CÂNCER DE BEXIGA Revisão da Anatomia e Definição dos Volumes de Tratamento Karine Campagnolo R3 -Unidade de Radioterapia do Hospital de Clínicas de Porto Alegre
Roteiro da Apresentação Revisão da Anatomia Volumes de Tratamento Volumes alvo Órgãos de risco Dose/Fracionamento Conclusões e Perspectivas
Roteiro da Apresentação Revisão da Anatomia Volumes de Tratamento Volumes alvo Órgãos de risco Dose/Fracionamento Conclusões e Perspectivas
Bexiga - Localização PELVE Pelve Menor: bexiga urinária e órgãos reprodutores Pelve Maior: delgado e cólon sigmóide MOORE L. Keith. Anatomia orientada para a clínica. Rio de Janeiro: Guanabara Koogan, 2001.
Anatomia 1. Ápice Parede Anterior 2. Fundo ou Domus Parede Posterior 3.Trígono Base 4.Corpo ParedesLateraise Superior 5. Colo SOBOTTA, Johannes. Atlas der Anatomie des Menschen. Copyright, 2000.
Estrutura da Parede da Bexiga Gordura Perivesical Serosa Três Camadas Musculares músculo liso Detrusor LâminaPrópria-vasos Mucosa ou Urotélio células transicionais MIILS E. Stacey. Histology for pathologists. 3rd Edition. Copyright  2007 Lippincott Williams & Wilkins, 2007.
Relações anatômicas Anterior Sínfise púbica Espaço retropúbico SuperioreLateral Peritônioesuas reflexões Inferior colo repousa nos músculos do assoalho pélvico Posterior Mulher : Fáscia vesicovaginal + Fascia retovaginal Homem : Fáscia Retovesical - Denonvilliers MOORE L. Keith. Anatomia orientada para a clínica. Rio de Janeiro: Guanabara Koogan, 2001.
Suprimento Arterial Artérias Ilíacas Internas Ramos Anteriores Vesicais Inferiores e Superiores MOORE L. Keith. Anatomia orientada para a clínica. Rio de Janeiro: Guanabara Koogan, 2001.
Drenagem Linfática Rede de capilares submucosos fora da camada muscular LN regionais. Ápice e Corpo drenam para LN Ilíacos Externos. SOBOTTA,Johannes. Atlas der Anatomie de Menschen.Copyright, 2000. Fundo LNIlíacosInternos. Colo drenaparalnilíacosinternossacrais e LN Ilíacos Comuns.
Roteiro da Apresentação Revisão da Anatomia Volumes de Tratamento Volumes alvo Órgãos de risco Dose/Fracionamento Conclusões e Perspectivas
Órgãos Alvo Bexiga Tumor Próstata e uretra prostática em homens LN Regionais: LII, LIE, Obturadores, LIC (antes da introdução da QT sistêmica) OAR Alças de delgado Cabeças femorais Reto
LN Regionais http://www.imaios.com/en/e-anatomy
Pelve Masculina http://www.rtog.org/corelab/contouringatlases/malertognormalpelvisatlas.aspx
Volumes Alvo - GTV Tumor + qualquer massa visível na cistoscopia e exames de imagem.
Volume Inicial CTV1 / Pelve Bexiga Uretra Proximal Próstata e uretra prostática LN Regionais LIE, LII, Obturadores e LIC (antes da introdução de QT sistêmica) ** RTOG: recomenda a inclusão dos LN regionais Mais comumente: técnica 4 campos
Volume Inicial CTV1 Pelve Campos AP-PA Superior: L5-S1/ S2-S3 Inferior: logo abaixo do foramen obturador Laterais: 1,5 a 2 cm do aspecto medial dos ossos pélvicos Proteções nas margens laterais para reduzir a exposição das cabeças femorais LEE, Nancy Y.; LU, Jiade J. Target volume delineation and field setup. Springer Verlag, 2013.
Volume Inicial CTV1 Pelve Campos Laterais Anterior: 1,5 a 2,0 cm do aspecto mais anterior da bexiga Posterior: 2,5 cm da porção mais posterior da bexiga e cai dentro do reto Proteções são usadas para reduzir exposição dos tecidos moles anteriores à sínfise púbica, o canal anal posteriormente e as alças de delgado anteriores aos vasos ilíacos externos LEE, Nancy Y.; LU, Jiade J. Target volume delineation and field setup. Springer Verlag, 2013.
Bexiga + qualquer massa visível nos exames de imagem CTV 2 / Bexiga
CTV 3 / Boost GTV àreas de doença bulky -Nemtodososprotocolosincluemessa3fase
PTV -2 cm de margem aos respectivos CTV s ( variável )
Dose e Fracionamento CTV1 / Pelve : 40-50 Gy CTV2 / Bexiga : 60-65 Gy CTV3 / Boost: até 70 Gy 1.8 a 2 Gy / fração / 5 x semana -padrão
Roteiro da Apresentação Revisão da Anatomia Volumes de Tratamento Volumes alvo Órgãos de risco Dose/Fracionamento Conclusões e Perspectivas
Conclusões e Perspectivas -A bexiga é um alvo cujo tamanho e posição variam amplamente durante o curso do tratamento -Técnicas modernas de RT estão sendo estudadas com o intuito de diminuir a toxicidade -Verificação on line diária -CBCT deslocamentos não são uniformes, sendo mais pronunciados nas direções anterior e superior dinâmica dos órgãos adjacentes e das características do paciente -A técnica de irradiação parcial da bexiga -deve-se levar em consideração o risco de localização incompleta dos locais de doença já que não mostrou aumento na sobrevida -Em alguns casos uma margem de 2 cm ao PTV é insuficiente para cobrir adequadamente o CTV
Conclusões e Perspectivas - Margens anisotrópicas ao PTV são possíveis -radioterapia adaptativa e estas margens serão menores se as correções dos erros de setup forem realizadas usando os tecidos moles como referência ao invés da pele e da estrutura óssea -IMRT-diminui a dose ao delgado, mas mesmo se acompanhada por IGRT deve-se ter cautela com a diminuição de margem ao PTV -movimento intrafração -RT como parte da terapia multimodal de preservação de órgão é uma boa opção à cistectomia radical, entretanto a ampla variação da bexiga faz com que o tratamento permaneça um desafio aos profissionais da área
kcampagnolo@hotmail.com
CLINICAL INVESTIGATION Bladder ADAPTIVE RADIOTHERAPY FOR INVASIVE BLADDER CANCER: A FEASIBILITY STUDY FLORIS J. POS, M.D.,* MAARTEN HULSHOF, M.D., PH.D., JOOS LEBESQUE, M.D., PH.D.,* HEIDI LOTZ, PH.D.,* GEERTJAN VAN TIENHOVEN, M.D., PH.D., LUC MOONEN, M.D., PH.D.,* AND PETER REMEIJER, PH.D.* *Department of Radiation Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands; Department of Radiation Oncology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands Purpose: To evaluate the feasibility of adaptive radiotherapy (ART) in combination with a partial bladder irradiation. Methods and Materials: Twenty-one patients with solitary T1 T4 N0M0 bladder cancer were treated to the bladder tumor 2 cm margin planning target volume (PTVCONV). During the first treatment week, five daily computed tomography (CT) scans were made immediately before or after treatment. In the second week, a volume was constructed encompassing the gross tumor volumes (GTVs) on the planning scan and the five CT scans (GTVART). The GTVART was expanded with a 1 cm margin for the construction of a PTVART. Starting in the third week, patients were treated to PTVART. Repeat CT scans were used to evaluate treatment accuracy. Results: On 5 of 91 repeat CT scans (5%), the GTV was not adequately covered by the PTVART. On treatment planning, there was only one scan in which the GTV was not adequately covered by the 95% isodose. On average, the treatment volumes were reduced by 40% when comparing PTVART with PTVCONV (p < 0.0001). Conclusion: The adaptive strategy for bladder cancer is an effective way to deal with treatment errors caused by variations in bladder tumor position and leads to a substantial reduction in treatment volumes. 2006 Elsevier Inc. Bladder cancer, Radiotherapy, Organ motion, Adaptive radiotherapy.
Bladder cancer radiotherapy margins: a comparison of daily alignment using skin, bone or soft tissue. Foroudi F, Pham D, Bressel M, Wong J, Rolfo A, Roxby P, Kron T. Source Division of Radiation Oncology, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia. farshad.foroudi@petermac.org Abstract AIMS: To determine the clinical target volume (CTV) to planning target volume (PTV) margins required for bladder coverage when using skin or bony or soft tissue matching on a daily basis. MATERIALS AND METHODS: Twenty-seven patients with T2-T4 transitional cell carcinoma of the bladder were treated with daily online adaptive image-guided radiotherapy using cone beam computed tomography. All daily CTVs were contoured by a single observer. A retrospective comparison of coverage of the bladder CTV using skin, bone and soft tissue matching was conducted. RESULTS: With the skin set-up, bladder CTV coverage with a margin of 0.5, 1.0, 1.5, 2.0 and 2.5 cm was 0, 19, 56, 93 and 96%, respectively. For the daily set-up based on bone, the respective coverage was 0, 41, 63, 89 and 96%. For soft tissue set-up based on the geometric centre of the bladder, coverage was 52, 89, 96, 100 and 100%, respectively. CONCLUSIONS: Based on coverage of the CTV, the required CTV to PTV margins are smaller for the daily online soft tissue set-up compared with skin or bone. Copyright 2012 The Royal College of Radiologists. All rights reserved.
Journal of medical imaging and radiation oncology 2010 Jun;54(3):256-63. doi: 10.1111/j.1754-9485.2010.02169.x. Improving bladder cancer treatment with radiotherapy using separate intensity modulated radiotherapy plans for boost and elective fields. van Rooijen DC, van de Kamer JB, Hulshof MC, Koning CC, Bel A. Source Department of Radiation Oncology, Academic Medical Center, Amsterdam, The Netherlands. d.c.vanrooijen@amc.uva.nl Abstract The aim of this study is to investigate to what extent IMRT can decrease the dose to the organs at risk in bladder cancer treatment compared with conformal treatment while making separate treatment plans for the elective field and the boost. Special attention is paid to sparing small intestines. Twenty patients who were treated with the field-in-field technique (FiF) were re-planned with intensity modulated radiotherapy (IMRT) using five and seven beams, respectively. Separate treatment plans were made for the elective field (including the pelvic lymph nodes) and the boost, which enables position correction for bone and tumour separately. The prescribed dose was 40 Gy to the elective field and 55 or 60 Gy to the planning target volume (PTV). For bladder and rectum, V(45Gy) and V(55Gy) were compared, and for small intestines, V(25Gy) and V(40Gy.) The dose distribution with IMRT conformed better to the shape of the target. There was no significant difference between the techniques in dose to the healthy bladder. The median V(40Gy) of the small intestines decreased from 114 to 66 cc (P = 0.001) with five beam IMRT, and to 55 cc (P = 0.001) with seven beam IMRT compared with FiF. V(45Gy) for rectum decreased from 34.2% to 17.5% (P = 0.004) for both five and seven beam plans, while V(55Gy) for rectum remained the same. With IMRT, a statistically significant dose decrease to the small intestines can be achieved while covering both tumour and elective PTV adequately.