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2012 State of the Art Techniques in IMRT, IGRT, SBRT,

Proton and Brachytherapy: Emphasis on Quality and Safety May 4 - 6, 2012

Kidne /Testis

Planning and Delivery III

Brian J. Davis, M.D., Ph.D.

Associate Professor Radiation Oncology

Department of Radiation Oncology

Mayo Clinic and Foundation

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Bladder/Kidney/Testis:p em o ogy an a a on u ca ons

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

Deaths/ r 14 880 13 570 360

Peer reviewed

, ,‘RT and Site’

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RTOG Clinical Trialsor oca ze sease

9706

9906

0233

0524

0926

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Testicular Ca: NCCN Guidelines 2012

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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% – ver: < y y ; < y y

– Small bowel:

• y < cc contour ng n v ua oweloops)

• <

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Dose Constraints• Quantec dose constraints

– Large bowel: V45 Gy <195 cc – Bladder: Whole bladder V80 <15%,

< , < , <

– Rectum: V50 < 50%, V60 <35%, V65 < 25%,,

– Testes:

• es os erone pro uc on y• Temporary azospermia < 1 Gy

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Bladder Anatom

•4 s es

•4 angles

•

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Bladder Anatomy: 4 Sides

• The base or fundus, which is related to the

rectum, seminal vesicles and ductus

e erens ma es ;

• The superior surface;• And 2 inferolateral surfaces, which is

puboprostatic ligament (male) or

pu oves ca gamen ema e y e

retropubic fat pad.

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Bladder Anatom• s es

Sup, 2 inferolateral

base

•

Apex, neck, lateral

• 4 ducts2 ureters urethra

and urachus

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Bladder Cancer: Primary

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Bladder Cancer - Lymphatic Pathway of Spread

Common iliac

nodes:19 %

External iliac

Perivesical nodes Internal iliac

Perivesical LN:

nodes: 15 %

75 %

Nodal disease is present in 20-40% at diagnosis

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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,,

iliac.

.60 (2011) 946 – 952.

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Dorin et al. 2011

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RTOG Clinical Trials: Bladder Fields

Four fields must be used

to encompass the entire

9706

bladder,prostate, and

pelvic lymph nodes below

the common iliac

9906

0233

bifurcation. The CTV1

( CTV1= pelvic

0524

field margins in the

superior-inferior

0926dimensions should extendfrom mid-sacro-iliac

re ion to ust below the

obturator foramen.

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Bladder Cancer: Treatment Fields

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Small Pelvic Fields b 3-D

small bowel for urinary diversions should they be needed

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Tumor boost fields by 3-D

• Only partial bladder to high dose

(total 65 Gy)

• Incorporate all TURBT and

•radiographic infoSimulate and treat with empty

a er

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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.

. . .

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Main IGRT studies illustrating bladder

chan es durin irradiation

Thariat, J. et al. (2011) Image-guided radiation therapy for muscle-invasive

bladder cancer Nat. Rev. Urol. doi:10.1038/nrurol.2011.173

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FDG-PET/CT for the Preop Lymph

Swinnen et al., EUROPEAN UROLOGY 57 (2010) 641 – 647

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Radiation Therapyfor Kidney Cancer

•

• rea men o

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Kidney: Landmarks

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Retrospective Data Supporting

uvan os - ep rec omy

. ancer

– 244 patients: 72% died of cancer

–

10 yr survival 19%

– Surgery + RT 5 yr survival 56%10 yr survival 34%

R i D S i

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Retrospective Data Supporting

-

. . , .

– 186 patients treated from 1985-96 with 114 ptsreceiving postoperative EBRT with a median dose of

50 Gy.

– Surgery alone DF survival 31.3%OS survival 29.5%

– urgery + surv va .OS survival 37.9%

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Kidney Cancer: Old Phase III Trials

ow ng o ene o re-op

– Rotterdam Trial.

• van er er ess ng ancer : :

• 1965-1972

• -

then 40 Gy

• No benefit to preoperative radiotherapy

– Swedish Trial. Juusela H. 1968-72• Scand J Urol Neph 11:277:1977.

• pat ents rece ve pre-op n a ran om ze as on

• 3300 cGy in 3 weeks. No benefit demonstrated.

Kid C Old Ph ‘III’

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Kidney Cancer: Old Phase ‘III’

Post-op EBRT

• Danish Trial

– -.

– 1979 - 1984. 65 patients randomized.

– 50 Gy in 20 fractions. 4 fractions per week.

– o erence n ou come - s gn can ox c y n arm w

44% of patients having liver, stomach and duodenal problems.

19% of deaths attributed to RT

• ewcast e – R. Finney Cancer Cancer 1973:32:1332

– 100 patients over 9 years. Randomized by birth date. 4 death due

to RT induced hepatotoxiciy - 55 Gy in 2.04 Gy fractions.

– No difference in outcome.

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Radiation Therapy for Kidney Cancer

age r mary

1993-1998: 91 23

1999-2003: 135 13

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Potential indications for adjuvant

ra o erapy: erez r e .

• Incomplete resection with gross or microscopic residual margin• Locall advanced tumor with erine hric fat extension or adrenal

invasion, T3a or T3c. (Renal vein or inferior vena cava

involvement alone (T3b does not necessarily increase the risk of

.

• Lymph node metastases. (LN mets are associated with both a

high rate of distant metastasis and local failure. Although RT

may decrease the local recurrence rate, an improvement in overallsurvival may not be demonstrated in this circumstance.)

C 42 l

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Case: 42 yo male• Abdominal pain and hematuria

• Right radical nephrectomy 1 month later

• Pathology: 5.5 cm grade 3, papillary renal cell

carcinoma without capsular invasion. NecroticLN immediately adjacent to the vena cava.

• Consults in Med Onc and in Rad Onc

• Patient advised regarding pros and cons of

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R di l I i l O hi t

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Radical Inguinal Orchiectomy

• Transinguinal radical orchiectomy

– agnos s an t erapy

www.emedicine.com/ med/images/259radorch.jpgwww.ucurology.urologydomain.com

S i L h d th

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Seminoma: Lymphadenopathy

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• ossa e a .

• MRC trial

• pT1-3, 30 Gy / 15 fx

–

– DL (n=242)

• 90% power to exclude 3% 3yr relapserate one-sided al ha

De elopment

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Development

– Testes originate intra-abdominally – Migrate through the inguinal canal

www.somethingiforgottoreference.com

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• on nuesuperiorly

• Mediastinum &

LNs

• crossover

– R to L is

common but L toR is rare

www.nucleusinc.com

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• PA field borders – T10-T11

– ps a era rena

hilum

– Transverse

processes – L5-S1

• Prescribed at

m p ane

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• DL field borders

– T10-T11

–

hilum down to L5-,

lateral acetabulum

–

– Mid-obturator

oramen• Prescribed at

midplane

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Radiation Thera Fields

Relapses 3 yr RFS 3 yr OS N/V, Sperm

.

PA 9 (4 pelvic) 96% 99.3%

(1 death)

Better Higher

DL 9 (no pelvic) 96% 100% Worse Lower

p=SS

,

needed for pelvic relapses

• reserve or pr or surgery

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• ones e a .

• MRC/EORTC

• pT1-3, randomized to:

–

– 20 Gy / 10 fx (n=312)

• 90% power to detect 3-4% difference between arms one-sided al ha

R di ti Th D

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Radiation Thera Dose

• e s

– T10-T11

– Contralateral transverse process

– – L5-S1

• a owe pr or surgery• OL uestionnaires

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•

Relapses Death

30 Gy 10 (3.2%) 0

20 Gy 11 (3.5%) 1

• More acute SE with 30 Gy (p=SS)

– e argy, na y o wor , eu open a

– N/V, thrombocytopenia (trends)

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Treatment•

– 90% curable

– Radiation Therapy – Ipsilateral

– Boost 500 cG / 4 fractions

• Involved nodes

• cm marg n

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Radiation Techniques

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• Clamshell

– Reduce dose to contralateral testis – Cannot u y e m nate ose

• Internal scatter (patient)• External scatter (collimator)

– – .

– Additional shielding – 0.1%

Kubo H., Shipley W. IJROBP 8:1741Kubo H., Shipley W. IJROBP 8:1741--1745,19821745,1982

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• Actual clamshell shielding

www.tcrc.acor.orgwww.tcrc.acor.org


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• Clamshell shield stand

www.tcrc.acor.orgwww.tcrc.acor.org

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Thank You!

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730 855 davis basics

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