Bladder Ca

Question 1

Bladder Ca risk factors (6)

Answer 1

• Male/Caucasian
• 65 years
• Smoker
• Occupational Carcinogen (napthylamine)
• chronic bladder infections
• exposure to cyclophosphamide

Question 2

Signs and Symptoms of Bladder Ca (3)

Answer 2

• haematuria
• Urinary irritation = Dysuria, frequency, urgency, pain, retention
• Obstruction = pain, infection, kidney damage

Question 3

Pathology and staging of bladder Ca

- most common histology

Answer 3

• Most common = transitional cell carcinoma
  but can also have adeno/squamous cell carcinomas
  and leiyomyosarcomas/ rhabdomyosarcomas (but these are rarer)

Question 4

Staging system used for Bladder Ca

Answer 4

• TNM

Question 5

Staging For Bladder Ca

• Ta
• T1
• T2
• T3

Answer 5

• Ta = non-invasive papillary tumour
• T1 = invades the lamina propina but not beyond
• T2 = invades the muscularis propria
• T3 = invades the pericervical muscle

Question 6

How would you examine and treat a T1 or Ta Bladder Ca?

Answer 6

Examine using = Cystoscopy

Treat using either; laser treatment, cryosurgery or cystodiathermy

Question 7

How would you treat a muscle invasive bladder Ca (T2/T3)

Answer 7

• Treat using RT and surgery

Question 8

What are is the criteria for receiving RT for bladder ca? (9 things)

Answer 8

• > 80yrs or able to withstand treatment
• Good general medical condition
• Good renal function
• Good bladder function
• Do not have inflammatory bowel disease/systematic adhesions
• > 7cm tumour
• No mets
• TCC
• Recurrent T1G3 or T2-T4a

Question 9

Dose Fractionation for Bladder - Radical and Palliative

Answer 9

Radical (whole bladder) = 64Gy in 32#
Palliative (whole bladder) = 21 in 3# (3 days alternating in one week)

or/ 36 in 6# given over 6 weeks.

Question 10

Treatment Considerations

Answer 10

• Empty bladder (bc this will reduce the dose being treated and doses to normal tissues, also more reproducible)
• Empty rectum (bc reduces OAR motion and inter fractional variation)

Question 11

Where would you do the CT scan from?

Answer 11

From L5 (inf) to inf part of ischial tuberoisities

Question 12

What should the CTV include? How would this change if the disease is at the bladder base?

Answer 12

• CTV should include all of the GTV and extravesical spread, should include the whole bladder.
• If the disease is at the base of the bladder outline the proximal part of the urethra, if t is a male outline the prostate and prostatic urethra

Question 13

How do you expand the margins for creating the PTV, and what do you also need to consider?

Answer 13

• PTV is an expansion of 1.5cm on the CTV and 2cm around the primary bladder tumour and extra vesicle spread.
• Need to consider that the bladder moves in a random direction and time (AP and Cranial) and in 60% of patients this causes the 95% isodose curve to be displaced over 1.5cm bw bladder wall.

Question 14

OAR in a bladder treatment

Answer 14

• Bladder
• Femoral H/Ns (V45 <60%)
• Rectum (V50<50%)
• SI
• Genitals (not the biggest concern bc further away from field)

Question 15

Side Effects of RT for Bladder Ca (Acute)

Answer 15

Acute

• Frequency and urgency due to radiation cystitsis
• Diarrhoea
• Nausea/ vomiting
• Skin reaction and fatigue
• haematuria

Question 16

Side Effects of RT for Bladder Ca (Late)

Answer 16

• Fibrosis of the bladder (decreased capacity)
• Late bowel damage
• Vaginal dryness and stenosis
• Impotence in men
• haematuria

Question 17

What imaging would you do for Bladder Ca and what do you need to consider?

Answer 17

• DO imaging that allows you to see soft tissue such as KV cone beam or MV (with implanted markers and gold seeds)
• Need to be careful if matching to a surrogate because may underestimate bladder movement even despite preparation protocol.

Question 18

If IGRT is not available, what would you do?

Answer 18

• EPI comparing bony anatomy with AP and lat DRRs daily for first 3-5 days, and then once weekly correcting for systematic errors.