بسم الله الرّحمن الرّحیم

1. بسم الله الرّحمن الرّحیم H. Emama M.D.

2. Bladder Cancer (Radiation Therapy) By: H. Emami Assistant professor of Radiation Oncology, Isfahan University of Medical Sciences, Isfahan, IRAN.

3. Bladder Cancer Superficial tumors TUR (standard) Low grade, Low stage Observation High grade, High stage, Multifocal CIS Multifocal Tumors Tumor associated with CIS If rapidly recur Interavesical therapy Or Radical Cystectomy Or Bladder preserving

4. Bladder Cancer Radical Cystectomy (standard) + CT CT + Radical Cystectomy if nodes are Negative (NCCN) category 1 Muscle invasion (T2) Chemoradiation + CT CT + Chemoradiation Partial Cystectomy + CT CT + Partial Cystectomy (NCCN) Bladder Preservation

5. Bladder Cancer Muscle invasion (T2) TURBT Chemo-radiation (40 - 45 Gy) CR In-CR Consolidation Chemo-radiation (64 – 66 Gy) Cystoscopic Evaluation Radical Cystectomy Recurrence

6. Bladder Cancer CT+Chemoradiation CT + Radical Cystectomy (NCCN) category 1 Pre-op. Chemoradiation + Cystectomy + Post op. Chemotherapy Perivesical fat invasion (T3)

7. Bladder Cancer CT+Chemoradiation CT + Radical Cystectomy in selected patient Adjacent organ (s) involvement(T4a) Chemoradiation Palliative therapy Radiation therapy Chemotherapy Involvement of pelvic or Abdominal wall (T4b)

8. Bladder Cancer (Chemoradiation Therapy) Pre-op. Chemoradiation or Chemotherapy (for down staging) T2 T3 Selected T4a Node negative Residue Positive LN(s) No New Bladder Post op. Chemoradiation (In high risk patients)

9. Bladder Cancer (Radiation Therapy) 1)-5000 cGy to the whole pelvis. 2)-Lateral boost to the bladder (1000 cGy). 3)-Cystectomy (4 to 6 week later). Pre-op. Radiation therapy Or Chemoradiation (for down staging) 1)-4500-5000 cGy to the whole pelvis + bladder boost Total dose 6400-6600 cGy + Cisplatin, Carboplatin, Paclitaxel, 5FU, Gemcitabine (low dose )(33mg/m2 twice weekly) Mytomycin-C + 5FU (NCCN) 2)- Two course MCV , then Chemoradiation Chemoradiation therapy (for bladder preservation)

10. Bladder Cancer (Palliative Therapy) Bone metastasis Hematuria Lung and Liver Met. Chemotherapy 3000 CGY in 10 fractions. 4000 CGY in 20 fractions. 1000 cGy in one fraction. 1000 cGy every 3-4 week for 3 times 600 cGy every week for 5 weeks

11. Bladder Cancer (Radiation Therapy Schedule) 1)-Convential (180-200 cGy/day) (Total 6400 cGy) 2)-Hyper fractionation (100 cGy X 3 times/day) (total 8400 cGy) 1000 cGy in one fraction 2100 cGy in 3 fractions 3)-Hypo fractionation 3500 cGy in 10 fractions 600 cGy weekly (total 3000 cGy 600 cGy weekly (total 3600 cGy)

12. Bladder Cancer (Radiation Therapy Techniques) Anterior-posterior portal Right lateral portal

13. Bladder Cancer (Radiation Therapy Techniques) Box Tech. (whole pelvis) Box Tech. (Bladder)

14. Bladder Cancer (Radiation Therapy Techniques) Two Lateral Arc Technique Three Field Arrangement

15. Bladder Cancer (Radiation Therapy) -External beam radiation is rarely appropriate for patients with recurrent Ta and T1 tumor or diffuse Tis. -simulate and treat patients with bladder empty. -use multiple fields from high-energy linear accelerator beams. -Treat the whole bladder with or without pelvic lymph nodes with 45-50 Gy and then boost the bladder tumor to total dose of 64-66 Gy. -Consider low-dose pre-operative radiation prior to segmental resection for invasive tumors.

16. Isfahan Isfahan Khajo Bridge