 55/20 bladder case. Could not get the sigmoid where I wanted it with 3D. It met their dvh constraints but had near circumferential full dose at sigmoid. Poor dude had diarrhea like crazy. Got better but with Imrt I feel strongly would have been avoided, the Imrt plan curved beautifully around sigmoid.
 
medgator said:
Sounds like it is a good regimen for non-chemo candidates....
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I’ve found it great with chemo. It was a standard option in BC2001 and the sunsets so far have shown no influence on dose chosen for clinical outcomes or toxicity. No problem with 64/32, but I prefer the shorter course.
 
medgator said:
Bladder empty for initial, boost with full bladder, cbct during boost. Can't imagine anyone is doing 3D these days, esp for boost. 64-66 total
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We generally switch the sequence, since many patients are not able to keep their bladder full during the later course of treatment.
So if the tumor is situated in an area where a full bladder will allow us to boost while sparing bowel, we will boost first with a full bladder and then treat the entire bladder at an empty state.
We generally do not include elective lymphatics.
 
1) Day 1: Simulate empty bladder.
2) Because some patients exhibit such bladder variation day-to-day, I bring patients back for a "Day 2" sim. This informs me re: how reproducible they are day-to-day, and helps me make a more temporally averaged bladder ITV. (Fuse scans, make ITV.)
3) In planning, I put three varying margins around the 2-day bladder ITV: 0.5, 1.0, and 1.5cm (PTV0.5, PTV1.0, PTV1.5)
4) Create three separate IMRT plans for each PTV, all to 64/32
5) Day 1 of tx: place empty bladder within the smallest PTV (that just fits) via CBCT, and mode up the plan that is linked to that PTV
6) In practice I find PTV0.5 ~30% of the time, PTV1.0 ~60% of the time, PTV1.5 ~10% of the time.
7) This is poor man's DART
EDIT: tx bladder only 100% of the cN0 time
EDIT2: (only bill one sim, one plan)
EDIT3: PTV sizes for a ~250cc bladder: PTV0.5 320cc, PTV1.0 380cc, PTV1.5 450cc
 
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anyone ever treated a bladder patient with controlled IBD before? I feel like we treated pelvic patients with IBD in residency, so I feel comfortable. My partner raised a question about it.
 
55/20 to empty bladder with 1.5 cm margins, trim off bowel superiorly. Daily cone beams to make sure top of bladder is in PTV.
44/20 to nodes at same time.

I'm always surprised nobody does 55/20 instead favoring more complicated boost plans. There was a survey on mednet I think that showed 10% or so usage of 55/20. Contouring a bladder and adding a uniform margin and maybe cropping a little bit of bowel. Simple right?
 
We generally do 64/32 but 55/20 with chemo very reasonable. We generally cover lymphatics electively. If focal disease, try to re-sim to allow for partial bladder boost, but if 1) inability to do full bladder or 2) multifocal disease or not limited to trigone or no good localization with clips at time of TURB-T, then just take the whole bladder to prescription dose.

Most of these patients are medicare so we do IMRT. Haven't treated a ton, as vast majority of patients don't see us and opt for NAC + cystectomy.


Related question: How many cover the entirety of the prostate electively? If so, what dose?
 
evilbooyaa said:
We generally do 64/32 but 55/20 with chemo very reasonable. We generally cover lymphatics electively. If focal disease, try to re-sim to allow for partial bladder boost, but if 1) inability to do full bladder or 2) multifocal disease or not limited to trigone or no good localization with clips at time of TURB-T, then just take the whole bladder to prescription dose.

Most of these patients are medicare so we do IMRT. Haven't treated a ton, as vast majority of patients don't see us and opt for NAC + cystectomy.


Related question: How many cover the entirety of the prostate electively? If so, what dose?
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Good question...

When doing sequential I have covered the prostate urethra in the initial elective volume as I was trained this way 10 years ago. Anecdotally I've seen way more failures/spread up a ureter than I have down a urethra. So not sure the utility of this.

I've done 45, boost to 66.6 or 46, boost to 64-66. Prostate covered in the initial 45ish volume but make sure that I don't over treat the rectum there - I'm trying to treat the prostatic urethra mostly, not the prostate, so I'm aggressively sparing rectum there...likelihood of failing in a peropheral zone of prostate up against the rectum seems very low.
 
Stopped including prostate. It's dogma b/c you would have removed it w/surgery that you should target it for RT, but doesn't make that much sense and don't see much spread down (like the wrestler said above).

55/20 is nice, just a bladder plus margin, can do 3D or IMRT and patients do really well. (No need to debate, as people who do 37 fractions or whatever will twist themselves into a pretzel explaining why. They both work fine.)

When you do 55/20 does MO give 5FU/MMC like study or weekly cis or something else like GEM?
 
How toxic is 55Gy/20 with chemo in real practice? Never done that.


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BobbyHeenan said:
When doing sequential I have covered the prostate urethra in the initial elective volume as I was trained this way 10 years ago. Anecdotally I've seen way more failures/spread up a ureter than I have down a urethra. So not sure the utility of this.
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Which means you are doing it the right way! Keep irradiating the prostate. It's the fact that you are treating it, that's keep recurrence rates low. And besides what's the downside to irradiating it? Urethritis?


The urologists do resect the prostate too when they perform cystectomy.
 
They take out the prostate because it makes their job easier. It’s a useless appendage

The chance for nodal or distant failure has got to be way way way higher than an isolated prostate failure
 
PhotonBomb said:
They take out the prostate because it makes their job easier. It’s a useless appendage

The chance for nodal or distant failure has got to be way way way higher than an isolated prostate failure
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They have always be telling me, they do it for tumor extention into the intraprostatic urethra. Especially in cases with CIS.
 
Palex80 said:
They have always be telling me, they do it for tumor extention into the intraprostatic urethra. Especially in cases with CIS.
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Well yes if there is evidence of concern of potential prostatic urethra involvement on MRI or Cysto, that is a different story
 
Palex80 said:
Which means you are doing it the right way! Keep irradiating the prostate. It's the fact that you are treating it, that's keep recurrence rates low. And besides what's the downside to irradiating it? Urethritis?
The urologists do resect the prostate too when they perform cystectomy.
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Palex80 said:
They have always be telling me, they do it for tumor extention into the intraprostatic urethra. Especially in cases with CIS.
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I wouldn't think any intravesicular therapies are "therapizing" the prostatatic urethra. And what about partial cystectomy for early non-CIS bladder CA and even sometimes MIBC; this would also invalidate a pay-attention-prostate mindset. I'm open to hearing some data about prostate's risk of involvement with bladder cancer. AFAIK there is none especially in regards to XRT patients. If anything there seems to be a lot of data (sin of omission reporting?) that it is rare, near 0%.

But you could produce more than just "urethritis" by prostate RT... although even then I'm no fan of urethritis if I can avoid it.

I mentioned that there is data that a pretty low-side-effect drug has activity in brain mets and may want to be at least considered after brain met RT; but for this no "meaningful" endpoints could be impacted... and don't engage in it just because it's "reasonable."
Now again AFAIK there is literally no (again please prove me wrong) data that doing/not doing prostate RT for bladder cancer has any pluses/minuses; but elective prostate RT is the "right way" to do it? Because it's reasonable maybe 😉
There is a vas deferens in logic between these two stances!
 
scarbrtj said:
I mentioned that there is data that a pretty low-side-effect drug has activity in brain mets and may want to be at least considered after brain met RT; but for this no "meaningful" endpoints could be impacted... and don't engage in it just because it's "reasonable."
Now again AFAIK there is literally no (again please prove me wrong) data that doing/not doing prostate RT for bladder cancer has any pluses/minuses; but elective prostate RT is the "right way" to do it? Because it's reasonable maybe 😉
There is a vas deferens in logic between these two stances!
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Because we have always been doing it like this!!!

These guys report on 320 cases of radical cystectomy. Among those 24% had prostatic urethra involvement and most of those cases did not have a contiguous involvement (meaning most of the cases did not have the bladder tumor grow into the prostatic urethra but rather an "extra" focus of the disease in the prostatic urethra.
Involvement of the prostatic urethra seems to have been bad news, in term of prognosis.

I don't know, Scarb, 24% risk (and 15% non-contiguous) sounds like a lot to me. Similar to the threshold used to decide lymphatics in prostate cancer or not.

Plus, if you get a recurrence in the prostatic urethra after primary RCT for bladder cancer, I think the surgical procedure is going to be nasty...
 
Palex80 said:
Because we have always been doing it like this!!!

These guys report on 320 cases of radical cystectomy. Among those 24% had prostatic urethra involvement and most of those cases did not have a contiguous involvement (meaning most of the cases did not have the bladder tumor grow into the prostatic urethra but rather an "extra" focus of the disease in the prostatic urethra.
Involvement of the prostatic urethra seems to have been bad news, in term of prognosis.

I don't know, Scarb, 24% risk (and 15% non-contiguous) sounds like a lot to me. Similar to the threshold used to decide lymphatics in prostate cancer or not.

Plus, if you get a recurrence in the prostatic urethra after primary RCT for bladder cancer, I think the surgical procedure is going to be nasty...
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This is good! Would still like to see RT-focused data (but it'st here where I think there's zero data about prostate). There is much higher risk of occult disease in mastectomy (or internal mammary!) specimens (away from the primary) than suggested by lumpectomy-only-sans-RT recurrence rates e.g. We see this a lot in cancer actually. So 24% is high but it's likely not indicative of the real untreated-prostate recurrence risk. If I were to publish my single-institution data 🙂 I would have 90+% long-term bladder LC rates sans prostate RT.
 
What about a patient with a single <1cm perivesical LN that is moderately PET+? LN is located in a region that would be encompassed by 1cm PTV expansion on the bladder. Are you forced to go conventional route and do elective nodal coverage in this scenario followed by boost to tumor + gross LN? Would your XRT recommendations change if primary tumor(s) was multifocal?
 
CodeRedDew said:
What about a patient with a single <1cm perivesical LN that is moderately PET+? LN is located in a region that would be encompassed by 1cm PTV expansion on the bladder. Are you forced to go conventional route and do elective nodal coverage in this scenario followed by boost to tumor + gross LN? Would your XRT recommendations change if primary tumor(s) was multifocal?
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You're talking about an exceedingly rare clinical presentation. But yes with very rare, unusual presentations, sometimes the thinking process has to change. But the reason there's ENI in bladder CA is due to some old guy at Mass General's afflatus... not some rigorous, data-driven process. It's one of the most invidious reasons to argue for a treatment in medicine. While I don't particularly assume every bladder CA is multifocal, total bladder RT covers for that potentiality. Suppose one could make the same argument for unknown microscopic disease in the nodes in the case of ENI (which assumes every patient has microscopic nodal dz, and treating it helps), but the toxicity differences for elective total bladder RT versus that plus elective nodal coverage are pretty large. (And there's citeable data going pretty far back in time that no-ENI chemoRT for bladder CA has ~zero percent isolated nodal relapse rates.)
 
scarbrtj said:
(And there's citeable data going pretty far back in time that no-ENI chemoRT for bladder CA has ~zero percent isolated nodal relapse rates.)
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Ok, a phase 1 23 patient study, not exactly a slam dunk. I am not staunchly defending ENI for bladder cancer, but not a huge fan of the whole "isolated nodal failure" argument as the proper endpoint for assessing the efficacy of treatment (frequently used by breast IMN coverage haters). Is this a validated endpoint in any way? Subclinical nodal disease never becoming clinically apparent but managing to met out is possible. Also, I'm not terribly far into my career but have already been involved in salvage therapy of at least 5 isolated nodal failures in bladder cancer, and also actually have 3 long term survivors from this group.

scarbrtj said:
but the toxicity differences for elective total bladder RT versus that plus elective nodal coverage are pretty large
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Data to back this? If the insurance overlords allow IMRT and a proper plan is generated, I think the addition of nodes typically adds low additional toxicity. However, if you are a elderly post hysterectomy female with bowel stuck all over the pelvis, maybe you really shouldn't be covering nodes unless there is a very compelling reason.
 
radmonckey said:
not a huge fan of the whole "isolated nodal failure" argument as the proper endpoint for assessing the efficacy of treatment (frequently used by breast IMN coverage haters). Is this a validated endpoint in any way? ... Also, I'm not terribly far into my career but have already been involved in salvage therapy of at least 5 isolated nodal failures in bladder cancer, and also actually have 3 long term survivors from this group.
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Probably? Off the top of my head, maybe... Lymphoma (ie ISRT vs greater). HNSCC?

Will assume these isolated nodal bladder failures are postop, RT-naive (chemo naive?) failures, not post-ENI (or post-non-ENI-RT) failures. If post-ENI failures, not a slam dunk for (but perhaps against?) ENI efficacy.
radmonckey said:
Data to back "toxicity differences for elective total bladder RT versus that plus elective nodal coverage are pretty large"? If the insurance overlords allow IMRT and a proper plan is generated, I think the addition of nodes typically adds low additional toxicity. However, if you are a elderly post hysterectomy female with bowel stuck all over the pelvis, maybe you really shouldn't be covering nodes unless there is a very compelling reason.
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Should have said "measurable" instead of "pretty large." But see previous examples (lymphoma, HNSCC, e.g.) how volume(s) affect toxicity. Data that V∝T (V=volume, T=toxicity) in rad onc? I'd call that a Law.
 
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scarbrtj said:
Probably? Off the top of my head, maybe... Lymphoma (ie ISRT vs greater). HNSCC?
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Not sure if those prove the point that lack of isolated nodal failure in bladder cancer (which you did not prove with your small phase 1 study to begin with) confirms lack of benefit of nodal irradiation.

scarbrtj said:
Will assume these isolated nodal bladder failures are postop, RT-naive (chemo naive?) failures, not post-ENI (or post-non-ENI-RT) failures. If post-ENI failures, not a slam dunk for (but perhaps against?) ENI efficacy.
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All received chemo at some point prior, one received bladder only chemoRT, none received ENI. The bladder only chemoRT patient had biopsy proven nodal recurrence and failed immunotherapy then successfully salvaged with two courses of SBRT to two sites of nodal recurrence now NED 3 years out (probably my most shocking success story). Maybe you could make the argument that if you had given ENI, it would not have been enough to eradicate the nodal disease anyways and then I wouldn't have had more room to appropriately ablate the disease later? Have heard some make the same argument in prostate.

scarbrtj said:
Should have said "measurable" instead of "pretty large." But see previous examples (lymphoma, HNSCC, e.g.) how volume(s) affect toxicity. Data that V∝T (V=volume, T=toxicity) in rad onc? I'd call that a Law.
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Ok, well "measurable" is much different than "pretty large" and I accept your revision. No doubt that elective nodal treatment on the whole will measurably increase toxicity measured across a large group. However, some patients anatomy can be extremely favorable, such as a male with excessive abdominopelvic fat, to the point where the small bowel receives almost no radiation and the only real increased dose is likely bone marrow. Additionally, its not no nodes vs nodes, there is also the concept of a mini pelvis which was used in many RTOG studies.

I don't have the answer. I have certainly done bladder only in quite a few patients and its clearly one standard of care, but at this point not the standard of care.
 
Would just say that even the 3D fields of not electively covering LNs generally covered obutrator and perivesicular LNs quite comfortably. Maybe even some low iliac LNs. Just something to consider when you do say bladder only with no ENI. Similar argument to what folks say in T1/T2 glottic larynx cancer about 3D fields vs carotid-sparing IMRT.

If I was truly doing bladder alone, I don't think something besides a 4 or 6-field box would be necessary. Are people doing bladder IMRT for bladder alone treatment to 55Gy or 64Gy, all for the sake of rectal toxicity? Again, don't treat bladder often, so interested in what others have to say.
 
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Three important questions here:

1. How many isolated nodal failures within "supposed" elective nodal volumes that were not treated would we expect in a cN0 case? Since most recurrences happen in the bladder it's questionable if ENI in the cN0-setting is valuable.

2. How much ENI is woth what in cN0 ? Is it a) pervesical nodes, b) perivesical + pelvic nodes, c) perivesical + pelvic + paraaortal nodes?

3. How curative can RCT be in a cN1-setting? If the chance of cure is very small, then there's little to reason to treat elective nodes beyond the obviously affected, since prognosis is bad anyway (bit like the debate of ENI in N2-NSCLC)
 
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