Bladder case

[LostResident1]

I have an 83-year-old patient with high grade urothelial ca sent from the VA. He had a TURBT and bilateral neph tubes placed there. Multiple co-morbidities. He was told he is not a candidate for surgery and sent to me. I ordered an MRI which showed extensive disease along the posterior wall, extra vesicular invasion of the prostate and bilateral ureters. There is also a 1.2 cm right external iliac lymph node.

My local urologist agreed with the VA in that he cannot do any more TURBT as its too vascular and he has to get to the base and he will "never get there". He recommended proceeding with RT+chemo. My initial plan was treating whole bladder and prostate to 64/32 but unsure of how to treat the elective and involved lymph nodes. I think doing 1.5Gy/day * 32 = 48 Gy elective may be too low of a daily dose. Maybe 1.8 Gy/day to 45 to the bladder, prostate, nodes, then sequential boost of the bladder, prostate, involved LN to 63 Gy? Any thoughts? Obviously not ideal to not have a max TURBT prior but I am backed into a corner.

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[BobbyHeenan]

I wouldn't stress about elective nodal coverage. Node + bladder cancer prognosis is awful. Focus on controlling that monster and the involved lymph node and making sure he gets through treatment.

Sure you can cover elective nodes, but if your bowel dosimetry is bad or he's having tons of GI toxicity I would stop elective treatment and just focus on gross disease/bladder. Or just treat gross disease now.

Interested to see what others think.

 

[DoctwoB]

Consider a second opinion from another urologist. I've never not done a TURBT or maximally debulked someone because it was "too vascular"

It will bleed. May need CBI or admission. It certainly won't be a complete resection, but there is plenty to debulk.

 

[TheWallnerus]

"Maybe 1.8 Gy/day to 45 to the bladder, prostate, nodes, then sequential boost of the bladder, prostate, involved LN to 63 Gy?"

Like it

Try to give concurrent carbo at least

(Did anyone see that new data recently... ESTRO?... about improved outcomes with ENI? I wouldn't do ENI here regardless.)

 

[Mandelin Rain]

"Maybe 1.8 Gy/day to 45 to the bladder, prostate, nodes, then sequential boost of the bladder, prostate, involved LN to 63 Gy?"

Like it

Try to give concurrent carbo at least

(Did anyone see that new data recently... ESTRO?... about improved outcomes with ENI? I wouldn't do ENI here regardless.)

 

[Ray D. Ayshun]

55/20. Can do 44/20 to the elective nodes and boost the positive one(s). Or nothing. James trial didn't really have any constraints I don't think. Jut minimize hotpsots.

 

[Palex80]

55/20 is great. I wouldn't cover electives, just get the N+ node in the volume.

You could try the RAIDER protocol as well. Toxicity results have been published.

Acute Toxicity of Hypofractionated and Conventionally Fractionated (Chemo)Radiotherapy Regimens for Bladder Cancer: An Exploratory Analysis from the RAIDER Trial

Adding concurrent (chemo)therapy to radiotherapy improves outcomes for muscle-invasive bladder cancer patients. A recent meta-analysis showed superior…

www.sciencedirect.com

Prescription:

https://www.clinicaloncologyonline.net/article/S0936-6555(21)00055-8/fulltext

 

[A_DeMichele]

palliation

 

[thecarbonionangle]

55/20. Can do 44/20 to the elective nodes and boost the positive one(s). Or nothing. James trial didn't really have any constraints I don't think. Jut minimize hotpsots.

This is precisely what i would do as well. Wouldnt waste my time with sequential boost. 55/20 is likely better anyways.

 

[evilbooyaa]

I have not heard any compelling arguments AGAINST the Choudry meta-analysis for hypofrac in bladder Ca - Hypofractionated radiotherapy in locally advanced bladder cancer: an individual patient data meta-analysis of the BC2001 and BCON trials - PubMed

It didn't include N0 patients but I wouldn't expect a difference in a N+ patient.

I now lean towards 55/20 to entire bladder + gross node, 44/20 ENI.