Kevin Love

Question 1

What is the lymphatic drainage for the bladder?

Answer 1

• first to the hypogastric, obturator,
• then internal, external and common iliac lymph nodes
• followed by para-aortic and inguinal nodes

Question 2

What is the Aetiology for Bladder cancer?

Answer 2

Peak age at 65
Smoking
Occupational carcinogens-napthylamine
Chronic bladder infection
Exposure to cyclophosphamide

Question 3

What is the epidemiology of bladder cancer?

Answer 3

2nd most common urological malignancy

3x more common in men especially Caucasian men

Question 4

What are the signs and symptoms?

Answer 4

Haematuria Urinary irritation: frequency, urgency, pain, retention, dysuria Obstruction: pain, infection, kidney damage

Question 5

What are potential distant mets?

Answer 5

LNs, lung, liver, bone

Question 6

What is the pathology for bladder cancer

Answer 6

90% are transitional cell carcinomas

squamous carcinoma, adenocarcinoma, leiomyosarcoma rhabdomyosarcoma

Question 7

What is the clinical management for superficial bladder cancer (TA and T1)

Answer 7

Repeated cystoscopy Cystodiathermy, cryosurgery & laser treatment

Question 8

What is the clinical management for Muscle-invasive disease cancer (T2 and T3)

Answer 8

Surgery (TURBT and Cystectomy) and Radiation therapy are standard for invasive TCC bladder cancer

Question 9

What is the criteria for radiation therapy?

Answer 9

• Age < 80 years (unless fit) An -adequate general medical condition
• Normal renal function
• No inflammatory bowel disease or symptomatic adhesions
• Good bladder function
• TCC -Single tumour of <7cm diameter
• Recurrent T1G3, T2-T4a
• No mets

Question 10

What is the radical fractionation?

Answer 10

64 in 32 for whole bladder in 6.5 wks

Question 11

What is the palliative fractionation?

Answer 11

• 21 in 3 given on alternate days in 1 week

- 36 in 6 given once weekly for 6wks

Question 12

What are some considerations prior to treatment?

Answer 12

• Empty bladder before scanning
• reduce volume irradiated and dose to normal tissues
• Rectum should be empty to reduce organ motion and interfractional variations

Question 13

What is the common patient positioning?

Answer 13

Supine, straight & level Arms on chest Headrest Knees bolster (indexed) Foot-stocks (indexed

Question 14

What are some CT sim considerations?

Answer 14

• Oral contrast for the Small bowel
• 3-5 mm slices from lower border L5 – inferior border ischial tuberosities
• Ant tattoo – ML & 2 lateral tattoos
• Confirm bladder is empty

Question 15

What does the CTV include?

Answer 15

Include GTV (primary tumour & extravesical spread) and the whole bladder, bladder base and proximal urethra

-for males the prostate and prostatic urethra are included

Question 16

What is

s the PTV expansion from the CTV?

Answer 16

1.5-2cm margin expansion (1.5 around bladder wall and 2cm, around primary tumour and extravesical spread)

Question 17

What are some OAR?

Answer 17

Small bowel Rectum (V50Gy <50%)
Bladder
Femoral heads/necks (V45Gy <60%)
Genitals

Question 18

What are potential field arrangements?

Answer 18

Posterior Oblique fields to miss Femurs and Rectum

VMAT or IMRT with IGRT use

Question 19

What are some treatment considerations?

Answer 19

Empty bladder & rectum Position as per CT- position Standard to set isocentre

Question 20

What are the acute side effects?

Answer 20

Frequency/ urgency from urination from radiation cystitis
Haematuria, Diarrhoea, N and V
Local skin reaction and fatigue

Question 21

What are the late side effects?

Answer 21

• Fibrosis, shrinkage of bladder
• Haematuria, telangiectasis
• Late bowel damage
• Vaginal dryness and Stenosis in women
• Impotence in men

Question 22

What are common imaging modalities used?

Answer 22

• kV cone beam imaging
• MV imaging with tomotherapy
• MV imaging of gold seed markers cystoscopically implanted into the bladder,

Question 23

What is the most common imaging procedure?

Answer 23

EPI comparing bony anatomy with the AP and lateral DRRs daily for the first

-3–5 days, and then once weekly correcting for systematic errors